HL Deb 08 February 1972 vol 327 cc1072-121

3.8 p.m.


My Lords, I beg to move that this Bill be now read a second time. The Bill is designed to reform the administrative structure of the National Health Service in Scotland—which has remained almost unchanged since it was established 23 years ago. Despite the many undoubted achievements of "the Health Service" there has been a growing feeling among those who work within it that the present system of administration should be recast. The last Government started the work on which this Bill is largely based. They issued a Green Paper in 1968 and had extensive consultations with all concerned. When we came to office we accepted the principles of the Green Paper, developed some of the proposals, and published a White Paper in July 1971—Cmnd. 4734.

After further consultations and taking into account our own proposals for local government reform we now present this Bill. Its main purpose is to replace the present system of administration which, as the House knows, is divided between three groups of authorities—responsible for hospitals, general practitioner services and local authority services. It is proposed instead to create one united service designed to do three things: first, to make the best use of our resources in Scotland, now running at about£200 million a year; secondly, to be capable of adapting easily to change in medical knowledge and practice; and thirdly, to enable the skills and experience of those working within the Health Service to be used to best effect.

Part I of the Bill ensures that the Secretary of State remains, as he must be, responsible to Parliament for the services provided since the service is financed from the Central Exchequer. The Secretary of State's powers are restated in Part I of the Bill. This is to take account of his obligaion to provide or secure the provision of an integrated service. They are also in some respects widened; for example, to reflect the fact that services for which local health authorities or education authorities have had responsibility will in future be vested directly in the Secretary of State. Clauses 1 to 3 cover the broad span of the Secretary of State's duties under Part I of the National Health Service (Scotland) Act 1947. These include responsibility for the services formerly provided by Hospital Boards under Part II of the National Health Service (Scotland) Act 1947, local health authorities under Part III, and family practitioners under Part IV. However, while Parts II and III are superseded, the basic machinery of Part IV is left intact and the family practitioners will retain and keep the same contractual relation- ship with the National Health Service as they have at present.

The remaining clauses in Part I of the Bill contain detailed provisions relating to particular services, largely adapting existing legislation to the new situation. For example, a number of local health authority services have always been subject to a charge, fixed or remitted at the discretion of the local authority. Clauses 4, 5 and 8, while preserving the existing position as closely as possible, now provide that any charges will be founded upon regulations which will be subject to the ordinary Statutory Instrument procedure. Clause 8 concerns family planning. It includes the existing power of local authorities to give advice and to supply contraceptive substances, and extends it to cover treatment for contraceptive purposes. The effect is to widen the existing range of powers so that the Secretary of State may, if he thinks fit, provide vasectomy and other forms of treatment required not only on medical grounds but also for social reasons. Such treatment would not necessarily have to be provided free of charge, and the extent to which it could be provided would have to be decided by the Secretary of State when he considered all the other competing claims on resources. Clause 10 is designed to ensure that the National Health Service is concerned not only with the prevention and cure of illness but also with the positive promotion of good health. Health educators sometimes need our support, as so many of our unhealthy habits seem to be so enjoyable.

The key provisions of the Bill are found in Part II. Clause 13, together with Schedule 1, provides the statutory basis for the new Health Boards. These will be responsible for all services in their area, and will take the place of five Regional Hospital Boards, sixty-nine boards of management, twenty-five executive councils and fifty-six local health authority services. These Boards will be appointed by the Secretary of State after wide-ranging consultations. There were representations that local authority members and professional interests should have the right of membership on these Boards, but members will not be appointed as representative of any special interest but (as was made clear in the White Paper published last July) the Government would like to draw upon a wide range of experience, including the health professions, local government and universities with a direct interest in Health Service facilities. The White Paper said that the membership would be "of the order of 15". This does not, however, prevent a larger membership where necessary, as circumstances vary so much. For instance, some Boards will be responsible for very large concentrations of population and services, and other Boards will administer widely scattered geographical areas. Schedule 1 covers the possibility of payment being made to the Chairman of a Health Board. It seems right to take this power, for the demands made upon Health Board Chairmen will vary greatly. Before any decision is reached there will be further discussion with all concerned, taking account of the needs of individual areas.

The Bill follows the same pattern as was established at the start of the National Health Service by leaving the administrative boundaries to be fixed by Orders, which will be Statutory Instruments subject to the Negative Resolution procedure. This flexible system is particularly necessary at a time when local government boundaries will change under the Bill to be presented to Parliament next year. It is important, however, that the proposed number and areas of Health Boards should be known. The White Paper suggested a single-tier system of 14 Boards designed to follow closely either the proposed new local government regional or district boundaries. Modifications to these boundaries were announced in December last and these can be taken into account. Some people have suggested a two-tier system because the two-tier system is an accustomed system in Scotland, but the Green Paper, the original Paper published by the last Government, suggested a single tier of 10 to 15 Boards. We felt, too, that Scotland's size and geographical area, and population of just over 5 million, made one tier more effective, because any service not provided on an area basis can best be planned for the country as a whole. Before we reach any conclusions on the boundaries of Health Boards we must, as the Bill makes clear, have consultations when we prepare the formal Orders under Clause 13.

One matter which is not dealt with in the Bill is the detailed management structure of the Health Boards. This is not a matter for statutory provision but it is one that we shall discuss with all those concerned, because each Board should surely be able to work out themselves the most effective management arrangements for their own area. Only yesterday we issued a consultation paper on the management structure and I made a copy available to the noble Lord, Lord Hughes. I regret that for some reason it did not appear until the last moment, but copies are available in the Printed Paper Office to any noble Lords who are interested in the subject.

Clause 14 brings in a new feature of Health Service administration, and this is the creation, except in very exceptional circumstances, of local health councils. These will not be part of the management structure but are designed to represent public opinion. Both local authorities and local voluntary organisations will be represented on them. They will be entitled to be supplied with information about the Health Service in their district, and to be consulted before major changes are introduced. No noble Lord can doubt the public interest in health matters of every kind. Nevertheless, it has been found in the past not always possible to ensure that public interest in health topics, or indeed criticism of services, finds an easy method of expression to the local management of the services. That is why we consider that the creation of local health councils is very important and can be very effective.

Clause 15 recognises the necessity for close links between Health Boards and universities. Clause 16 introduces the type of professional consultative machinery which general medical practitioners, dentists, chemists and opticians have always enjoyed in relation to executive councils. The Health Boards will be expected to make arrangements to ensure that they can get the views of the relevant professions on all issues. These new area professional committees will also take over the functions of the existing local medical and other committees which now advise executive councils under the present structure.

Part III of the Bill concerns the new central machinery of the Health Service. It is, I think, a fortunate fact that Scotland is a convenient size for Health Service purposes. For example, there are some decisions which cannot be taken by individual Health Boards, and there are services which need to be provided on a larger scale than that of the Health Board. It is for these purposes that two new organisations are being created under the Bill; the Scottish Health Service Planning Council, under Clause 17 and Schedule 2; and the Common Services Agency under Clause 19 and Schedule 3. The Planning Council will have a representative from each Health Board to assist them. This new Planning Council and its associated committees will supersede the existing Scottish Health Services Council, and I should like to take this chance of thanking all those who have given of their work and study and time in the development of the National Health Service in Scotland since it began.

As its name implies, the new Common Services Agency will be the agent of the individual Health Boards and of the Secretary of State, in a range of activities which must be handled on the basis of all the people throughout Scotland. Most of the functions involved are, in any case, already centrally organised in a variety of ways; some others, such as major building projects, are mainly the concern at present of Regional Hospital Boards which will disappear on reorganisation. There are also important functions which at present are handled not by National Health Service staff, but by civil servants. These functions, which include Health Service research and intelligence, hospital supplies and the Scottish Health Education Unit, fit naturally into a National Health Service. But they are a part of the Scottish Home and Health Department at present, because the present Health Service structure offers no alternative headquarters.

We believe that these functions should not be artificially divorced from the rest of the Health Service, and we therefore propose to transfer them, and the staff at present employed on them, to the Common Services Agency. Day-to-day management of the Agency will be carried out under a committee on which both the Department and the Health Boards will be represented. Clause 18 provides at national level for professional committees, broadly similar in nature to those that are to be recognised at the Health Board level. They will advise the Central Planning Council, and we think they will probably find it convenient for certain purposes to establish joint committees and sub-committees with the Council.

Part IV of the Bill is concerned with co-operation between the new Health Service authorities and local authorities, which will remain responsible for environmental health and for other services, such as education and social work, which must maintain close links with the Health Service. The Bill marks the disappearance from the Statute Book of the honourable title of Medical Officer of Health. The country has been well served by its public health medical officers for over a century. However, their distinctive contribution to community health, both in that capacity and in that of school medical officers, will not, I am glad to say, come to an end. These officers welcome the opportunity of working closely with other parts of the Health Service. As they will become officers of the Health Boards, they will have a powerful influence on the development of services in the future. This will be equally true of local authority dental and nursing officers.

Thus, Clause 21 provides for the designation of particular medical officers of Health Boards to perform certain specific functions which are at present laid by Statute on the medical officer of health. Clause 22 enables Health Boards to provide whatever medical or other professional advice may be required by local authorities. Not only local health authority staff will change their employers as a result of the Bill. Everyone employed in the National Health Service will be affected in some way, even though in many cases no change of duties or of places of work will be involved. It is therefore of the greatest importance that the interests of all staffs should be safeguarded.

Part V of the Bill—Clauses 24 to 37 and Schedule 4—is concerned with the transfer of staff and property. Clause 28 creates a Staff Commission on lines which have worked successfully in other situations, such as the reform of local government in London. Clause 29 contains a number of detailed provisions to ensure that existing employing aut horities will have power to make arrangements for the transfer of their staff to new duties. Clauses 25 to 27 make the necessary provision for the transfer of property, rights and liabilities.

As the House knows, we hope that the Appointed Day will be April, 1974, and well ahead of that day we hope to have the new Health Boards established on a "shadow" basis, so that they can transfer the existing staffs where necessary and keep the period of uncertainty to a minimum. As will be seen in the Explanatory Memorandum, the effect on public service manpower is expected to be neutral.

Part VI of the Bill deals with endowments and other trust property. The National Health Service inherited from the old voluntary hospitals quite large sums which have been bequeathed or donated for a variety of purposes. These are still being given. These endowment funds have been kept as nearly as possible in line with the intentions of their donors. The same principle has been adopted on this occasion so that, so far as possible, the purposes of existing endowments are preserved, even though in many ways the statutory distinctions between services provided in hospitals and other Health Services are disappearing.

Part VII contains a variety of provisions, most of them of a formal kind. There is, however, a new specific power for National Health Service organisations to give assistance to developing countries. As might be expected, the financial balance between central and local government is kept by Clause 51(7), which makes possible an adjustment of rate support grant in recognition of the fact that local authorities will not in future have to spend money on personal health services. The total cost of this reform under this Bill is about £2 million up to 1975. This is shown in the Financial Memorandum and relates to transitional administrative matters.

This is a fairly long Bill, and I hope that I have said enough to show that it is a far-reaching measure which alters the structure of our National Health Service in Scotland to a considerable extent. It takes account of the scale of administration in our country, and a special opportunity is given by the close relations which have existed for many years between the central Department and the health professions throughout Scotland. Above all, the Bill is the start of still further determined efforts to solve the very real health problems of Scotland. These will differ over time, as we manage to contain the illnesses of childhood and as the diseases of old age grow in importance. I suggest to the House that higher standards of physical health need to be matched by the advances in the understanding and treatment of mental disorder. The administrative machine proposed in this Bill has, therefore, we believe, the major merit of being able to adapt to these changing demands and to many others which we can as yet hardly foresee. I beg to move that the Bill be now read a second time.

Moved, That the Bill be now read 2a.—(Baroness Tweedsmuir of Belhelvie.)

3.30 p.m.


My Lords, it is indeed a pleasure to begin my remarks on this Bill this afternoon by thanking the noble Baroness for the way in which she has presented this Bill to your Lordships: with her usual clarity and, having regard to the importance of the Bill, with commendable brevity, also. I hope that, unusually, I shall be able to follow her example. Thanks to having a 100 per cent. increase in strength on this side of the House in these matters, my task is a little easier. For those who do not work in these complicated mathematical ways, I should perhaps explain that a 100 per cent. increase in this respect means that there are now two of us instead of one.

My Lords, I would wish first to express satisfaction that this Bill indicates that the National Health Service is no longer a subject of political controversy, because the Bill is based almost equally on the White Paper produced by the present Government and the Green Paper of its predecessor; and, while there are differences between the White Paper and the Bill and between the Green Paper and the White Paper, none of these differences, I think, is of major importance. It is therefore possible to discuss this Bill perhaps outwith the usual realms of Party controversy, because I think we can say with truth that the National Health Service is now an accepted part of the administrative structure in this country.

I speak on this measure with a certain useful background. I had more than a quarter of a century in local government with an authority which was, among other things, a health authority. I was for more than a dozen years chairman of a Regional Hospital Board; and I was for what I found a commendably brief period a member of an executive council. Looking at the subject from the experience which I acquired in these different directions, I would assure the noble Baroness that I am in complete agreement with the proposals for altering the structure from a tripartite one to a single tier, placing the control of the administration in one body. I believe that this will undoubtedly prove to be a change for the better. No one can accuse either this Government or any of their predecessors of rushing foolishly into change for change's sake, because a 23-year experience of the first form of administration does either one of two things: it shows perhaps the possession of a fair degree of caution on the part of Governments, or (perhaps I should say, "and") it shows that the first structure was one that stood the test of time remarkably well and that the passage of a long time was needed to show the best way in which change could take place.

The Bill which is before us to-day is very much a skeleton structure. The Secretary of State is given a very great degree of power to make orders and regulations. Running through the Bill—and I cannot guarantee that I am completely exhaustive in this list—I find that in every one of Clauses 4, 5, 8, 13, 15, 24, 25, 26, 27, 31 to 39, 40, 43, 49 and 52 the Secretary of State has power to make orders or regulations, and in some others he also has power to give directions or to make arrangements. It is in this way that, in due course, flesh will be put upon this skeleton. It is the form these orders and regulations, these directions and arrangements, take that will determine the extent to which the resulting body will still encase the National Health Service spirit as we have known it up to the present.

My Lords, I do not object to this method, of proceeding. When so important a part of our life has to be legislated about, it is I think proper that we should be able to do this in a way that enables change to take place without the necessity of coming to Parliament for a completely new Bill. But it is important that Parliament should have the maximum opportunity to examine what is being done under these orders and regulations. Giving general approval to the method does not, in my view, absolve us from the necessity to look at some of the details in these clauses, and we on this side of the House may wish to make some Amendments to increase Parliamentary supervision in some directions.

In this connection, perhaps the noble Baroness the Minister, when she comes to reply to this debate, may wish to indicate, for example, on what basis it has been decided that some of the orders are to be put before Parliament under the Negative Resolution procedure while other orders are not to come before Parliament at all. I know that all the regulations will come before Parliament in due course in the form of Statutory Instruments, but all of these, and the orders which come before Parliament, are to be subject to the Negative Resolution procedure. Some of those which came before Parliament under the 1947 Act—for instance, I think the compensation proposals—required an Affirmative Resolution. I should like to know just why nothing in this very important Bill is considered of sufficient importance to require the Affirmative Resolution procedure. I should like particularly to ask why Clause 46, which gives the Secretary of State very extensive powers in an emergency—virtually to change the whole pattern of the Service —does not require, either before or after, any Parliamentary procedure whatsoever. May I say, in passing, that in the Explanatory Memorandum attached to the Bill, at the top of page vi, Clause 46 is erroneously referred to as Clause 45. I do not suppose that that in any way invalidates the procedure.

I should now like to turn briefly to some specific provisions in the Bill. First of all, I would refer to the Health Boards. The White Paper spoke of 14 Boards with a membership which generally would not exceed 15 in number. This is a very small body to carry out this most important range of functions. If I may take the region with which I was formerly associated, the Eastern Region of Scotland, that has functions carried out at present by a Regional Hospital Board, a certain number of boards of management, a certain number of executive councils and a certain number of local authorities. Ail told, the number of people who are engaged on a voluntary basis in carrying out this task exceeds 200; and under this Bill they are to be replaced by not more than 15 volunteers. This indicates that it is most important that the members of the new Health Boards are people of the very highest quality, and people dedicated to making the Service work in the most efficient manner possible.

But, my Lords, no matter how well they may be chosen, they will have an impossible task unless they are given a very good committee structure, and unless they make full and wise use of the principle of co-option. To a certain extent the local health councils, to which the noble Baroness has referred, will be a help, although we must remember that unlike the existing bodies, these health councils will have no executive powers whatsoever. They will purely be consultative and advisory bodies, and only experience will tell to what extent they will satisfy the public. Sometimes consultative bodies turn out to be the creatures of the executive bodies they are supposed to advise. Sometimes they are regarded more as publicity agents for these bodies, rather than as bodies putting over the public point of view. But if they work as the Green Paper, the White Paper and the Bill hope they will work, then undoubtedly they will help to supplement the small number of people who will be actively engaged in the executive functions of the Health Boards. I agree that the chairmen of these Boards will have a very important task to perform, and I would wish to say very seriously that much of the success of the Boards will depend on a judicious choice of chairmen. A wrong chairman of any of these Boards will be almost a major disaster.

The White Paper spoke of a possible improved system of payment of members other than the present basis. The Bill, as the White Paper indicated, provides that the chairman shall be paid a salary on a part-time basis, but the Bill does not follow up what was said in the White Paper about the possible alternative basis of payment, and all that will happen so far as the other members are concerned will be that the present system will continue. This is not always satisfactory, as it involves paying travelling expenses and possibly recompense for loss of remuneration in one's job. I hope that the Minister will be able to say more about this aspect, because this is much too large a job to be handed over to up to fourteen people on the basis that for all the time they will be expected to give to this work they will receive only their travelling expenses, plus some small subsistence allowances if they can show that they have lost wages in the process.

There has been a great deal of discussion about the composition of the Boards and the way in which they should be chosen. Some people thought they should be elected bodies. Personally I do not subscribe to that view. I believe that, with the reorganisation of local government, and with people having to choose a regional authority and a district authority, we should completely sicken them for voting at a local level if we asked them to vote for a body like a local Health Board. It seems to me that the principle of appointment by the Secretary of State, while undoubtedly open to many objections, does at least enable a choice to be made as to the most suitable people. I would draw attention to a possible defect of the Bill in this connection which has been brought to my notice by someone in the Health Service. The 1947 Act laid down that at least half the members of a Regional Hospital Board should be other than medical practitioners. I believe it has been indicated that with the Health Boards this same sort of principle will apply. I hope it will be made quite clear, at least in regulations if it does not go into the Bill, that some sort of decision along these lines will be taken, because it was always felt that the Boards would be least effective if they appeared to be dominated by the medical profession. I hope to receive a satisfactory assurance from the noble Baroness on that point.

Now as to the statutory bodies to which she referred, I think the Scottish Health Services Planning Council and the Common Services Agency are an inevitable adjunct to the sort of structure that is going to be set up in these Health Boards. If they are properly constituted and suitably empowered I think they will provide essential services in the most satisfactory way. However, I have some doubts about the wording of Clause 19. Clause 19 gives very wide powers indeed to the Secretary of State to determine the functions which will be carried out by this central Common Services Agency. It may be that he would direct, say, only major building projects to that Agency, but there could be a great deal of argument as to what a major project is. It might be that he would take almost the whole of the building services out of the hands of the Board and concentrate upon an unduly large proportion of them. Of course he might go the other way and give the Agency far too little to do. I do not claim to be an expert reader of these measures because I greatly miss the help given by the professionals who can tell you what the thing is supposed to mean, and I find it a little difficult to find this out for myself; but so far as I can see, there is no provision for anything that is being done here to be subject to prior or later approval of Parliament. If I am correct in that assumption, then I would wish to table Amendments to bring this matter under supervision by Parliament, possibly by way of the same Negative Resolution procedure.

My Lords, the White Paper makes no reference—and I must in fairness say neither did the Green Paper—to an industrial health service. This is something which I believe exists to a limited extent on a purely voluntary basis at the present time, depending entirely on the arrangements that industry makes for itself. But the trade union movement is not alone involved. There are many others who believe that the Health Service will not be complete if it does not at least foresee the provision at some time of an industrial health service. I certainly wish to give notice that I am at least considering whether or not a form of words should be inserted in this measure (which, if we are lucky, may take us over the next 23 years) to enable something to be done in future along these lines without coming back to Parliament with a completely new Bill.

Finally, the White Paper refers to consideration being given to the appointment of a Health Commissioner. There is no reference to that in the Bill, for reasons which I think we all understand; but I hope that a statement which was attribu- ted to the noble Baroness's right honourable friend some time ago, about the appointment of a Health Commissioner (and which was promptly denied) will turn out in due course to be a denial only in time and not in permanent fact. If the Government are not going to make provision for the appointment of a Health Commissioner we on this side of the House would be failing in our duty if we did not table an Amendment to make that possible. There is no field of activity concerning the general public where the need for an Ombudsman is more generally felt and more generally demanded, and it would be a cardinal omission if this Bill should leave your Lordships' House without recognition of that fact.

As is not uncommon in these matters of Scottish legislation I find it easier in a Second Reading speech to concentrate on points of agreement than on points of disagreement. I have no intention of looking for ways of making the noble Baroness's task more difficult at the Committee stage. I do not believe in amendment for amendment's sake, but I think there is room for amendment of this measure, and I hope that when such Amendments are tabled, whether they are accepted or not, it will be recognised on both sides of the House that the Amendments are put forward in a constructive attempt to make what I believe is basically a reasonable measure still more reasonable.

3.50 p.m.


My Lords, I should like to congratulate the Minister very much on the way in which she has introduced this Bill, and also, if I may, the noble Lord, Lord Hughes, who has indicated that the Bill is not controversial and the Opposition are not opposed to it because it is based on a combination of work done by the Labour Government when they were in office and now carried on by the present Government. I think that the Bill has been welcomed generally all through Scotland and I should like to add my welcome to it. Like the noble Lord, Lord Hughes, I am still actively engaged in local government. I am at the moment chairman of the Social Work Committee of Roxburghshire so I am deeply interested in the possible effects of the reorganisation of the health services which I hope will still remain very co-operative, as they are to-day, with the social work services, since the two must work closely together to provide an effective and useful service. In the Borders, which I represent, we are glad to have a region, a Border region, composed in exactly the same way as is envisaged in the reorganisation of local government. I think that that will work satisfactorily from the point of view of the Health Service.

I feel also that it is a good plan to have 14 Boards. This will not be too great a number, for in Scotland our conditions are very varied between highly concentrated industrial areas and widely scattered rural areas. I am glad that the appointment of the majority of members will be by interest and experience and not by election. I agree with Lord Hughes about this. I think it is a responsibility that the Secretary of State can take and will take, I am sure successfully, and it gives a wide choice to him of people he can appoint to these Boards. I rather agree with the noble Lord, Lord Hughes, that the size of the Boards, the numbers on the Boards, might perhaps be reconsidered. In our area it will not matter very much; but in a highly-populated industrial area I can see that to have only 15 members on the Health Board will give a tremendous amount of work to each of them. It may be that a larger number will be more effective.

Clause 5 refers to the care of schoolchildren, to their dental care, opthalmic care and so on. I am in favour of this being under the care of the medical profession, the Health Board; but I should not like to see a division between the local education authority and the Health Board in connection with the care of children at school. I think it important that the education committee, the social work committee, and the Health Board should work closely together in connection with school children and school care. They do so now and I think that that should be continued.

I was glad to see—and the Minister mentioned it—the inclusion of Clause 8. I think this very important. This is the clause on family planning provisions. I believe, although I am not sure, that this is the first time that such provisions have appeared in a Bill of this kind. I am sure it is very valuable. I wonder whether the Minister could explain the wording of Clause 21(3). It is not easy to understand. It says: A designated medical officer may exercise any powers conferred by any enactment on an authorised officer of a local authority if the local authority authorises him in writing so to do. This seems to me to be somewhat complicated. Perhaps it would be possible to make it clearer. There is no mention in connection with "designation" and "designated" individual persons or nursing officers for district nursing or community nursing. I think that this point might be considered. In my area we found it was useful to have close associations with the district nursing authorities in the area. I think it would be important to have a designated officer in connection with nursing on the local health committee.

Co-operation in the areas arises in Clause 16 dealing with local consultative committees. Here there are lists of people and professions who might be appointed to local consultative committees. In that list there is no mention of social workers or of representatives of the social work committees. I think that that point again might be considered by the Minister. It would be most unfortunate if consultative committees were set up and no social workers were appointed to those committees, since at the present time there is close co-operation between the representatives of the social work committees and the medical profession.

Another point is on the function of the local health councils. There are only in an advisory capacity, but they could be, and in my opinion should be, the committees that represent the consumer interest. In this mass of administrative committees and professional bodies I am a little concerned about who is to speak up for the consumer, the patient, or the old person. I think it very important that the "consumer" should have a voice on all these bodies. It would be very unfortunate if the Health Boards were to act without consulting the local health councils. It should be made clear what are to be the powers of local health councils. The Bill says: The Health Hoards should consult with the local health councils on such occasions and to such an extent as may be prescribed". This is a little ambiguous. I should like to see it almost mandatory that they should have this consultation. In the Borders we have for some time now had a consultative committee of health and social services which work in close co-operation, and that committee is very effective.

Part 3 deals with the appointment of the central bodies. It is important to define the relationship between the central bodies and their local counterparts. On these central bodies I hope that the Royal College of Surgeons and the Royal College of Medicine will have representation and will be in consultation with these people. I have a letter from the Royal College of Surgeons in Edinburgh who are concerned lest the help that they can give, which must be very great, should not be used to the fullest capacity. I hope that in the formation of these different councils the Royal Colleges will not be left out.

There is also one fear that I have—and perhaps it is because I have no professional qualifications at all in connection with medicine, though I have worked for a very long time in social work. It is that if we appoint too many committees, and if they do not have very distinctive functions, we may find, when things are going wrong, that a person on one committee may blame another committee for the fact that his committee cannot do what they want to do. To use a colloquial phrase, there may be some "passing the buck". I should not like to see this happen. The relationship of the local committees and the central councils must be very close indeed if we are not at times to fall between two stools.

There is the section which was referred to by the Minister and by the noble Lord, Lord Hughes, on the future of staff and employees. I think that is of enormous importance. I understand that there is some anxiety among the professional staff in the existing service about what is to happen. I do not feel that strongly myself, since there is a great shortage of doctors and nurses and I think it very unlikely that there will be any redundancies. Equally, in the new set-up it is of the greatest importance that those in the services should have the opportunity to transfer into the new organisation and to have all the advantages of their long service recognised, so that they may be fitted into the new service without any loss of prestige, money or position. My Lords, I believe that a great deal of misunderstanding could be avoided if the Minister could announce early what the reorganisation will mean for professional people. The noble Baroness said in her speech that that was her intention, and I hope that she will carry it out. I am sure that anxiety is unnecessary and that it could be allayed early for those who are working in the organisation and are worried about their future.

The noble Lord, Lord Hughes, mentioned what I, too, recognise as the great authority of the Secretary of State. He has to make all, or nearly all, of the appointments. While I have great faith in Secretaries of State for Scotland I think that we should consider the wide section from which these appointments may be made. I hope that this will not prove to be too much of a dictatorial power. I recognise that it is a right which the Secretary of State should have, but I see some danger, and perhaps there ought to be some safeguards in respect of this great responsibility which the Minister has taken upon himself.

I think that the reorganisation plans are good and, so far as I know, they are welcomed, as I have said. But one must always remember the object of all this organisation, which is a bettter and more efficient Health Service for Scotland. That will not be brought about by administration alone. No one has ever helped the sick or cured the ill by filling in a form or receiving more instruction. It is the personnel that matters, the people dealing with the individual, the people who are working in the community, in the nursing services and in the hospitals. At the end of the day it is not St. Andrew's House but opinion in the towns, the areas of the Highlands and the Borders and the big cities, which will matter. The provision of adequate accommodation in hospitals will recommend the scheme to the public. I hope that this will be borne in mind during the whole of the course of this legislation. But as presented to-day by the Government the Bill has my wholehearted support.

4.4 p.m.


My Lords, I think it is generally accepted that the idea of this enabling Bill is good, replacing as it does three Services by one. However, the real test of the Bill will be the way in which the Service is administered. I do not intend to speak at length, but rather to draw the attention of the Government to certain aspects of the Bill and to some clauses of it which, if not put into effect with more sympathetic understanding than is too often the case with centralised control, could lead to disaster. In an area like the Highlands, it is highly advisable for the efficient continuation of the existing Health Services that district offices are maintained by the new health authority to allow for close co-operation between the local authorities' education, sanitary and social work departments. Unfortunately, the formation of districts in various areas is not covered by the Bill but is a matter to be decided by the Area Boards after they are formed.

The Area Health Board for the vast area of the Highlands, consisting of about 15 officers, cannot possibly be representative. Obviously, a large Health Board would be unwieldy, but a small one must have adequate advice from below; and by this I mean local advice from local knowledge. It is therefore imperative, in my view, that the local health councils should have "teeth". If they have no authority, no money and no power, they will degenerate into a "Friends of Hospital" type of committee. They would indeed have some nuisance value through putting up impractical schemes, but it is extremely doubtful whether many people of the right calibre would be prepared to serve on such a committee. The Common Service Agency is good as long as local conditions are remembered. Civil servants may be quite unaware of conditions in, say, Loch Maddy Hospice, with two maternity beds, if they are accustomed to thinking in terms of hundreds of beds.

My Lords, I should like to bring before the Government a matter worthy of their attention and which has already been mentioned by the noble Baroness, Lady Elliot of Harwood. While the functions of the staff commission sound splendid, I would point out that employees have been told nothing of the future which lies not so far ahead and, understandably, there is considerable anxiety. My next remarks are not to be taken to imply that I am the latest recruit to Women's Lib. But married women who serve on boards will be required to give a great deal of their time to these duties, and in my view sympathetic consideration should be given to allowing extra domestic help, and the allowance for this should be a legitimate expense. Finally, while wishing this Bill well, I trust that it will be administered as effectively in the far-flung areas as it probably will be in the cities, towns and more concentrated areas of Scotland. Perhaps one of the omissions in the Bill which gives rise to some surprise is the complete absence of any mention anywhere of the patient. One might be excused for thinking that he or she is the most important person in any Health Scheme.

4.9 p.m.


My Lords, I should like to join with others in thanking the noble Baroness, Lady Tweedsmuir of Belhelvie, for the excellent way in which she has presented this Bill, and also to congratulate the noble Lord, Lord Hughes. There is a great deal in the Bill which will be for the good, and which will be a reform and not just an administrative measure. Looking down the list of speakers I am terrified: I think I should say at once that I had a Scottish mother. The noble Lord, Lord Inglewood, lives on the very Borders; and as for the others, they are all hereditary Scots.

My Lords, according to sub-paragraph (b) of the Explanatory Memorandum, the Bill seeks: to provide means in each area of representing the interests of the community and ensuring that the views of the health care professions are given full weight in the planning and management of services". This is a splendid objective, and, so long as it is carried out well, it is very much for the good. In general, the Bill follows the tendency of the present Government to seek a more managerial structure for the reorganisation of the National Health Service and, in consequence, a less professional one. As has been said, a great deal of power is handed over to the Secretary of State, and a great deal of what happens will depend upon how he chooses to use his power. I should be the first to agree that doctors are not always the best administrators; and I fully agree with the noble Lord, Lord Hughes, when he says that Health Service boards and other bodies should not be entirely dominated by the medical profession. My profession must be careful not to forget that there are many other extremely important professional groups involved in the Health Service, including the managers themselves, and notably dentists, nurses, and social workers. We must not regard ourselves as being the only people who should have a say. I think that any Secretary of State of intelligence will know where to get his advice and will not be out to alienate or ignore the medical profession.

The whole organisation brings up the question as to what extent the composition of committees and boards should be determined by Statute. To my mind, there is much to be said for a good deal of freedom of action—one might say of wide freedom of action—in the hands of the Secretary of State so that he should not be too tied down. It is laid down that many of the appointments have to be made after consultation with the various organisations concerned. We can normally assume that this will be done in a responsible way. Nevertheless, when we read that the chairmen and the whole of the area boards are to be appointed by the Secretary of State, albeit after these consultations have taken place, and that no medical men really need to be appointed either to the area Health Board or to the proposed Health Service Planning Council, then the profession is liable to become just a little nervous. If I may say so, the rather cavalier way in which the professions are treated in the Industrial Relations Act does not inspire the profession with complete confidence.

I am glad, however, to sound a general note of welcome and approval, which I think most of my colleagues in the medical profession would share, to what I think will be a valuable experiment in Scotland. I should like to reiterate the question posed by the noble Baroness, Lady Elliot of Harwood, who asked what exactly are to be the functions of this somewhat mysterious "designated medical officer" We hope to hear some more of him in the winding-up speech. We may be using Scotland as a kind of Health Service guinea pig, because in some ways their administrative problems are less complicated than are ours in England and Wales. But we must also recognise that their Health Department has been most successful and far-seeing, and we may have a good deal to learn from the experiments which they seek to put into action.

The medical profession has already given general support to the idea of the integration of the Health Service in all its three main branches at the present time. In fact, I think one can say that the insistence that sooner or later this must be done really came from the medical profession. I think that the idea of an area medical committee, with the medical members of all three branches—that is, the general practitioners, the hospital doctors and those who work in local authority and school services—all being on the same committee could be a valuable experiment. We must hope that they will be able to speak with one voice, otherwise they will find themselves breaking up into a number of warring sub-committees. As an ex-President of the Family Planning Association, I should like to join the noble Baroness, Lady Elliot of Harwood, in welcoming the provisions for family planning in Scotland. During the passing of the Family Planning Act I expressed a little concern as to what was going to happen if we practised contraception in England, but not in Scotland.

Finally, I feel that above all the new proposals offer opportunities for flexibility and, with the wide powers that are being given to the Secretary of State, one can only hope that future Secretaries of State will be equal to the challenge which is being offered to them.

4.15 p.m.


My Lords, I rise to intervene in this debate in a spirit of inquiry, and I hope that no noble Lord will mistake that for criticism. I have always felt that where we have separate legislation for Scotland and England and Wales, and there is often a very good reason for having two such Bills, we should not introduce new differences or perpetuate unnecessary old differences without some explanation and justification. I hope that my noble friend the Minister in her winding-up will be able to say something about this.

Secondly, since I live on what my noble friend Lady Elliot describes as "in the Borders", but I would call "on the Border", I am conscious of the different systems of administration on both sides of the Border approved by Parliament, and also of the frequent difficulties in co-operation across the Border which result.

In other circumstances we are now hearing a lot about "harmonisation of legislation"—that is, of course, in the European sense. I hope it cannot be said about us that, while we talk about this in the European sense, we do nothing about it here at home. There are, I believe, differences between this Bill and the proposed scheme for England and Wales, which we have not yet seen. Before we finish with this debate, I hope that my noble friend will be able to give us some idea of what these differences are. I think it is only right that Parliament should know.

I hope no noble Lord will think that I am just suggesting that Scotland should conform to what is proposed for England. I am doing nothing of the kind. It could be the other way round, and that what is now being proposed for Scotland is something which should be reflected in the Bill for England and Wales. But as we have not yet seen the Bill for England and Wales, it is hard for us to consider the problem as a whole. It has been said to me that some of these likely differences stem from the fact that the population of England and Wales is much larger and denser than Scotland. But I would suggest that the population of parts of the North of England, and the general layout of the country, is much more like the South of Scotland, and it could well be that, if any system is deemed better for Scotland than what is proposed for England, it might be better for the North of England, too. We ought to be given some information about this.

I am sure that my noble friend will agree that differences must in their nature complicate administration, lower efficiency and often increase costs. When I looked through the Bill, I found in Clause 20 references to co-operation between the Health Boards and the local authorities to secure and advance the health of the people of Scotland. I expected this to be followed by a subsection saying that such Health Boards in the Borders would be under a statutory obligation to consult with their opposite numbers South of the Border; but there is no reference to that at all. If we continue to Clause 47 we see that there is a further reference to co-operation with and assistance to authorities and persons outside the United Kingdom. England and Wales are not divided from Scotland by an impassable ocean, but by a Border which people are crossing all day and every day, and this is of some importance from the health point of view. Yet, so far as I can see in this Bill, this aspect is not mentioned. I urge my noble friend to introduce at a later stage a clause which will put an obligation on the Health Boards in the Borders to co-operate with the English organisation on the other side. That seems to be a most unreasonable omission.

My next point is a more general one. The end of the tripartite system has been welcomed, and the transfer of greater powers to the Secretary of State may mean greater efficiency when looked at from a certain point of view, but as we are Parliamentarians we must also take note of another side: it is transferring power from the locally elected representatives into the hands of officials, which in practice will probably mean officials of middle seniority. However able and however devoted they are, that is not the same thing from the point of view of the individual citizens. So if we approve this, we should do so fully aware of what we are doing.

Under the heading "Consultation" almost anything can result. We put words in Bills imposing on Ministers an obligation to consult, but it must be that in the end the Minister has to make his own decisions; he has not necessarily to pay regard to these consultations. I do not know whether the Scotsmen feel that the drafting of the clauses where consultation is referred to are worded as they ought to be. I should not like to go into that.

Referring again to my first point about the differences that there might be between this Bill and the English Bill which we have not yet seen, we are led to believe that somebody called a "community physician" is going to be created in England. I can see no reference to a "community physician" here, but I have heard references in the debates, and I have found reference in the Bill, to a "designated medical officer". Is this the same person by another name, or is he a different person with different powers? If he were the same person, I should have thought it would be easier to give him the same name in both Bills. No doubt my noble friend will be able to explain that. It is a pity that so often the same powers are described in two Bills in different words so that in the end there is slight confusion where there need be none, and if disputes arise, unnecessary money in lawyers' pockets.

At the present time in England it is easy for a person if he or she so wishes, to be admitted to a hospital other than the nearest one and I believe that it is possible on occasions for a person who wishes to go to hospital on the other side of the Border to do so. Take, for instance, the expatriate Scots (of whom there are many in the North of England) who, in spite of the fact that we have admirable doctors in many of our hospitals, mostly led by teams of Scotsmen, may prefer to go back to hospitals in their home towns. Can we be assured that it will be as easy for them to return to their home towns as to be admitted to a hospital in a neighbouring English town, and vice versa? Similarly, is it going to be possible for the nursing services to ignore the Border where it is more convenient for a nurse posted on one side of the Border to cross over and carry out her duties in a hamlet on the other side rather than have another nurse travel a greater distance? Those are the small points that I like to think can be looked into and overcome.

I have been told recently that while it may be possible now for a person who wishes to enter a hospital the other side of the Border from where that person is resident, there is a quite unnecessary complication should he or she die while in such hospitals and that this can cause extra work for the hospital and officials and unhappiness for the family concerned. This may sound a small administrative point, but it is a human one.

To end on a lighter note, my recollection from service in the Ministry of Agriculture is that whereas the Scottish Agricultural Department was responsible for almost all sides of such work as the Minister of Agriculture did in England, he was not responsible for animal health. It was deemed important by all that animal health should be looked after by one authority, not only in the interest of animals, but also in the interests of human beings because some diseases are transferable to humans. But here, in contrast, when you come to the more important subject of human health you find the opposite decision.

My Lords, only one or two of my points are points of principle and others are points of detail, but it would be of interest to this House if my noble friend could give us more information, if not today at least at the next stage of the Bill.

4.27 p.m.


My Lords, this Bill, so ably introduced by the noble Baroness, is truly revolutionary. It sweeps away the entire administrative structure which we have known for the past 23 years, a structure to which both the professions concerned and the public have become accustomed and which to most people appears to be working well. At any rate, I have heard few complaints in recent years, and those which have been brought to my notice will not be remedied by anything within this Bill. They were matters of small concern about the lack of staff in certain departments. As an example, I will talk of the shortage of physiotherapists in a hospital adjacent to my home where there is only one physiotherapist, a quite remarkable man, who has to deal each forenoon with some 30 or 40 patients in his own clinic and then has to spend the rest of the day giving his attention to patients in the wards. In a mining area a shortage of physiotherapists is a deeply felt want; but seemingly physiotherapy is no longer the fashionable occupation for young women which it was a few years ago and, in consequence, they are hard to come by.

We are not told where the existing administrative structure has fallen short to such an extent as to entail the setting up of a completely new structure. It might be helpful were the Minister to inform us on that matter when she comes to wind up the debate. I cannot help feeling that the Bill is in great part the outcome of that desire, so dear to the heart of administrators in general, for nice, tidy arrangements. To-day the Health Service, as we have been told and ought to know, is in three parts: the hospital service administered by the Hospital Boards and management committees; the general practice service administered by the executive councils, and the local authority health services administered by the local authorities. That would seem to me to be a logical division of work and responsibility. I can only suppose that the argument is that as they all deal with health they should all be under the one authority. But while they are all concerned with health, each deals with a different function. So I am prepared to gamble—something I seldom do—that on the taking over of these three services by the Health Boards it will not be long before each one is in a compartment of its own.

The purpose of the Health Service is to care for the sick committed to its charge. Unless it can be demonstrated beyond any reasonable doubt that administrative changes, even though they may provide a tidier structure, are to benefit the patient, they do not serve the end to which the Health Service is committed. We are told in the White Paper—and I quote: The reform of the Health Service administrative structure is a means of enabling the doctors, nurses and other health professions to work together with greater case and effect for the benefit of their patients and the whole community. Are we really expected to believe that merely by transferring administration of the three services to one board the doctors, nurses and other health-care professions will work together with greater ease and effect for the benefit of their patients"? I personally do not believe it. And I think that, quite unintentionally, it may cast a slur on the devoted work presently being done by doctors, nurses and all employed in patient care, and in that I include the administrative staff.

It is claimed that the bringing together of the hospital service and the general practitioner service will enable the general practitioner to have greater facilities available to him and a wider role to play. But to-day general practitioners have access to the hospitals, and many of them, as well as attending their own patients in their own homes and in their clinics, are doing a number of sessions each week in a hospital. They have in fact available to them all hospital facilities; but that of course cannot apply where, as in the Highlands, a doctor's practice is far removed from a hospital. In this connection it has been represented to me that, while the family doctor is, and should remain, the mainstay of the health-care system, the trend is for him to be pushed further and further away from his patient, and that if this trend continues the family doctor may in the course of time completely disappear, to the very great detriment of all in need of medical care. The feeling I understand arises from the very great extension of such things as health centres and other openings for doctors, where they can obtain employment on a sessional basis which provides a much less hazardous and a more natural way of life than that of the general practitioner or family doctor.

This is a trend that should, I believe, be carefully watched, for the disappearance of the family doctor would be a drastic disaster. No longer in illness would there be available that friendly man, whom we have all known and who knows all about us. Instead of his visiting people in their homes or receiving them in his clinic, the patient would have to attend the health centre where he would receive attention by a doctor who was completely strange to him—a doctor who knows probably nothing about the patient or the patient's family circumstances—and where, as a casual visitor, he can have very little interest. I remember being told some time ago by an eminent consultant that it was impossible to do the very best one could for a patient unless one knew his environment at work and in his home and all the family circumstances.

I wish to comment, and I will do so as briefly as I possibly can, on some of the committees and councils to be established under the Bill. First of all, the Health Boards. Their duty, as I understand it, is to administer the health services provided by the Secretary of State, who appoints the chairman and such other members as he sees fit, after consultation with town and county councils and such other organisations as he sees fit, including medical professional bodies. The White Paper states that members will be chosen for personal experience in administration. The Secretary of State has also said, as has been alluded to already, that a majority of each Board will be persons who are neither employed in the National Health Service nor members of any of the health professions. As one who is proud to have served on a local authority, I feel that they most certainly should be consulted. It is a pity that professional members of the Boards are not expected to give the collective views of their profession, which are to he obtained from the National Consultative Committees. I say that because in my experience a Board member giving views, whether his own or those of other people, gives a much better impression to the members of the Board than if those views are presented to them in a report from some other body. May I here emphasise something that has already been spoken of by the noble Lord, Lord Hughes. I wish to emphasise that it is of the utmost possible importance that both the professional and the administrative staff of the Health Boards should be of the very highest quality.

Then there is the Health Services Planning Council, which has the duty of advising the Secretary of State on the exercise of his functions under the Act. Here, the chairman, the vice-chairman, six of the Secretary of State's officers and an unspecified number of others are appointed by the Secretary of State. Among these others I hope, in view of their interest in the maintenance of high specialist professional standards, the Royal Colleges may be considered. Each Health Board also appoints one member, and so do those universities with a medical school. I note that the Council is to consult the National Consultative Committees on such occasions as may be prescribed. I wonder whether the House might be informed of the proposed frequency of such consultations. Should there not be almost continuous consultation between the two bodies?

Then there is a strange provision in the Bill which I simply cannot understand, to the effect that the Secretary of State can refrain from laying the Planning Council's annual report, or part of it, before Parliament, if he is satisfied that it is against the public interest so to lay it. The National Consultative Committees are of course the representatives of the professions engaged in care and treatment. These committees are set up by the professional bodies themselves. If approved by the Secretary of State they are recognised, and their function is to advise the Planning Council on the provision of services. The Secretary of State can appoint additional members. The Health Boards are to consult them on such occasions and to such extent as may be prescribed. A little more information as to what these words mean would be welcome, because they are repeated continually in almost every clause of the Bill. Professional teaching interests are to be represented by such members appointed in a manner to be prescribed, and in asking the noble Baroness whether she can give us some further information on the point, may I with deference remind her that the three Royal Colleges have each large post-graduate teaching interests with large schemes for expansion, and I would hope that they would be consulted. Then there are the health councils. These are set up by schemes from the Health Boards, and of course their function, as we have already been told, is to represent the interests of the public in the Health Service.

Finally, I would refer to the university liaison committees. Constituted by order of the Secretary of State, they have a duty to advise the Health Board in relation to the provision of facilities for undergraduate and post-graduate clinical teaching, for research, and for advising the Board and university concerned of any matter of common interest. The committee is to consist of such number as the Secretary of State sees fit, but not less than a third are appointed by the university, and an equal number by the Health Board, any other number being provided in the Order constituting the committee. May I again remind the Minister of the interests of the Royal Colleges in teaching and in research, in both of which they are actively and heavily committed, and ask that they be consulted in relation to the appointment of such number of other members as may be provided in the Order, and in relation to other matters concerned with teaching.

The Common Service Agency, which was referred to by the noble Lord, Lord Hughes, at some length, seems to me to be something completely new. Its purpose is to discharge such functions of the Health Boards as the Secretary of State may direct. This is a somewhat vague undertaking, but the Minister gave examples of what is in mind, and, following on the invitation given by the noble Lord, Lord Hughes, I hope the noble Baroness will enlarge on that. It will have been noted that the Health Boards are taking over from the local authorities the medical and dental inspection, supervision and treatment of pupils. This is something that I thought might be more easily conducted if left to the local authorities. After all, there are all kinds of arrangements, such as the fitting in of classes and inspections, which might be more easily undertaken by the education committee of the local authority. But the responsibility for the prevention of illness, and for care and aftercare, and the care of mothers and young children, vaccination, immunisation and the family planning service, should obviously go to the Health Boards.

My Lords, though, as the noble Lord, Lord Platt, has told us, the Bill has been generally accepted by the medical profession, which I understand has been generously consulted—although let me add that their expressed views have seemingly made little impact on the Bill now before us—and the representatives of the profession were, according to my information, listened to with that courtesy which we should expect, there remain matters of real concern which are still outstanding. One of them is that the disappearance of the hospital boards of management may place in the hands of officials too much authority for the interest of efficient management. In particular, in hospitals with under-graduate teaching commitments the need for strong professional and university representations cannot be over-emphasised. My Lords, my feeling is that this Bill brings into too great prominence the importance of administration, to the detriment of, and indeed to such an extent as almost to exclude, what is of far greater importance—the care and treatment of the patient. I hope it will never be forgotten that the outstanding purpose of the Health Service is patient-care.

4.44 p.m.


My Lords, this is a Bill the importance of which compels the interest of every Scotsman, and I listened with the greatest care to what the noble Baroness said when she introduced it. I was also most interested in the speech made by the noble Lord, Lord Hughes, and I look forward all the more to the speech to be made by the noble Baroness in winding up in the light of the anxieties which have been expressed by my noble friend Lord Strathclyde. In view of his great experience it will be interesting to see how things will work out, and I hope that many of the anxieties which he expressed will prove to have been unfounded. I also look forward to hearing what the noble Baroness will have to say to the points raised by my noble Border friend Lord Inglewood on the interesting problems which present themselves in rural areas which are separated only by a notional boundary like the Border. Perhaps the noble Lord, Lord Platt, was right when he said that in this matter Scotland is being treated in some ways like a guinea pig. I should like to join with him and my noble friend Lady Elliot of Harwood in welcoming Clause 8. For many years I was Chairman of the Scottish branch of the International Planned Parenthood Federation, and Clause 8 represents the fulfilment of something many social workers and social reformers have pressed for over a period of many years.

I have only two other small points to make which arise from recent experience I have had in being a casual visitor to a number of hospitals, mainly in rural areas. The first point concerns design. I am thinking of one particular hospital which is forecast, I believe, for Mother-well. Interested as I am, and in contact as I am, with the figures for future road traffic and the number of vehicles on the road, it is well to remember that even to-day the correct figure for parking facilities per bed is, I believe, four. In other words for a 400-bed hospital there should be parking facilities for 1,600 vehicles. This may sound odd, but in years to come it will not be, because one has to remember that not only are all the members of the staff to-day motor vehicle owners but there is a high percentage of technical people working in the laboratories, and so on, which help to swell the number. In addition—and here I speak from personal experience —in rural areas, where it follows that public transport is not generally available at all hours of the day and night and where visitors have to come from long distances, they must come in their own vehicles or be given a lift by somebody else. Thus the number of visitors' vehicles superimposed on the number of vehicles belonging to the staff of the hospital gives the large figure of parking space required per bed. I would go so far as to say that this is so important that in the future the actual selection of a site for a hospital may be in some measure controlled by whether or not access to it for the staff and the visitors who come to see the patients will be available.

The only other point I wish to make also concerns hospital design. This again springs from experience in the last year or two. Post-operative treatment is now advanced to such an extent that a hospital designed not many decades ago may have more beds than are required for the theatre accommodation. I believe it is well worth asking the Secretary of State, when he comes to consider the money to be spent, not on the construction of new hospitals but on existing ones, to remember that it might be wise to spend more money than might be expected on improving theatre accommodation, so that beds in surgical hospitals for which there are long queues of waiting patients are not kept empty, as many of them are at the present time. Beds are empty because post-operative treatment has released so many of the patients which the existing theatre accommodation feeds in to the wards. This means waste of space, waste of heating and waste of staff. If what I have said is worth considering. I hope it will be considered in the future, but in the meantime I look forward to hearing the reply to be made by the noble Baroness to this most interesting debate.

4.50 p.m.


My Lords, I should not normally have the temerity to intervene in a Scottish debate, even for a sentence or two, but I was stirred to do so by the closing words of the noble Earl, Lord Cromartie. Before I come to them, however, I should like to say how very much I welcome Clause 8. As someone who has been concerned for a very long time with family planning matters, I am very glad to see this recognition of the duties of the Secretary of State given a statutory place in the Bill. I also want to say one word in support of the noble Earl, Lord Cromartie, concerning allowances. These are referred to, according to the various bodies concerned, in Clauses 14, 16 and 18 and in Schedules 1 and 2. I should very much like to hear from the noble Baroness what is her attitude to the point raised by the noble Earl. The chairman of the Health Board is at long last to be paid, and I must say that I welcome this. I trust that this is also to be done, as I understand it is, in England and Wales. Up to now, persons who have given a tremendous amount of work and service in this sphere have had no recompense at all, whereas somebody going a few times a year to a committee concerned with gas or electricity, or a new town, has received quite handsome remuneration. It seems to me only right that we should tilt the balance a little in favour of those who do equally hard work in some of the social services.

I am somewhat concerned about the position of women members of these various bodies, and whether they will in fact be fairly treated under the arrangements for allowances. Although provision is to be made for compensation for loss of remunerative time, a housewife's time, as the noble Baroness knows, is usually regarded as non-remunerative. The fact that she may have to incur quite considerable expense to run her household adequately if she has to be away from home a good deal may not be covered at all. Merely to pay for domestic help, as I think the noble Earl was suggesting, is not necessarily satisfactory, if the provision is so hedged around in the regulations that, for example, the domestic substitute must be in the home on the particular day when the housewife is engaged in the committee; it may be far more efficacious and convenient for her to be there on some other day. The sort of provision made, that the allowances shall not be paid except in connection with the performance of such powers or duties, may preclude payments of that sort, and indeed has done so in other circumstances. It is not only a question of domestic help. Any woman who has been engaged in public life and tried to run a home knows that she has to pay more on convenience foods because they are quicker to cook, or expensive things like steak because they are quicker to cook. She may encourage her husband to take her out for a meal so that she does not have to cook at all, which is also more expensive. She has other incidental expenses which do not fall quite so heavily on the male sex. She has to have more frequent "hair-dos" or buy more hats if she is to appear to advantage in public. She has a number of additional expenses in public life which do not come under the heading of compensation for loss of remunerative time.

I hope very much that the noble Baroness, Lady Tweedsmuir, will take this matter seriously, because although one may be facetious up to a point, it is a very real difficulty. Particularly under the reorganisation of local government and of the Health Service, we shall be concerned with very large areas, no doubt in Scotland, and certainly in Wales, and this will mean that people will be away from home for considerable periods of time so that their family life is disrupted. Therefore, if we are to have women playing an adequate part, as they certainly should, in the reorganised Health Service we must look realistically at their circumstances. I have every confidence that the noble Baroness will do so and will bring her influence to bear on her male colleagues.

4.55 p.m.


My Lords, may I first of all apologise for being absent for a short time during the course of the debate? I had to attend a very important meeting representing noble Lords on both sides, and I could not escape it. Apart from that short time, I have heard the debate, and have enjoyed it immensely. I shall have a word to say about the last point made by my noble friend Lady White. I should like to begin by putting on record the appreciation of every one of us of the remarkable service which this Health Service has given to the people of Britain during the past 23 years. It is a Service of which we are entitled to be proud, and when one remembers that it did not get off on the best footing, it is amazing how the difficulties have been hammered out during this quarter century. I thought it only right that we should to-day record our gratitude that it was made possible.

I do not want to go into the Bill in any detail. The best tribute I can pay to the Bill as it stands is to say that normally with a Bill of this kind one is inundated with complaints from many organisations asking why they specifically have been left out and have not had specific representation. On this occasion, I had not until to-day, received a single complaint or inquiry about it; and I thought that was a remarkable tribute to the contents of the Bill. I give a little share of the credit for this to my noble friend Lord Hughes, who started off at a very early stage and who was associated with the Green Paper. But inasmuch as I have received this letter I think I must put it on record. The Royal College of Surgeons of Edinburgh feel that perhaps they have been missed out. They stress the important part that they have played in the course of the last 23 years and would like to feel that they will not be omitted when consultations come to take place. They feel that they have a contribution to make. I think in a way I am underlining part of the speech made by the noble Lord, Lord Strathclyde. So, having put that on record, may I now come to the Bill?


My Lords, if I may intervene for one moment, as this has been mentioned already about five times, may I point out that there is of course a Royal College of Physicians of Edinburgh.


Yes, my Lords, this is the great difficulty in legislation itself; that whenever one organisation is specified there are another hundred who want to know why their names are not included as well.




But all I was doing was confining my comment to one specific letter that I had received from one organisation. I think very much of the Royal College of Physicians of Edinburgh, under the care of Dr. Halliday Croome (I do not know if he is still their President), whose patient I was for a long time in the Royal Infirmary of Edinburgh. I am very grateful to him and I would not overlook his organisation.

I was about to say that this Bill lays down general guidelines. My noble friend Lord Hughes said that the real meat of it will be seen when the resolutions are put down and we seek to implement what the Bill contains: because if one goes not only through the clauses but even the opening Schedule to the Bill one finds that the members will be appointed as the Secretary of State for Scotland thinks fit. If you go to Schedule 2, you find that appointments will be made "as the Secretary of State for Scotland thinks fit". So throughout the Bill there is considerable power vested in the Secretary of State. I hesitate to think what might have been said if some other Government had introduced proposals of this kind. However, there it is in the Bill.

But I want to refer to Clauses 3, 10 and 20, because I think it is a tribute to the Bill that we can have three clauses in one Bill from the Scottish Office extending to eleven lines. This is the type of clause I can understand. Each contains very careful and important pronouncements. The first one is in Clause 3 which says: It shall be the duty of the Secretary of State to secure the provision of general medical, general dental, pharmaceutical and general ophthalmic services in accordance with the provisions…of the Act… Then Clause 10, which has only three lines, says: The Secretary of State shall have power to disseminate, by whatever means, information relating to the promotion and maintenance of health and the prevention of illness. Then Clause 20 says: In exercising their respective functions, Health Boards, local authorities and education authorities shall co-operate with one another in order to secure and advance the health of the people of Scotland. My Lords, no one would dissent from the provisions of any of these three clauses. They lay down clearly, specifically, and concisely what is intended by the Bill. We should like the noble Baroness, if she can, to spell out a little more clearly what in fact is contained in these three clauses. I am certain that your Lordships' House would be grateful to her if she could expand on them just a little, because they are so important in the context of the Bill.

May I come to Clause 14 which deals with local health councils. Indeed, I think this was a point made by the noble Baroness, Lady Elliot of Harwood, when she spoke about the interest of the consumer inside the Service. I was interested to read yesterday in the Guardian a report of a speech made by Professor Abel Smith at a Middlesex gathering. The Professor said that he was calling first of all for a complete transformation and reorganisation of the health services—something like what we are doing for Scotland this afternoon. If he was argu- ing any case at all, he was arguing that there ought to be a very firm provision for the patient and for the public inside this organisation. It was his feeling that too frequently in the past we have over emphasised the needs of those in the professions. We do not want to under estimate them; without them we can do nothing. However, it is equally important, if advice is to be given, that advice may be obtained from the layman and from those who are patients in the services.

I also think that when the Government are looking at this question they might well look at what power is to be given to these councils. I do not want in any way to be critical of consultative committees in other services, be it transport, electricity or consumers' councils and so on, but at the end of the day we all know that all they can say to the Minister concerned is, "We don't like it". They may make certain recommendations, but having gone that far they can go no further. What is felt in a very wide part of this field is that something more substantial might be done by these committees. All I ask the noble Baroness to do is that, when she is thinking over these appointments and what the committees themselves are going to do, she might also give a little thought to some responsibility being given to them. No committee dies so quickly as a committee that knows that it comes along and just talks and does nothing else. This gives them no encouragement. Therefore, I would ask the noble Baroness to look at that question.

I turn to Clause 17, which has already been commented on by the noble Lord, Lord Strathclyde. He mentioned this particular clause in a speech which I enjoyed enormously. I will not say that he gave an enthusiastic reception to the proposals in the Bill, but on this particular issue I think I agree with him. This central body apparently is to have considerable power; indeed, one wants to know just how far it can go. I should have thought that it would he the duty of the noble Baroness to say a little more about it. As one reads the Bill, the Council could in fact make recommendations contrary to all the other advice that has been received from other bodies. I do not think that is going too far. Like the noble Lord, Lord Strathclyde, I did not like, nor do I like, the concluding paragraph of that clause, which reads: Provided that, if the Secretary of State, after consultation with the Council, is satisfied that it would be contrary to the public interest to lay any such report, or a part of any such report, before Parliament, he may refrain from laying that report or part. I think that it is giving very extensive powers to the Secretary of State to say that he can deny Parliament the information with which this Council provides him. I do not know whether this power has ever been in previous legislation. If the noble Baroness can quote a precedent for a provision of this kind, I should be interested to hear it. I have not come across one. Even if she can, I think it is a very dangerous proviso to make in an Act of Parliament. In order to be convinced on this I should certainly need to have some very good reason from the Government Front Bench. When the noble Baroness conies to reply, I have no doubt at all that she will seek to explain this part of the Bill, and indeed the powers of this body, because I think this is one of the clauses to which we shall have to give particular attention in Committee.

May I now turn to Clause 19, which deals with the Common Services Agency. I should like to know just what work this agency is going to do. It seems to me that considerable power is included in the nine subsections of this clause and before one could agree to them I think one would need to know what effect they are going to have on the Health Service as a whole.

Those are some of the questions that worry me at the moment. As I said before, I have no doubt that when the orders come to be made then, and only then, shall we see what really are the proposals of the Secretary of State. I must say, in conclusion, that I think that, on the whole, the Bill goes along the right lines. I think that most people would agree—there are certainly some who would not—that to get into this one-tier form of service will be a great advantage. Indeed, so far as I can gather, there are many South of the Border who would like to have similar proposals covering their part of the country. Let them not be deterred, because I remember when the original Bill of 1947 was going through the Scot- tish Standing Committee, of which, indeed, the noble Lord, Lord Strathclyde, was then a member. There were in that Bill certain proposals which the Scots did not like. Indeed, one of them referred to the ambulance services in connection with the Health Service. Despite the fact that I was then a Back Bencher in the Government of the day, between us we ensured very substantial changes which gave Scotland better, and distinctly different, health services from the rest of the country. It is in this way that I look at this particular Bill. There can be no limit to the improvements we make. On the whole, I would certainly, on behalf of my noble friends, give a generous measure of welcome to the Bill.

5.9 p.m.


My Lords, I should like to thank the noble Lords, Lord Hughes and Lord Hoy, and all noble Lords who have spoken, and my noble friend Lady Elliot of Harwood, and the noble Baroness, Lady White, too, because I think that the House will agree that this has been not only a very interesting debate but a very constructive debate. After all, we have in the noble Lord, Lord Hughes, who spoke from the Front Bench opposite, one who has spent 25 years in local government and 12 years as chairman of a hospital board. There are also many others who can quote from personal experience, and it was from that experience that they sought to raise points which they believe will improve the Bill. It is for that reason that I am going to read carefully the Report of this debate. I think it needs reading, because there are some points of detail which I should very much like to take into account. However, I will now try to answer the main points which have been made.

First of all, I am glad that the Bill has been welcomed by everyone, except perhaps my noble friend Lord Strathclyde who called the Bill revolutionary and questioned whether it would do any good. I would say to him again, as I sought to say in my opening speech, that it is just because over the years those who work within the professions have felt that some change was needed from the tripartite structure, as it is called, to a structure which united the whole service, that first the Green Paper and then the White Paper came out and now there is this Bill. But I would certainly join with my noble friend in saying that when we talk about a Bill which is basically designed to alter administration, we have also to put ourselves in the position of the patient—who, my noble friend Lord Cromartie said, was not once mentioned—and try to see whether the services will be better as a result of this Bill.

The noble Lord, Lord Hughes, said that this is really a skeleton structure, that there will be a large number of orders and regulations and that great power is given to the Secretary of State. The noble Lord, Lord Hoy, also made that point. Indeed, it is so, and the first question I asked when I read the draft Bill was: "How many orders are there which are subject to the Negative Resolution procedure and how many regulations, and is there any precedent for the size and number of these provisions?" I was then referred to the 1947 Act. The whole object of having this large range of regulations and orders is to make the system flexible enough to adjust easily to changes in medical knowledge and practice, and, at the same time, also to allow Parliament the opportunity to comment on the contents of schemes or regulations.

The noble Lord, Lord Hughes, asked me about compensation. It is true that there was an Affirmative Resolution procedure in the 1947 Act, but compensation is now governed by regulations under Section 35 of the Health Services and Public Health Act 1968. That is why in this Bill the regulations are subject to the Negative Resolution procedure. I looked into the number of the various orders which it would be necessary for the Secretary of State to make in order to bring the Bill into operation, and I worked out that if we grouped them together, as many of them will be, we should have about 16 major orders and the same number of regulations, all of which are subject to Negative Resolution procedure.

The reason why some of the orders are not subject to Negative Resolution or Parliamentary procedure is this. If one looks at Clause 53, one will observe that it is only the major provisions which really come under this Parliamentary procedure. For example, there are such matters as determining or varying the area of Health Boards; constituting Health Boards or joint committees of Health Boards; transferring the rights and liabilities of existing bodies; transferring local authority property or staff, and dividing hospital endowments or local authority trust property between Health Boards. Those are the main subjects which we feel should come under Parliamentary procedure.


My Lords, may I interrupt the noble Baroness for one moment on this point? This is the reason I found it difficult to understand why some were to come before Parliament and some were not. Under Clause 13(8), which states that where the Secretary of State feels that it may be in the interests of efficiency that a joint committee should be established for the area of two or more Boards, he may make an order. There may be the most intense interest in, and perhaps even controversy about, whether that is the best method, but that will not come before Parliament. It seems to me that that is just as important as some of the matters which are to be subject to Negative Resolution, and that is why I could not understand the basis of division.


My Lords we shall probably all think that some subjects are more important than others, but on the example of constituting Health Boards or joint committees of Health Boards, which the noble Lord mentioned, it is perfectly true that Clause 13(l) is included in the Negative Resolution procedure under Clause 53, and that the others are not. The reason is that we felt that the constitution of a Health Board was really much the most important of the lot. In the case of a joint committee, one is really considering whether two Health Boards in different areas should co-operate together, perhaps on the provision of a specialist service or something of that nature.

The noble Lord, Lord Hughes, also mentioned the industrial health services. A deputation from the S.T.U.C. was received on November 19 to discuss various matters and they stressed the need for a comprehensive industrial health service. As the House will know, the Employment Medical Advisory Services Bill is at present going through its Committee stage in another place. That Bill provides for the replacement of factory doctors, appointed under the Factories Act 1961, by employment medical advisors working for the Department of Employment, who will have the duty of informing and advising the Secretary of State for Employment on matters concerning the safeguarding and improvement of the health of employed persons. We have not included a provision covering that subject in this Bill, partly because of the Bill which I have just mentioned and partly because we feel that to incorporate even wider responsibilities now might lead to considerably greater difficulties, if not to confusion. But it goes without saying that there must be close consultation between all of these bodies, just as I hope there will be consultation between the social work services and the new Health Boards.

The noble Lord, Lord Hughes, asked why there is no provision in the Bill for a health commissioner. We have had careful discussions on this matter and I can say that although it is true that my right honourable friend the Secretary of State for Social Services did not make the statement attributed to him in the public Press, I certainly expect him to make a Statement on this subject very shortly, possibly next week. Until that is made, I do not think I can usefully discuss the matter.


So long as he keeps on smiling when he makes the Statement.


My Lords, I am now thoroughly put off my stroke. My noble friend Lady Elliot of Harwood, with her experience of local government and of the local health authority (I think she was chairman, if I recall correctly), spoke particularly of the need for the social work departments of the local authorities to work very closely together with the Health Boards, and also, of course, the local education authorities. I should like to assure her that we are doing all we can to find out the best means whereby this can be done, and we have a working party which is studying it at the moment. It is a working party composed of representatives of the local authorities and of those within the Health Service. My noble friend also asked about the designated medical officer, and whether it would not be a good idea to have the equivalent of a nursing officer. I share with her exactly the same admiration for the nurses, in the very difficult and sometimes trying work which they undertake, but I think she can be assured that the nursing profession will certainly be brought into consultation—indeed, it is absolutely essential that they should be—within the Health Boards.

Now a word about the local health councils, which were referred to by both my noble friend Lord Cromartie and my noble friend Lady Elliot, and also I think by the noble Lord, Lord Hoy. My noble friend Lord Cromartie thought that the local health councils should have "teeth", and this point was echoed by other noble Lords who spoke. As I explained in opening this debate, the Health Boards will be obliged to consult the local health councils, and the local health councils, as will be observed from the terms of the Bill, will be able to bring any particular matter which they wish to raise to the attention of the Health Boards. If one looks at Clause 14(9) of the Bill, one will see that they will have considerable power, which will come in regulations, to obtain the information they require—for instance, on costs or on waiting lists at local hospitals, or anything of that nature. However, I will take great care to read again what has been said on this matter, because I quite agree that, as in another field, that of community councils and local government, it is very important that local health councils really do represent the consumer, and that everyone takes note of what they have to say.

Various noble Lords, notably my noble friend Lord Strathclyde, the noble Lord, Lord Platt, my noble friend Lady Elliot and the noble Lord who spoke last, asked about a memorandum from the Royal College of Surgeons; and I should also like to pay tribute to the Royal College of Physicians. As to the central medical committee, as it may well be called (it is now called the local consultative committee), Clause 16, which reflects paragraph 19 of our White Paper, clearly says that when the consultative committees, which are composed of the professional members working within the Health Service, have satisfied the Secretary of State that they have a committee as designated here under Clause 16, it must be recognised. In other words, its advice must be taken; and, of course, in this the advice of the Royal Colleges would certainly be taken, and also in connection with the appointment of the Health Boards. I should very much like to give that assurance here to-day, because I regard it as very important.

I was very glad of the welcome given generally to Clause 8, regarding family planning: I think it had a very wide welcome from all parts of the House. My noble friend Lord Inglewood said that he was speaking in a spirit of inquiry, and that he wished to find out whether there were going to be very great differences between the organisation of the English National Health Service and that of the Scottish Health Service. Of course, he will be aware that there has not yet been published a White Paper as such regarding England and Wales, and when I have my noble friend the Minister of State for Social Services sitting here listening to this debate—at least, he was here an instant ago—it is not for me to say in detail what is likely to be in the Bill. However, I could perhaps help a little on the general administrative hierarchy, because I think this is generally known.

It is proposed, as I understand it, that in England there will probably be 15 Regional Health Authorities, closely related, I understand, to the 14 existing Regional Hospital Board boundaries, and about 70 area health authorities outside London, with boundaries following those of the new local government counties and metropolitan districts or groups of boroughs; and that the Regional Health Authorities will be responsible for planning, the allocation of resources, the coordination of their activities and the monitoring of their performance. If my noble friend will leave it like that, as this is a debate on the Scottish Health Service, perhaps he will allow me to say only that we felt in Scotland, as indeed was felt by the previous Administration, that owing to the geographical size of Scotland and to her population—just over 5 million—the best solution for us was a single tier administrative system of Health Boards, about 14 in all; but, of course, we should have these professional committees, and (what I may call) these local consumer committees to advise the Secretary of State; and of course there would be the Common Services Agency and also the planning council.


My Lords, would my noble friend allow me to ask one very short question? Can she say that the English authorities in the North of England will be under any statutory obligation to consult with their Scottish opposite numbers?


My Lords, I am glad my noble friend has raised that point because I did in fact have a little whisper on the Front Bench to find out what was going to happen; but I understand that this has not yet been decided. So far as the Scottish Health Service is concerned, while one would hardly dare to say that they should go over the Border to consult with their neighbours in England and Wales, I would have thought it would have been only a matter of common sense to do so. My noble friend Lord Ferrier, who also welcomed Clause 8, with his experience in this particular field of the Health Service, said he felt it was very difficult that in some areas there were too many beds available and in some areas not enough. It is, I think felt that if all sides of the health profession can join together in the planning, management and administration of the Health Service, we shall have a very much better chance of overcoming this particular difficulty.

The noble Baroness, Lady White, in a speech with which, if I may say so, I had considerable sympathy, spoke of the ways in which one could attract married women, in particular, to work within the Health Service on some of these committees. She pointed out, quite rightly, that a housewife is not considered to be earning, and therefore the provisions in Schedule 1, which provide that remuneration shall be paid in respect of loss of earnings, will not apply. If I may say so, the noble Baroness gave some amusing examples of how expensive it is to be in public life: either you have to have more "hair-dos" or you have to have more hats, which of course make the "hair-dos" even more necessary. The question of women working part-time is a very difficult one, I must confess. They are not at the moment eligible under Part III of Schedule 1, or for domestic help, either, which was mentioned by my noble friend Lord Cromartie. This is a point that I should like to look at, to see whether anything can be done without making the provision too wide—because this is the real difficulty.


My Lords, may I interrupt the noble Baroness? May I ask her to look at the provisions applicable to women who are members of local authorities? As I understand it, certain financial provisions are made there which enable this difficulty to be overcome. Surely, if it can be done in the sphere of the local authority, it should not be too difficult to overcome the difficulty in this direction.


My Lords, I think the real problem is not the payment of allowances—travelling allowances or, indeed, subsistence allowances. The problem as put to me, which I think is still the case in local government, is the problem of a housewife who is not, strictly speaking, earning in some other occupation. She would of course be eligible for allowances of that kind in Part III of Schedule 3 but not for recompense for loss of earnings as such.


My Lords, I do not want to push the point too far at this moment, but I think the provision goes further, because certain local authorities, if not all, realise that if women are to be attracted to serve on these local authorities in a voluntary capacity then they have to put in other women to undertake their duties in the home. I think that in this respect women are compensated. All I would do to-day is to ask the noble Baroness to look at the matter.


My Lords, that I will certainly do, as I assured the noble Baroness who specifically raised this question, because I think it is important. We will see what can be done.

The noble Lord, Lord Hoy, in winding up this debate, asked me certain specific questions about certain specific clauses, and I am glad to say that he chose three clauses which are very short, which was a great help. He chose in particular Clause 3. This is the provision which retains, as did Part IV of the 1947 Act, the independent contractor status of the medical practitioner. Clause 10 concerns health information: for example, the Secretary of State at this moment has undertaken a campaign, which the noble Lord and others may have seen, of warnings against cigarette smoking—that kind of health education which is not, strictly speaking, prevention or cure but is of an informative nature.

The noble Lord then referred to Clause 20. This is really included in the Statute so as to make it absolutely clear that the social work authorities, the education authorities and the National Health Service authorities shall really try to work together; because, of course, there will always be a certain division between social work and the Health Services and it is most important that an administrative division should not in fact lead to a division in practice. That is why Clause 20 is there. I have referred to Clause 14 which refers to the powers of the Councils and I have said that although we will look at this, I am doubtful whether they could have greater powers. Then the noble Lord asked, concerning Clause 17(3), why the Secretary of State should have the power not to lay part of a report before Parliament if he thought fit. To give just one example, what was really in mind was if there was a question of a building contract which was subject to litigation, that kind of matter would not be laid before Parliament. It would be a very rare occurrence, and this clause was intended to make quite sure that when this happens it is not obligatory on the Secretary of State to lay such a matter before Parliament.

The last question the noble Lord asked me concerned Clause 19 and the Common Services Agency. He asked what the Agency would do. The kind of work that we had in mind was work such as that done by the Dental Estimates Board, the Drug Accounts Committee, the legal office, building contracts and that kind of thing, and the training and welfare of staff. There are a considerable number of responsibilities which could with advantage in fact be transferred from the Secretary of State's Department to the Common Services Agency.

My Lords, I did not wish to speak for too long, but I wanted to answer some of the major points which have been put; and I would again thank everyone who has taken part in this debate because it is at this stage, at the Second Reading of a Bill, that we rely on the experience of many noble Lords who may have spent a large part of their lives working within the Health Service or with local authorities. We are most grateful, and we shall take careful note of what has been said.

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