HL Deb 12 February 1973 vol 338 cc1243-59

2.55 p.m.

THE MINISTER OF STATE, DEPARTMENT OF HEALTH AND SOCIAL SECURITY (LORD ABERDARE)

My Lords, I beg to move that this Report be now received.

Moved, That the Report be now received.—(Lord Aberdare.)

On Question, Motion agreed to.

Clause 2 [General powers and duties of Secretary of State to provide services]:

LORD BROCK moved Amendment No. 1:

Page 1, line 19, at end insert— ("Provided always that nothing done by the Secretary of State under this power shall limit the existing freedom of a member of the medical profession in the performance of his professional duties.")

The noble Lord said: My Lords, I beg to move this Amendment concerning line 19 on page 1. As I explained at Committee stage, the Amendment then moved was intended to protect fully the clinical freedom of doctors. The original Amendment was rightly criticised because it included any profession, and it was pointed out that it would apply to architects, engineers and all those professional people who are involved in the Health Service. This is not what was intended, and the revised Amendment applies only to the medical profession. It seeks only to protect the clinical freedom of doctors, the absolute desirability of which would be accepted without question by most people. Certainly a patient undergoing treatment would not wish to think that what his doctor advises or proposes to do to help in his treatment should be in any way influenced or modified by edict from above—that is, from administrative or official sources.

At the Committee stage one noble Lord felt that the medical profession was asking for too much; indeed, he seemed to think that there was some sinister connotation in the Amendment. That is not intended in any way. The purpose of this Amendment is simply and solely to maintain the present clinical freedom accorded to doctors by long tradition. The primary object of this clinical freedom is to protect the patient. The benefit that the medical profession gains is solely related to the safeguarding of the interests of the patient, who is thereby assured of obtaining the treatment and management that his doctor advises from his own judgment and knowledge; and that is in no way intimidated or altered by the Administration. I cannot see that anyone can really object to this. It surely must be accepted that the doctor must not be directed or regimented in the actual treatment of his patients.

A difficulty lies in a proper definition of "clinical freedom" that would satisfy legislation. I realise that herein lies an element of weakness, but I am very willing to accept any improvement in the wording of the Amendment which would make it clearer. I repeat that the Amendment contains no sinister connotation and does not seek administrative freedom or preference. There is no evidence, intimation or even suspicion that the present Secretary of State has any but good intentions towards the clinical freedom of doctors. Indeed, the Minister gave the House an absolute assurance that the Secretary of State does not wish to interfere in any way with the clinical freedom of the medical profession in the performance of their professional duties. He observed that it was not thought necessary to write this into the 1946 Act and that the principle has never been questioned. We welcome this assurance by the Minister, but we have to think of a possible successor who might not have such good intentions. It could be that in future the medical profession might have cause to regret its reliance on good intentions only. After all, this Act will govern us for a very long time. For that reason, it would seem wiser to have this assurance of clinical freedom inserted into the Act. I beg to move.

LORD TODD

My Lords, may I ask my noble friend whether the word "medical" in this Amendment also includes "dental"?—because surely this would apply to the dental profession as well as to the medical profession.

LORD ABERDARE

My Lords, I was interested to see that the noble Lords, Lord Brock, Lord Amulree and Lord Platt, have returned to this matter and provided some wording which they hope will meet the object they are after, which is to preserve the clinical freedom of doctors. I should think, as does the noble Lord, Lord Todd, that they really mean the clinical freedom of the dental profession as well; and that is only one more difficulty about the Amendment to which I should like to draw your Lordships' attention.

As I tried to make clear at the Committee stage, the problem always is that it is almost impossible to define in legal terms what is meant by clinical freedom. This Amendment still goes further than I am sure is the intention of the noble Lord, Lord Brock. It is not, in fact, confined to clinical freedom and as it stands at present would apply to any duties carried out by a doctor in his professional capacity. It would, for example, preclude the Secretary of State or the health authorities acting on his behalf from issuing any limiting instructions to administrative medical staff about the performance of their administrative duties. It might conflict with the duties of the Secretary of State elsewhere in the Bill to make staff available to local authorities. It would even be possible to argue that the control or allocation of financial and other resources was in effect a limitation of the freedom of a doctor in the performance of his duties.

I mention these facts merely to underline the difficulty of writing clinical freedom (which we all understand and which none of us wishes to trespass upon) into this Bill. As the noble Lord said, on December 18 I gave an absolute assurance that the Secretary of State does not wish to interfere in any way with the clinical freedom of the medical profession, or the dental profession, in the performance of their professional duties. I am happy to repeat that assurance. But as I also said then, it is extremely difficult to define this concept in legal terms.

There are many other provisions in the proposals which I am sure will act to safeguard the clinical freedom of doctors. There will be medical members of the Regional and Area Health Authorities and of the district management team, and there will be strong professional advisory machinery. When we come to Schedule 3, on the subject of the Health Service Commissioner, the clinical freedom of doctors is specifically excluded from any action taken by him. I am sure there can be no doubt in the House about the vital importance of preserving a doctor's clinical freedom to act as he thinks best in the treatment of his patients. But I cannot advise your Lordships to accept this Amendment. There are overriding reasons why it is very difficult to put the concept of clinical freedom into the Bill.

LORD LEATHERLAND

My Lords, somebody has to come to the rescue of the medical profession here. It would be a good idea if we could accept the Amendment. I appreciate what the noble Lord has said on behalf of the Ministry, that administrative actions may be taken and orders given, and it would be necessary for the doctors to comply administratively with those orders and take part in those actions. If the word "ethical" were inserted between the words "existing" and "freedom" the clause would then read: … that nothing done by the Secretary of State under this power shall limit the existing ethical freedom of a member of the medical profession in the performance of his professional duties. The undertaking that the noble Lord has given, both on his own behalf and on behalf of the Secretary of State, is nothing with which we can quarrel. But it may well be that in 20 years' time the Secretary of State could be a quack, standing in this market-place with his bottle of medicine. He may have that kind of background. He may have a prejudice against the established regular medical profession. He might take advantage of an Act of Parliament which has not been perfected in the way that this Amendment would perfect it. I should like to support the Amendment.

3.3 p.m.

LORD BROWN

My Lords, we ought to think more rationally on this matter, and I support the Minister here. Spokesmen for the medical profession have on a number of occasions suggested in this House that they ought to have absolute freedom. I remember in the debate on the Rothschild Report the same comments being made. Nobody is in dispute with the principle which is being defended here; everybody wants the medical profession to have the clinical freedom that they have enjoyed in the past. But to insert in the Bill a clause which insists that any existing freedoms of the medical profession are maintained in the future would be absolutely absurd. Whereas in the past there might have been freedom to use enormous resources on some types of case, the choice to-day is either to save the lives of thousands of people by using these resources, or to save the lives of two by using similar resources in that direction. These decisions about priorities and use of resources can be important.

The medical profession cannot hope to escape altogether from some limitations on the freedom to use resources. They already have to face these facts like anybody else. There might be extreme cases where a high-powered medical committee advised the Government that the continued use of a certain drug was extremely dangerous, and the public might be extremely anxious about that. It might be felt that, in the national wellbeing, the use of the drugs should cease, at least until more facts had emerged. The Secretary of State would be in a position where he could not take action, in spite of the fact that the whole country was screaming for action. One could go on proliferating the number of cases under which the maintenance of whatever freedoms now exist is perpetuated in the future, and this would become increasingly embarrassing as time went on. To try to insert into the Bill an Amendment such as this, giving anybody maintenance of existing freedoms, is a pawn for the future of a very serious sort. This is not the way to safeguard the understandable and important desire of the medical profession for continuing the type of freedom which they have always had, and which everybody wants them to have. It does not need to be put into legislation in this form, with all the future embarrassments which might arise from so doing.

LORD PLATT

My Lords, I am in a somewhat difficult position: I can see both sides of the argument perfectly well. I agree with most of what the noble Lord the Minister said, and with what most of what the noble Lord, Lord Brown, has said. I was very interested in the support of the noble Lord, Lord Leatherland. I am quite sure, as my noble colleague Lord Brock has assured the House, that the medical profession is not asking for unlimited powers on any kind of action that it takes, administrative action, and so on, and that this should in some way be sacrosanct. That is not what we are asking for.

On the other hand, we have to look al the other side of the coin: there are the extraordinary words in Clause 2(1)(b): The Secretary of State shall have power … to do any other thing whatsoever which is calculated to facilitate or is conducive … to the discharge of such a duty. If the medical profession is not asking for unlimited powers, the Secretary of State surely is. It might be wise to put in some carefully guarded words which safeguard us a little. I agree with my noble friend Lord Todd that this matter should include the dental profession. I wonder whether the Minister would accept a slight change of wording of this form. This is not the time to make drafting Amendments, but the existing freedom of a member of the medical profession in the performance of his professional duties should be amended to include the words, "medical and dental". The words, "professional duties", should be replaced by "clinical duties". Would that be more acceptable?

LORD AUCKLAND

My Lords, one of the main difficulties about the whole of this Bill is that nobody wishes to criticise the medical profession unnecessarily. We are rightly very proud of the medical profession in this country. Speaking as one of many laymen present, it seems to me that this Amendment is too widely drawn. What exactly do we mean by the term "medical profession"? Do we mean doctors who are fully qualified as well as doctors who are not fully qualified? It is necessary to have some line drawn here. Does this term apply to a medical registrar or to a fully qualified doctor? It seems there is some justification for the Amendment applying to the latter, but it may be questionable whether it should apply in full to the former.

LORD DOUGLAS OF BARLOCH

My Lords, it may be that the wording of this Amendment is open to criticism. I do not propose to offer some formula to solve the problem. It is a mistake to regard an Amendment of this kind as being designed to confer some benefit or privilege upon doctors. This is a totally wrong outlook. The purpose of this Amendment is to protect the patient, to make sure that he is not subjected to some treatment which is directed from Whitehall and has no alternative outlet. There can be great differences about the advisability of one treatment or another, but in the end it is the patient who must be considered and who, if there is doubt, has to make the decision whether he will have the treatment or not. But if it cannot be offered to him, then he is deprived of this opportunity.

3.11 p.m.

BARONESS SUMMERSKILL

My Lords, I have yet to hear any evidence that the clinical freedom of the doctor is in jeopardy. None of the doctors who have spoken has told me this. I am thinking of the case of prescribing. It has always been said that doctors must have their clinical freedom; there must therefore be complete freedom to prescribe as they think fit. In consequence, the pharmaceutical bill of the National Health Service has now reached a colossal amount because the doctors are using their clinical freedom to prescribe proprietary medicines, all of which bring colossal profits to the pharmaceutical industry but do not necessarily bring profit to the patient.

As an example of this, on Friday in another place an effort was made to ensure that an insurance scheme was set up in order to protect the patient who might suffer in consequence of wrong prescribing—by "wrong prescribing" I mean "unwise prescribing". I was very impressed with the fact that the first two Members who rose—in the other place one has to declare one's interests—said they had an interest in the pharmaceutical industry. They then damned the Bill, and the Bill was finally negatived because it is possible in another place for one individual just to say, "Object!"—in such a way that he cannot even be identified. I almost suspect that perhaps the pharmaceutical industry had its voice in that. So when I listen to doctors pleading for more freedom, I think we should also point to cases where doctors have abused that freedom by prescribing drugs which are not very effective and finally find their way into the medicine cupboards of the patient.

LORD BROCK

My Lords, first of all I would tell the noble Lord, Lord Todd, that my Amendment included the dental profession. I should like to thank the Minister for his reply. I think it is clear from the discussion that the definition of "clinical freedom" remains very difficult. I doubt whether in this Report stage we shall achieve a successful definition which would commend itself to many people. I thank the Minister for the repetition of his assurance on the opinion of the Secretary of State and his respect for clinical freedom. If my noble colleagues agree, I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

3.14 p.m.

THE EARL OF MANSFIELD moved Amendment No. 2: Page 2, line 7, after ("and") insert ("(except in Greater London)").

The noble Earl said: My Lords, I beg to move Amendment No. 2 standing in my name and that of the noble Lord, Lord Garnsworthy. If it is convenient to your Lordships, I should like also to speak to Amendments Nos. 3, 4, 5, 6 and 7, which go to the same matter. Clause 2 of this Bill in effect transfers the responsibility for the provision and running of the London Ambulance Service from the Greater London Council to the Secretary of State. The Council's specific powers, contained in Section 43 of the London Government Act 1963, a mere nine years ago, are repealed in Schedule 5 to this Bill. This series of Amendments is designed to restore the position to what it is now under the 1963 Act. Your Lordships may see that the wording is identical to that which I moved at the Committee stage of this Bill. On that occasion I was most powerfully reinforced by the noble Lord, Lord Garnsworthy, and several other noble Lords added their support. At the end of the debate my noble friend Lord Aberdare undertook to have discussions with me to find out what might be achieved by way of a compromise, and in consequence of that undertaking I withdrew the Amendment. Discussions took place. They were fruitless, and I believe it is no breach of confidence to say that the matter rapidly resolved itself into one of principle and there was no room for compromise at all. There the matter rests. The Amendments have been retabled and your Lordships will see that they have in effect very much what I might call a Cross-Bench flavour. This, one may think, and indeed it is true, reflects the great sense of unease that there is over these provisions throughout your Lordships' House.

It is not my intention to repeat the arguments used in the previous debate. The case for preserving the status quo rests, I suppose, on two premises. First, there is the matter of principle. I suggest to your Lordships that it is right in this case to leave well alone unless there exists a compelling, or at least a convincing, reason for change. No such reason has been made out up till now. Indeed, my noble friend Lord Aberdare on the last occasion [OFFICIAL REPORT, December 18, col. 846] went out of his way to say how efficient and well managed the London Ambulance Service is. It is true that my noble friend claimed that co-ordinated management might make for a closer working relationship in certain fields he mentioned, such as accident or emergency cases. That may be so, but reorganisation may well have the opposite effect to that which is intended. I am anxious to avoid pointing the finger of recrimination in these matters, but I believe that the Greater London Council has for some time been pressing the Department to experiment with an emergency cardiac service, and it has commissioned a study group to look into the matter. That is an example, I suggest, of the very forward-looking way in which the Greater London Council discharges its duties under this Part of the 1963 Act.

The second plank of my argument is this. Even if this is a matter of principle, and it may be—that is to say, that it is right to remove or transfer the Ambulance Service from the Greater London Council—it is equally right that in this case an exception to this principle should be made. One feature of the debate which we had at the Committee stage of this House was the state of ignorance of many noble Lords, and I include myself among them, as to the details of how the service would be run in the future. This was not through idleness or, I hope, stupidity on our part; it was because the details were not there to be read or listened to. Some of them were provided by my noble friend in the course of the debate. It is no discourtesy, I hope, to him to say that one's sense of unease was only increased as these details were unfolded.

Let us take some of them. First, the joint management committee to be set up by the four Regional Health Authorities. It is answerable to whom, my Lords? No details were given as to who is to set it up, or how. How is the service of a great city such as this to be organised and run by a hotchpotch joint committee such as was described? As to staff, my noble friend said that they would be transferred completely. But there is a great deal of overlap. In an organisation such as the London Ambulance Service, many of the staff give of their expert time and experience to matters other than ambulances. Would they be transferred with half a job to do, or would the ambulance service be transferred without them and they would be left where they are? One does not know.

My noble friend said that the design and maintenance and housing of vehicles would be transferred, in the sense of course that the vehicles would be physically transferred, but the depots where they are kept or maintained either would be transferred or would be shared under some sort of agency arrangement. But what if the Greater London Council were unwilling or unable to set up an agency? Would some sort of line be put down the middle? One just does not know. What is perfectly certain is that whatever the expense, eventually a complete new infrastructure would have to be erected—new buildings, new arrangements and new people. It seems to me, and I think to others in your Lordships' House, that there is a lack of thought and perception in the minds of the Government as to what is to happen. One thing I suggest is plain so far as the London Ambulance Service is concerned: the arrangements will be more cumbersome, they will certainly be more expensive, they may well be less efficient. But the most important matter so far as I am concerned is the matter of accountability.

At the moment the Ambulance Service is run by a committee which is answerable, electorally speaking, to the people of London who, every so often, have to put their confidence (or the lack of it as shown by the results) in the people they send to County Hall. If this provision goes through, then the running of the London Ambulance Service will be vested in a body which will be entirely remote from the people of London as a whole and not answerable to them in particular. I beg to move.

3.23 p.m.

LORD ABERDARE

My Lords, I am happy to confirm what my noble friend Lord Mansfield said about what occurred at the Committee stage, and I am grateful to him for having come round to speak to us at the Department. I can also confirm his account of what happened on that occasion. Although I was able, hopefully, to offer some help in assuring my noble friend that we would if possible associate members of the G.L.C. with the running arrangements of the ambulance service when it was transferred to the National Health Service, I agree with him that we finally parted on grounds of principle.

We cannot get away from the fact that the whole purpose of this Bill is to unify within a single management structure all three arms of the Health Service which are at present seperately organised. This does not mean that we are criticising any of the Health Services that exist at present. My noble friend said, "Leave well alone". But if we were to adopt that principle we might as well leave the whole system as it is, because there are many medical officers of health, and many local health authorities, who are doing an excellent job. But what we are trying to do with this Bill, in conjunction with the Local Government Act, is to provide from April 1, 1974, a totally new working structure of local authorities and the National Health Service which we believe will mean an improvement in all these services in the future.

Although some of us may regret the division between the health services and the social services, it is inevitable if we decide that we are going to keep a separate National Health Service and not put it under local authority control. So it becomes a matter of drawing a dividing line between the two. Both the last Government and the present Government have seen the correct division to be between, on the one side, those services that call for medical and nursing skills and, on the other, those that do not. This leads us inevitably to the transfer of the ambulance service, which has always been part of the local health services, to the National Health Service. I believe that the arguments for the change are very strong indeed.

I feel sure that if any of your Lordships had the misfortune to fall ill or to suffer an accident you would wish to feel that from that moment you were in the care of the National Health Service, and the first part of the health services that would come to your assistance would be the ambulance service. To my mind, this means that the ambulance service should have the very closest links with the doctors, the nurses and the hospitals who will eventually treat that particular casualty. The ambulance services are conveying sick and injured people—that is their function—and it is essential that they should be integrated with the hospital and the other health services, and should feel that they are a lively part of them. In many parts of the country I have seen this future good practice being put into effect by ambulance crews being invited into the hospitals to see what happens to patients after they have been brought there. In particular, the ambulance services have a very important role in the hospital accident and emergency departments, especially with the rising toll of motor car accidents, and it is all the more important that there should be the closest links between the ambulance service and the hospital.

In these circumstances, I believe the development and improvement of the ambulance service is best planned in conjunction with those who make use of it—the hospitals and the doctors. Equally, in the new organisational set-up it is important that the voice of the ambulance service is heard within that set-up; in other words at the district level when the district management team is considering matters affecting the ambulance service, particularly the accident and emergency services. It is important that the ambulance service is an integral part of the district and should have its voice heard.

It is for these reasons that the ambulance service as a whole wants to become a part of the National Health Service. I suggest this is equally true in London—indeed, possibly more here than elsewhere—because of the very complications that exist in London: the toll of motor accidents; the complicated distribution of hospitals and accident and emergency departments; the range of places where patients live, some coming from outside London and requiring transport into London, so that close co-ordination is needed. The London Ambulance Service has been concerned only with accidents and with the movement of patients for hospitals and general practitioners. It has never had duties to perform in connection with the Social Services Department, and therefore it is only logical that it should stay as part of the health services.

My noble friend mentioned two main grounds of principle for his Amendment. First, he said: leave well alone. Well, I have tried to explain why I think the ambulance service should be an integral part of the National Health Service. Secondly, he urged that we should make a special exception in the case of London. But there are very real difficulties in doing this. Subsection (2B) of his Amendment No. 3 is completely out of line with the rest of the Bill, which provides that local authorities shall cease to be local health authorities and deletes the reference to such authorities. It would thus apply to the G.L.C. provisions that are being repealed elsewhere in the Bill. The noble Lord no doubt has in mind the thought that Amendments would be made preserving these provisions in relation to the London Ambulance Service; but this would give a very odd result. We should be preserving local health authority provisions for the benefit of an authority—the G.L.C., which is not and never has been a local health authority—at a time when elsewhere local health authority functions are disappearing.

My noble friend also stressed the question of accountability. If one looks at the financial provisions which he is proposing in a later Amendment, No. 94, one sees clearly how difficult a matter this is. The normal arrangements for rate support grant could not apply. The alternative which my noble friend proposes is that the whole cost of the Ambulance Service provided by the G.L.C. should be met by the Secretary of State. This surely cuts across the normal principle of local authority finance, and indeed across the normal principles of financial accountability and responsibility. The G.L.C. would have a blank cheque with which to draw on central Government funds, and great as our respect is for the G.L.C., I do not think it is right, in the face of conflicting priorities, that it should be exempt from the normal financial discipline of having to find the resources fur a Service such as this.

My noble friend's Amendment would mean that the G.L.C. would call the tune and the Secretary of State would pay the piper, a financial principle to which I could not advise your Lordships to subscribe. My noble friend may feel that these are technical difficulties, but in my view they are not. They go to the root of his suggestion, and I do not believe that the principle of what he proposes has been really thought through.

If your Lordships were to agree to this Amendment we would have a situation in which, except in London, the Ambulance Service throughout the country would be an integrated part of the National Health Service. In London it would be run by a body, the G.L.C., which would have no health functions. Moreover, we should have a situation where in London its work would be exclusively for the N.H.S., yet that service would have no financial control over its operations. This seems utterly illogical to me and I cannot believe it would be in the best long-term interest of the Ambulance Service. I therefore hope that your Lordships will not accept the Amendment.

3.33 p.m.

LORD GARNSWORTHY

My Lords, the House will appreciate the care with which the noble Lord, Lord Aberdare, replied to the remarks of the noble Earl, Lord Mansfield. Nevertheless, I have the feeling that many of your Lordships will share with me regret that the consultations that have taken place appear to have led absolutely nowhere. I do not exaggerate when I say that when the matter was before us in Committee there was every likelihood of an Amendment such as this being carried had the matter gone to a Vote. On that occasion I sought to persuade the noble Lord, Lord Aberdare, to agree to consultations, and the Vote was thereby avoided; it may well be that the position would have been better had I not so pleaded on that occasion.

The noble Earl, Lord Mansfield, as on the earlier occasion, made a speech of great moderation and persuasiveness. He based his case to-day, as on the previous occasion, on very strong arguments indeed. Most of your Lordships will recall the arguments he adduced in Committee and the virtual unanimity that existed, at any rate among those who took part in that discussion. We have been waiting this afternoon to hear from the noble Lord, Lord Aberdare, something he has not been able to tell us, as he was not able to tell us in Committee—namely, what possible gain will the people of London have as a result of transferring this Service? The reason he gave was the underlying object of the Bill, which, he said, was to unify the Health Service. But the object of the Bill is to improve the N.H.S. for the people of this country, and if it will not achieve that, then we must look very carefully at the proposals for change in the machinery of control.

Nobody will dispute that the G.L.C. is a democratically elected body and that at such times when there are elections the people can question the candidates about the services for which they are responsible. But we have no indication that under the Bill as drafted there will be any suggestion at all of democratic control of the Ambulance Service in the Greater London area. The noble Lord may play with the fact that the G.L.C. is not to be a Health Authority. I agree. It is not, and not since its inception has it been, a Health Authority. In so far as it has been suggested that the Ambulance Service needs to dovetail into the general set-up in the detailed manner in which the noble Lord described, he himself said in Committee how well the London Ambulance Service was doing precisely that.

Let us take a look at the machinery which the Government are setting up, a subject on which the noble Earl, Lord Mansfield, touched. Consider the number of Area and Regional Health Authorities involved. In Committee the Government said that one Regional Health Authority would be made responsible for the whole of London. The Government themselves seem to have appreciated that this machinery falls down badly, for they propose that control should be in the hands of a committee representing all the authorities concerned. I asked in Committee whether a provision to this effect would be put in the Bill and the noble Lord replied "No", though he said he could give an assurance that it would happen.

But what advantage is there in this complicated machinery that exchanges a simple form of democratic control for what I would call a mess of pottage? The noble Lord said that London would have, as it were, carte blanche to spend what it liked on the Ambulance Service. I can see no difficulty that could not be overcome so far as finance is concerned, for the Government appreciate that there is a distinction in this great metropolis; and this is one area of the country which perhaps could quite successfully retain democratic control over this Service. I ask the noble Lord again, because the House is entitled to know, at what point is the present Service failing? At what point can we anticipate that there will be any improvement at all?

The noble Lord felt sure that if any of us had the misfortune to fall ill we should wish to feel that we were in the care of the Health Service. I do not think any of us will worry about in whose care we are so long as we get to hospital quickly. What criticism can be voiced of the Ambulance Service as it exists at the present time? I sincerely hope that the Government will be persuaded by your Lordships that they ought not to stand on what they say is the principle of securing a unified Health Service. The most important thing is that we have something that is working really well, whose efficiency nobody questions. Nobody has given any indication of what improvement we can expect. If the Ambulance Service is transferred to the National Health Service, the facilities of the Greater London Council will still be used and precisely the same staff will be operating them. I hope that the House will give its support to the Amendment moved by the noble Earl, Lord Mansfield.