§ 3.2 p.m.
§ Moved, That the Bill be further considered on Report.—(Lord Aberdare.)
§ On Question, Motion agreed to.
§ Schedule 1 [Additional provisions relating to new authorities]:
BARONESS SEROTA moved Amendment No. 33:
Page 50, line 9 leave out ("as he thinks fit") and insert ("being not less than 15 and not more than 25 of whom not less than one third shall be appointed by the local authorities within the area of each Regional Health Authority, namely the metropolitan county councils, the county councils, the metropolitan district councils, the Greater London Council, the London borough Councils and the Common Council of the City of London")
§ The noble Baroness said: My Lords, I beg to move Amendment No. 33 on the Marshalled List. There now has been time to consider more carefully the detailed reply which the noble Lord, Lord Aberdare, made at the Committee stage to the many arguments that have been advanced for including the knowledge and experience of a reasonable number of elected local authority members in the strategic health-care planning and co-ordinating tasks of the Regional Health Authorities, and for the need, particularly in some cases, for the Regional Authorities themselves to be rather larger bodies than the normal 15 members envisaged in the White Paper. At that time I was encouraged, particularly by the noble Lord's undertakings to the noble Lord, Lord Brooke of Cumnor, and the noble Viscount, Lord Amory, to reconsider certain aspects of the size and composition of the Regional Health Authorities in the light of our debate in 1403 Committee, to the point of withdrawing my own Amendment. I also took his point about the practical difficulties in some of the particular proposals we had made on the suggested method of joint local authority and Area Health Authority appointments and on the range of local authorities which should be involved in making them.
§ I must also take this opportunity of thanking the noble Lord for meeting us before this stage of the Bill to see whether there was any way of resolving our differences over the issues of principle as well as the practicalities involved, as was suggested in Committee particularly, I recall, by the noble Lord. Lord Vivian. However, having had that discussion, I was not really surprised to find that the Government were not themselves putting forward any Amendment to their original proposals in Schedule 1 as they seem to be absolutely, in fact almost obstinately, committed to their original concept of giving the Secretary of State complete power to select and appoint all the members of the Regional Health Authority in addition to the chairman, albeit after consultations with the interests specified in Schedule 1 to the Bill, thereby completely disregarding the arguments that have been advanced both inside and outside Parliament to the contrary.
§ Since we have already discussed the composition and the functions of the Regional Health Authorities at some length during the Committee stage on a range of Amendments submitted by a number of noble Lords, I will not attempt to-day at Report stage to repeat again in detail the basic objections we have to the Government's approach which were shared by other noble Lords and are already on the Record. We cannot, however, let this opportunity pass to-day without at the very least seeking to modify, if not to change, the Government's already out-of-date approach to these crucial questions which will undoubtedly have a lasting impact on the pattern and the quality of our health-care services in the future. We still find that their absolute doctrine of delegation downwards and accountability upwards has almost become the slogan, if not the symbol, of the unified Health Service which is now quoted automatically 1404 against any alternative form of reorganisation that is suggested; and their determination to separate the management of the Health Service completely from any form of public representation dominates, I would say almost to the point of obsession, the preparation and the planning of the new organisation through a rigid and a bureaucratic system of direction, control, monitoring, described in the Grey Paper from the Central Government machine downwards through a tight system of ministerial appointments to these major controlling bodies, who in their turn appoint all but four of the members of the Area Health Authorities.
§ In our view, it denies and precludes any element of direct or indirect democratic participation and co-operation of consumer or staff interests in the policy and decision-making process at the regional level, the area level or indeed the district level. Surely a social service such as the National Health Service must above all be adaptable and responsive to public needs and include and utilise local knowledge and experience of the direct care-giving level to the full, both in the provision of day-to-day services and at the strategic planning level where the overall decisions on objectives are taken, and where priorities, including resource allocations, are to be made. No attempt whatsoever, in our view, to devise a counter-bureaucracy to promote greater public understanding of the problem and the achievement of the National Health Service can ever be a substitute for real participation.
§ We are therefore seeking in this Amendment to persuade the House to provide at the least for an inclusion of not less than one-third of members of Regional Health Authorities to be appointed by the named local authorities within the areas of the regions, and also to allow for greater flexibility in the size of the 14 regions in order to reflect more fully the very real differences in the characteristics of their constituent areas and the actual number of matching local authorities which will be providing the complementary social services, including those with general planning functions. The health regions, as several noble Lords will know from the White Paper, will vary, on the one hand, from Region 14, which includes the county of Lancashire, with its population of 1,300,000 people, 1405 plus the ten metropolitan districts in Greater Manchester, comprising populations of between 200,000 and 300,000, to Region 4, which covers the counties of Norfolk, Suffolk and Cambridge with their much lower but far more scattered rural populations. Surely, it would be only sensible to allow for a larger membership for the former, if only to lighten the burden of members who, apart from the chairman, will be giving only voluntary and unpaid service at regional level. In our view, the local knowledge of elected local authority members, of the area they represent, of the people they represent, and of the complementary social services that they will be providing, is essential to the co-ordinated planning of integrated health-care programmes at regional level.
§ While the House is considering this general question of the composition of the Regional Health Authorities it might perhaps be convenient if I spoke also to Amendment No. 34, which follows this one, which is designed to include Area Health Authority members among the list of bodies to be consulted by the Secretary of State before he makes the appointment. When this question of including the knowledge and experience of Area Health Authority as well as local authority members in the deliberations of regions was raised in Committee, the noble Lord, Lord Aberdare, indicated that this would be achieved by arranging for the Regional Health Authority to be represented in the Area Health Authority membership of the joint local authority Area Health Authority consultative committees that are to be established under Clause 10 of this Bill.
§ Once again it seems that the policy of the Government is of delegation downwards, and they simply do not appear to trust those who will be in closer touch with the services at district and at area level and who surely should be allowed, if chosen by the Secretary of State, to contribute their practical knowledge of the working of the local health and community services upwards into the deliberations of the Regional Health Authority.
§ I cannot believe that the proposals we are making in these Amendments are either dangerous or unwise. On the contrary, we think that they could only benefit the regional planning of our health services. Nor could we accept that they 1406 would result in the Regional Health Authorities becoming a "collection of minorities", as I think the noble Lord, Lord Aberdare, described them—indeed, as he feared—because those of us who have served on Health Service bodies and other public bodies know that this is simply not the way the system works in practice. Every new group that is committed to the management of a public service such as this in my experience quickly develops its own sense of corporate identity and its own sense of corporate loyalty, and to suggest that that can only happen if the Regional Health Authorities are composed entirely of Government appointees is, in my view, to fly in the face of all our experience.
§ I read with great interest yesterday in The Times the article by Professor Elliott Jaques on the planning and management of the National Health Service; but I am afraid that I cannot agree with the view he takes that to mix public representatives on accountable managerial bodies is to create confusion and irresponsibility. Nor can I believe that any noble Lord—and there are many Members of this House who have served on local authorities—would ever agree with such a conclusion. If we were to, it would be the end of democratic government as we know it in this country; and I for one, having served on a number of different kinds of local authorities and also on health and service bodies over a period of years, simply do not believe that it is impossible to provide efficient, accountable services and also encourage their development through a vigorous democracy.
§ Therefore I move this Amendment in the hope that it will receive wide support in the House, and that the Government will have the courage to depart from the somewhat rigid doctrine of complete separation of executive function and management function which they have adopted so far, and will agree that at least at regional level we should include the relevant local authority members, to enable them to contribute their knowledge (as I said before) both of the public they represent and of the services they provide to the strategic planning function of the region. I beg to move.
§ 3.15 p.m.
§ LORD BROOKE OF CUMNOR
My Lords I wonder whether it would be to the convenience of your Lordships and the 1407 Government if I were to speak to Amendment No. 34 so that we might then have a general debate on Amendments Nos. 33, 34 and 35. I am quite willing to take Amendment No. 34 separately, but it seems to me that it would be a saving of time if we could take them together; otherwise we should have to go twice over a great deal of the same ground.
I am afraid I cannot share the liking expressed by the noble Baroness for the idea that one-third of the members of a Regional Health Authority shall be appointed by somebody other than the Secretary of State. I appreciate the force of her arguments, but I can see this matter also from the point of view of the Secretary of State. These Regional Health Authorities will have immense power; they will supervise the spending of enormous quantities of public money, and it seems to me to be not unreasonable in those circumstances, as all the money will be coming from the Exchequer, that the Secretary of State himself should have the right to appoint all the members of the Regional Health Authority. I feel certain that some of these Regional Health Authorities will need to comprise more than 15 persons, and in that respect I share the view of the noble Baroness; but in the Amendment standing in my name and that of my noble friend Lord Amory we have dealt with that point.
We are not proposing that any members of the Regional Health Authority should be appointed directly by the local authorities within the region. Our Amendment would establish three points: first, that there must be some persons on the Regional Health Authority who are local government men. We cannot accept the view that all of those who run the National Health Service at regional level should be management "kings" or "queens" and should have no special link with the people whom the hospitals and other medical services are going to serve. That is our first point.
The second point is that there should be four OT more such persons in each Regional Health Authority, and I am contemplating that it will be the Government's decision in the end to have 15 as a minimum, but in a number of cases to go above 15 in a numerical membership of the Regional Health Authority. Thirdly in our Amendment there is the point which I think was not mentioned at 1408 all in our debate on the Committee stage of the Bill, namely, that those who form the local authority tranche, so to speak, of the membership of the Regional Health Authority should be, at the time of their appointment, members of local authorities within the region. I feel quite sure that it would not be so satisfactory if the Secretary of State were to appoint people simply because they were good local government figures if in fact they were not, at any rate at the time of their appointment, serving in local government within the region.
What I think has bedevilled a great many of these debates and maybe has led to misunderstanding of the Government's purpose is the view set out in an uncompromising manner in paragraph 106 of the White Paper, which seems to cut off the members of the Regional Health Authority from any capacity or any duty to consider the interests and desires of the public in the planning which they are undertaking as a Regional Health Authority. Perhaps I may read again one or two sentences from the paragraph in that White Paper, in which the Government saidThe expression of local public opinion can be catered for in one of two ways. It can be done indirectly by including in the membership of the health authorities local people serving in a representative capacity. Or it can be done more directly, through bodies specially set up for this purpose, with direct links to the authorities. The Government prefer the second course. It allows each of the interests—management and the community —to concentrate on its own special function.…There it is said in the plainest terms that the desire of the Government is to have a Regional Health Authority which will consist of management characters; and they will be, as it were, checked on by the community health councils who alone are to represent the interests and desires of the public. This is what worries us exceedingly. I have great faith in the ability and imagination of Secretaries of State—especially the present one—to seek out and appoint good men to a Regional Health Authority, but our Amendment seeks to impress upon him through the force of law that there must be a direct element on the Regional Health Authority which is specially cognisant both of the local authority services and the public interest in the whole matter.
1409 I could understand the Government framing their plans as they have done if none of the services which will be taken over by the Secretary of State and the Health Authorities had ever been local services, but all the personal health services have been run exclusively by local government up to now and that is where one finds the knowledge of them. That is why it is imperative for the Government to include in the membership of the Regional Health Authority those who have experience of local government work and who can positively help the chairman of the Regional Health Authority and the Secretary of State in bringing the new system into successful existence and guiding it aright.
Probably there is not a great deal of difference between my noble friend Lord Aberdare and my noble friend Lord Amory and myself on this matter, but there has hitherto been an unwillingness to agree to any change in the Schedule, which lays down how the Secretary of State shall proceed to appoint a Regional Health Authority. I beg my noble friend Lord Aberdare to consider again whether there is not some means by which he can do something to satisfy the local authority associations—the four of them are unanimous on this point, though none has actually drafted my Amendment—and everyone concerned in local government that there is a real understanding by the Government of the points which my noble friend Lord Amory and I have been seeking to make and that there will be no possibility of the local government experience and knowledge being squeezed out or left out from these extremely important bodies, the Regional Health Authorities.
§ 3.22 p.m.
§ LORD BROWN
My Lords, I rise to demonstrate to the noble Lord, Lord Brooke of Cumnor, and the noble Viscount, Lord Amory, that in spite of the strictures from them to which I was subjected on the last occasion when we debated this part of the Schedule, I remain quite unrepentant. One of the things bedevilling the whole discussion is exemplified by the words used by the noble Lord, Lord Brooke, when he referred to "management kings and queens." In the previous debate he spoke of the danger of the Regional Health Authorities being composed entirely of 1410 technocrats, but when one looks at the Bill as drafted it is clear from Clause 1(2)(a) that the Secretary of State will consult with county councils and local authorities in general before making these appointments, the purpose of the clause being to indicate that there will be on these bodies people with experience of local government.
In this sense I should not take objection to the Amendment which stands in the name of the noble Lord, Lord Brooke. I believe I am right in saying—the noble Lord will correct me if I am wrong—that when in Committee a similar Amendment was before your Lordships the noble Lord called for the appointment of local authority people on the Regional Health Authorities. His Amendment which is before us to-day is not in the same terms, because it merely says that there should be appointed by the Secretary of State people who also hold a role in local government. This suggestion seems to me to be quite unobjectionable, even if it may be unnecessary in the light of the wording of the Schedule as drafted.
Those who support the Amendment moved by my noble friend Lady Scrota are inclined to take the attitude that those who oppose it are being undemocratic and that the road to democracy lies in having people appointed by local authorities to these bodies which are called Authorities and which are accountable to the Secretary of State. Indeed, if they were not accountable to the Secretary of State democracy would break down, because the Secretary of State would not be able to be accountable to Parliament, and I could not think of a greater departure from democracy than that. My noble friend's proposal would not leave the ultimate decision in the hands of the local authority representatives on the Regional Authority, but it would be in breach of an important principle, which is that those who are accountable to, say, the Secretary of State must be appointed by the Secretary of State; if they are not appointed by him they are accountable to someone else or somewhere else, and one then gets a mixture on these bodies of two sorts of people.
It is suggested that this is a move away from democracy, but let us consider where we stand now. Hospital management committees now often feel that they are 1411 representative of the public at large, but they are not. They are appointed, in one way or another, by the Government—they are not elected by local authorities—and if one talks to the members of local hospital management committees one often finds that they say that as far as their representative functions on behalf of the public are concerned, they are nonexistent; they become rubber stamps and bow to medical opinion on the hospitals management committees. This Bill will take us to the establishment of an ombudsman, at any rate to begin with, and that is surely democratic. It will then take us to the establishment of the community health councils, and I am glad to see that the Minister has tabled Amendments which will mean that these councils will be composed entirely of people who are put there by local authorities and other bodies in the community and that for the first time there will be an opportunity for the public, patients, parents and everyone else to impact on the Health Service in a way that is not possible to-day.
I therefore suggest that this Bill is a move in the direction of democracy, and my personal experience of industry leads me to support it strongly. At one time in my career I was much criticised—indeed, I became quite notorious—as being the idealistic industrial democrat who would ruin the company in question because I should be letting democracy run riot. In fact, my colleagues and I in that company had clearly separated the management of the concern from the representatives of those employed in it, and by keeping them separate we had introduced a degree of participation which was acknowledged by trade unionists, shop stewards and employees to be of an unusually high order. It was based on a separation of executive management from the representation of employees. That is a principle which, with respect, some Members of your Lordships' House do not seem to understand. One looks at Europe to-day and sees the supervisory boards, partially composed of those elected by employees. I talked a year ago to the chairmen of three very large German industrial companies and I asked them, "What happens when you discuss wages and like matters on these supervisory boards? Does it not mean taking the negotiations 1412 out of the place where they usually reside and putting them into the supervisory boards?" All three replied, "We would not think of discussing issues of this kind in a supervisory board." I asked when the board would discuss such matters, and they said, "In an informal meeting when the representatives of the employees are not present."
That is the position into which one gets if one mixes these things. One plays at democracy instead of giving the public a real opportunity to impact on the Health Service. This must be done either through Parliament—in Parliament, on great issues of principle—or at a reasonably local level, which is catered for by the provisions of this Bill in the setting up of community health councils, with complaints about maladministration going through the ombudsman. With respect to my noble friend, I think she has this principle wrong. We all want the same thing—namely, an efficiently run Health Service. To get that, we must have sound managers, good technicians and people (this is where the point made by the noble Lord, Lord Brooke, comes in) with experience of local administration appointed to those bodies by the Secretary of State. Alongside that, one wants these community health councils to give an opportunity for patients and others to make their complaints. If one looks at the terms of reference of the community health councils one finds that they are very strong indeed. They give the councils great authority to investigate problems, visit hospitals and call for reports and the councils are going to have professional staff to aid them in their job. So it is on those grounds that, with respect, I believe my noble friend's Amendment is unnecessary and is a confusion of principles. The Amendment of the noble Lord, Lord Brooke of Cumnor, seems to me to be entirely inoffensive and I hope that it will be considered.
§ VISCOUNT AMORY
My Lords, my noble friend Lord Brooke of Cumnor has outlined so clearly the reasons for the next Amendment, which stands in his name and in my name, that I need not say anything more about it, but I should like to say that I agree with everything he said. I found myself in agreement also with nearly everything which the noble Baroness, Lady Serota, said. I am not 1413 going to rehearse our fears, which still persist, that this whole organisation may prove a very bureaucratic one, nor am I going to rehearse the reasons we gave at the Committee stage for believing that local government membership at the Regional Authority level and Area Authority level will be invaluable to those Authorities. The object of the Amendment of the noble Baroness, Lady Serota, and of the Amendment of my noble friend Lord Brooke of Cumnor is really the same, namely, to ensure, if we can, that local government participation will be real. I am not going to be tempted into a discussion in depth about democracy with the noble Lord, Lord Brown, because I want to preserve what little ammunition I have ready to try to persuade my noble friend Lord Aberdare (who shares our views to a much greater extent, I believe, than does the noble Lord, Lord Brown) to meet us as far as he can.
The other point made by the noble Lord, Lord Brooke of Cumnor, which I want to emphasise and with which I believe my noble friend will agree is that the local government members—and he has made clear to us that he believes that there should be some on these Regional Authorities—will be members who are currently engaged in local government and not people like myself who were once but are no longer actively engaged in local authority business and therefore not up to date. The next point we want to emphasise, and again I believe that my noble friend Lord Aberdare will agree with us, is that because of the very different sizes of these regions and their differences in complexity it is essential that the membership provisions of local government representatives should be flexible also and should be related to, among other things, the geographical features of the region. May I just mention the region in which I live, the South-West, which will consist of Cornwall, Devon, Somerset and Gloucester. If the participation is to be real that will clearly require more local government members than perhaps will a county which in itself is important and big, like Essex, or like several others for which I could quote a stronger case. We should like to know a little more from my noble friends, not so much about "whether", as he has told us that he believes that there must be a proper representation 1414 of local government members on the Regional Authorities, but "which" local authorities. I assume that they will be mainly the major authorities at the county level. We should like to know how they will be chosen and how he proposes that the numbers shall be related to the size and complexity of the region. We look forward with interest to his telling us to what extent he supports the principles behind these two Amendments.
§ LORD COBBOLD
My Lords, may I on a slightly different point, return for a moment to the question of the cost of these and the other new authorities which are to be set up under the Bill? Your Lordships may remember that I raised this question on Second Reading and in Committee, and the noble Lord, Lord Aberdare, was good enough to tell me that he would keep me informed. Many of us are anxious lest this proliferation of authorities should mean more money for administration and less money for the care of patients, for teaching and for research. I realise that it may be difficult at this stage for the Minister to give precise estimates of cost, but I am sure that the House would be glad of any further information which the Minister is able to give. For example, are we entitled to assume that as Area Health Authorities are going to do most of the executive work the staff and accommodation requirements of the new Regional Health Authorities will be less than those of the present Regional Health Boards? I hope that even now the Government will give some assurance, at least, to the House that if the new administrative set-up proves more expensive in staff, premises, and expenses generally, this will not involve a decrease in the money available for the real purposes of the Health Service.
§ 3.36 p.m.
§ BARONESS WHITE
My Lords, I had not intended to intervene on this Amendment which was moved by my noble friend, but after the speech by my noble friend Lord Brown I feel that one must say something. One fully understands that with his great experience of industry my noble friend Lord Brown would be disposed to take the line that what is good for industry is good for a public service, but I am afraid that one cannot accept that point of view if one has had much experience of local government and 1415 comparable public service. The two are not the same.
There is, of course, a very important managerial element in a great organisation such as the National Health Service, and in the article by Dr. Elliott Jaques which was printed in The Times yesterday some of the reasons why one must look carefully at management are clearly spelled out. For example, he said:The Grey Book"—that is to say the handbook on management—has also taken a great stride forward by framing its organisation proposals in terms of working levels rather than in grades.I believe that that is probably true and is something which makes the book on management valuable. But when one comes to the whole question of policy-making, not administration, then it seems to me that I must take issue with my noble friend. For example, he seems to be of the opinion that we have adequate safeguards for the public interest if we accept this management structure without going any further than the Bill as it now stands. He seemed entirely to overlook the fact that what we are discussing at the moment are the Regional Health Authorities, and he repeated to-day what he said in his own letter to The Times yesterday. As I did not take down his precise words to-day, I will quote from his letter in The Times in which, referring to the Ombudsman and the community health councils, he said:Never before has the public been so potently represented and so able to influence a national service.I do not wish to be discourteous to my noble friend, but anyone who has studied regional matters will appreciate that neither the Ombudsman nor the community health council will have the slightest influence at regional level. It is not their function. Regional level is strategic planning on a wide scale, and it is for that reason that we are so much concerned that the public interest in policy-making shall be preserved. That is why we are at one with the noble Lord, Lord Brooke of Cumnor, and the noble Viscount, Lord Amory, in their concern that there shall be some organic link between the major local authorities and these Regional Health Authorities.
§ LORD BROWN
My Lords, would my noble friend allow me to ask her one question? Would the noble Baroness tell the House which members of the present Regional Health Authorities are elected to-day?
§ BARONESS WHITE
My Lords, I am sorry to say that it seems to me that this again illustrates the lack of experience of my noble friend in such matters, because at the moment what we have are Regional Hospital Boards and they are concerned exclusively with the Hospital Service; they have no responsibility for the very considerable area of health care which is now to be transferred from the elected local authorities; nor do they have any real interest in the major social planning of the geographical areas in which their hospitals happen to be placed.
As I say, we are very much concerned that there should be this real link between the regional hospital authorities and the major local authorities. We make no bones about it that we would in due course wish to have regional provincial authorities of some kind; but we recognise that these are not possible yet, and therefore one cannot argue that they should be brought into the picture in this Bill. We hope that that may be something for the future. We must take the local authorities as they are to be under the Local Government Act.
Where we differ from the two noble Lords on the other side is that we suggest that the authorities should appoint their own representatives to the Regional Health Authority; that they should not be appointed by the Secretary of State. In support of this suggestion I think I might, perhaps helpfully, refer to the speech which was made at Newcastle-on-Tyne on Saturday by the Leader of the Opposition in another place, speaking for the Labour Party. I happened to be there and I also have the full context of his speech, so I am at an advantage, I suppose, over every other Member of your Lordships' House who was not there and who has had to rely on Press reports. I think a number of newspapers in fact quoted Mr. Wilson's expression of view about what he called the "fetishism" of the Treasury and the Civil Service of appointing members of governing authorities, and suggesting that if they were not directly appointed one would not be able 1417 to ensure strict financial control. He referred to this as the "Whitehall fallacy". He went on to say:We must get rid of the doctrine of Whitehall nomination. The governing authorities"—and he was speaking now of the Health Service—must represent two groups, the producers of the service, in the medical profession and the other Health Service employees, and the consumers, through their elected representatives. How the representatives of the medical and other professions are to be selected is a matter for consideration; but if democracy is to mean anything at both area and regional level the consumer interest, the democratic interest, must be in control, and not a group of individuals nominated by the Secretary of State. In the short run, the democratic interest must be indirectly elected by local authorities, in the long run directly elected.And then he refers to the possibility, we hope the probability, of regional authorities ultimately being established for a much wider range of functions than the Health Service itself.
I thought I should intervene at this stage, as I say provoked somewhat by my noble friend Lord Brown, so that the House should be in no doubt as to the way in which we are looking at this matter, although the precise form of our Amendment is of course necessarily tailored to local government as it is at the present time.