§ 2.50 p.m.
§ LORD ABERDARE
My Lords, I beg to move that the House do again resolve itself into Committee on this Bill.
§ Moved, That the House do again resolve itself into Committee.—(Lord Aberdare.)
§ On Question, Motion agreed to.
§ House in Committee accordingly.
§ [The EARL OF LISTOWEL in the Chair.]
§ Schedule 1 [Additional provisions relating to new authorities]:
BARONESS SEROTA moved Amendment No. 45:
Page 49, line 9, leave out ("appointed by him as he thinks fit") and insert ("being not less than fifteen and not more than twenty-five of whom one-third shall be appointed jointly by local authorities for each county and each district and by the Area Health Authorities wholly or partly within the region of the Regional Health Authority or in the case of Greater London jointly by the London Boroughs and the Area Health Authorities wholly or partly within the area of the Authority and by the Inner London Education Authority, one-third to be jointly appointed by persons representative of the following categories, namely
§ The noble Baroness said: I beg to move Amendment No. 45, standing in the names of myself, my noble friend Lady White and my noble friend Lord Garnsworthy. The Committee may recall that during the consideration of Clause 5 of the Bill on the second day of the Committee Stage I indicated some of our basic objections to the proposed nature and functions of the Regional Health Authorities. Now we come to consider their proposed membership, as set out in bare outline in paragraph 1 of Schedule 1. As at present drafted, this gives the Secretary of State the ultimate decision as to numbers and choice in the appointment of all the members of the 11 proposed Regional Health Authorities as he thinks fit, after consultations with the interests specified in paragraph 1(2) of the Schedule—in fact just as he does now in the case of the 14 Regional Hospital Boards.
§ I am sure that members of this Committee, above all, recognise the great contribution, both past and present, that members of the existing Regional Hospital Boards have given through their time and energy to the development of the Hospital Service in the past 25 years. Many of your Lordships have served on these Boards and are familiar with the responsibilities involved. It is equally fair to say that the most frequent criticism that has been made of the Boards is that they are far too remote from the people that they serve. This Bill, unfortunately, utterly fails to meet this criticism by taking the opportunity of reorganisation to make the new Regional Health Authorities more representative, both of the professional and of the public interests that are directly involved. We see this as a particularly retrograde step at a time when we are removing from democratic local government the whole range of community health services which have been locally administered ever since the beginnings of local government itself.
§ Judging from certain Amendments to the Schedule which follow on the Marshalled List, it seems that other noble Lords share some of these views in principle, although we may differ a little about the numerical balance of interests that should be included in the Regional Health Authorities as of right, rather than leaving their numbers and composition entirely to the absolute discretion and choice of the Secretary of State after the consultation specified in the Schedule. I am therefore glad that we are to have a general debate on this group of Amendments as a whole on the understanding that this will not preclude further consideration of the individual Amendments themselves, or prevent us from putting questions to the Minister on any or each of them as we proceed.
§ Broadly, the effect of the Amendment that I am moving will be to limit direct ministerial appointments to the new authorities to one-third of their total membership 12 after consultation with the interests specified in paragraph 1(2). In Amendment No. 49B we are seeking to amend sub-paragraph (2)(d) to include specific reference to the trade unions and voluntary organisations instead of the present vague reference to "other bodies". The Amendment would provide that the local authorities, jointly with the Area Health Authorities within each health region, would have the right to nominate up to one-third of the membership of the new Authority; and the main health professions, as specified in our Amendment, would be responsible for providing and nominating the remaining one-third.
§ The Amendment is put forward in the belief that the contribution and participation of all these groups is essential to the development of co-ordinated health service policies which are truly sensitive and adaptable to consumer and professional needs and interests in the localities that they serve. The case for reflecting Area Health Authority knowledge and experience in the membership of the new Regional Health Authorities was to be the subject of a separate Amendment which was formerly down on the Marshalled List in the name of the noble Lord, Lord Reigate. Unfortunately, I understand that he cannot be with us to-day. According to the Grey Paper on management arrangements in the National Health Service (with which most noble Lords are now familiar), the areas are to have full planning and operational responsibilities for providing comprehensive health services in their areas, and it is difficult to see how they can be completely excluded from the regional planning process at member level and only allowed access to the Regional Authority through the bureaucratic chain of command. Nor do I believe that there can be any question of the direct concern of the relevant local authorities within each health region in the overall planning provision and coordination of health services with the great range of social services that they themselves provide directly for the public living in their areas, since Clause 10 of the Bill places a clear statutory duty on local authorities of every kind, and Health Authorities generally, which presumably includes Regional Authorities as well as Area Authorities, to co-operate in the exercise of their respective functions to secure reciprocal and complementary 13 health and social services that are required to advance the health and welfare of the people of England and Wales.
§ Although Clause 10, subsection (2), of the Bill provides for statutory consultative committees of members for this specific purpose at area level, there is no comparable recognition in the Bill of the need for some form of joint planning at regional level where strategic planning decisions are to be taken. The only recognition that I can trace in the many documents that have been issued on the reorganisation of the Health Service is a reference in the first report of the Working Party on collaboration suggesting that the region is to be represented at area level at joint consultative committee meetings. Can the Minister confirm this? If this is the intention, can he say who is to fulfil this particular function? Is it to be an appointed member of the Regional Authority, or is it to be an official? I find it difficult to see how the Area Health Authorities or the local authorities can effectively fulfil the general statutory duty under Clause 10 if they are not included in the regional planning process through members of the Regional Authorities as of right. If this is not acceptable to the Government I hope that the Minister will be able to tell us in the course of this debate how they see this essential relationship working in practice.
§ With regard to the proposals in our Amendment that the health professions should be directly involved in the work of the region by providing one-third of the membership, I already explained on Second Reading that we on this side of the Committee have no great love for Clause 8 which groups and isolates the health professions in parallel but separate advisory committees which then have to be recognised by the Regional Health Authorities. We believe that they too should pay their full part, contributing their skills, their knowledge and their experience to the planning of services, which after all they so largely provide, by participating directly in the policy decision-making process of the Regional Health Authority itself. The separate professional advisory machinery which the Bill provides, and was foreshadowed in paragraph 100 of the White Paper, envisaged building into the new structure, to ensure that the health professions exercise 14 an effective voice in the planning and operation of the Health Service at all levels. We do not see the advisory committees as any real substitute for this; and I was interested to see in subsequent Amendments on the Marshalled List that we shall shortly discuss that the medical profession in particular is not fully satisfied that the proposals as at present designed will really achieve this. Presumably the nursing profession, which is so vital to the Health Service, would be among the "other professions", as they are described in the Bill, that would appear to the Secretary of State to be concerned in the terms of paragraph 2. They are not even mentioned, and I hope the Minister will be able to confirm to-day that it is the intention of the Secretary of State to include them, too, as of right in the health professions other than the medical profession that he intends to consult.
§ The Committee will see from the Amendment that we are also concerned about the proposed size of the Regional Health Authorities; and a subsequent Amendment on the Marshalled List, No. 59, relates to the one I am now moving in that it provides a device for, if necessary, joint appointments between the relevant authorities to the Regional Health Authorities. We are anxious that the Bill should provide for greater flexibility than is apparently intended at the moment in the size of the regional authorities up to a limit of, say, 25 members and beyond the figure of 15 suggested as the likely norm in the White Paper to cater for those situations where, for example, in Region 14 (the Lancashire and Greater Manchester local Government regions) and Region 12, which includes the counties of Hereford, Worcester, Shropshire and the seven Metropolitan Districts that will make up the West Midlands Region, there will be as many as 11 Area Health Authorities and 11 matching local authorities operating within the boundaries of the health region. While fully appreciating the desire of the Secretary of State to keep the new Regional Health Authorities relatively compact, there must be, surely, some recognition of the range of interests and different kinds of areas they are catering for, quite apart from the very important question of seeking to lighten the heavy burdens that will fall on this small group of 15 members who, apart 15 from their chairman, will be giving voluntary, unpaid service to the Health Service without even, apparently, the kind of attendance allowances which their colleagues in local government will be receiving under the provisions of the new Local Government Act.
§ Perhaps I might also take this opportunity, as we are having a general debate, and to save time later on, to make specific reference to our Amendment No. 49B, which refers to the inclusion of trade unions and voluntary organisations in the lists of organisations in paragraph 12 that the Secretary of State must consult before he appoints the Regional Health Authorities. The case for this is so self-evident that I feel I need scarcely take up the time of the Committee to make it. Perhaps the Minister could tell us whether it is intended to include them and, if so, whether the Government are prepared to accept an Amendment which I think should commend itself in all parts of the Committee, remembering as we do the contribution of both the voluntary organisations and the trade union movement to the National Health Service.
§ Throughout all the previous lengthy debates on the reorganisation of the Health Service and on the proposed membership of the new health authorities the Government have until now refused to listen to those both inside and outside Parliament and from all parts of the political spectrum, and to those even within the Service, who are opposed to the rigid distinction which appeared first in the Consultative Document, then in the White Paper and the Grey Paper, and now apparently in the Bill—or, rather, in the order-making powers in the Bill, which seek to establish a rigid division between the management functions of the new Health Service authorities which are to be exercised by members entirely appointed by and accountable to the Secretary of State and any form of democratically elected consumer or direct professional participation in the policy-making processes in the Health Service, except of course for the proposed inclusion of four local authority members at area level suggested in the White Paper. I, for one, still cannot accept that any element of democratic participation and efficiency are by definition incompatible in a public social service such 16 as the National Health Service which, above all, must be publicly acceptable and especially flexible and sensitive to consumer need and to public reactions to the services provided. Nor can I understand how the Government can speak with two such different voices on the same subject almost at the same time. This House and the other place spent a long time last Session in considering in great depth, and indeed at great length, how to improve and strengthen democratic local government which provides almost all our other major social services: education, housing, environmental planning and the personal social services. Now we are being told that the representative function and efficient management are incompatible in one body and that it is inappropriate, if not dangerous, to allow any form of representative interests in the administration of the unified Service.
§ These Amendments are submitted to the Committee in the firm belief that the local authorities, Area Health Authorities, the health professions and trade unions and voluntary organisations should be included as of right in the new regional authorities, which we would still prefer to see as regional councils for the reasons I have already given in our debates on Clause 5. Since other noble Lords have further Amendments to this Schedule, and the same part of the Schedule, I would only conclude with the hope that the Government really will be prepared to listen to-day and to take heed of the general debate we are now to have on the composition and on the methods of appointing the regional authorities. I beg to move.
§ 3.8 p.m.
§ LORD BROWN
In discussing the Amendments before us we are very much concerned with matters of principle. I start with the suggestion that it is a proven fact that if one is appointed to a role, then one is accountable to those who appointed one. That means to say, in contradiction to my noble friend on the Front Bench, that if you do not keep separate the management structure and what one might call the representative structure, then you have on one and the same body people who are diversely accountable to different bodies. One of the principles which we are debating is 17 the principle that you must keep management, on the one hand, and representation of those affected, quite separate. Amendment 45 would bring about a mixture of persons on the Regional Health Councils: people responsible to local authorities and others, on the one hand, and people responsible to the Secretary of State, and eventually to the Government, on the other. This would be to the grave detriment of the efficiency of the Health Service, and as a result patients would suffer, money would be wasted and the services would not be as complete as they would otherwise be.
There are many who continue to think that by excluding representatives of employees or representatives of patients, and so on, from management functions you are being undemocratic. My own experience convinces me that it is only by keeping them separate that you really get a fair share of what we regard as democracy. It is the individious position in which representatives are placed when they are given accountability to higher authority, apparently, as a result of their being put upon a management body, and are also held simultaneously responsible to those who have appointed them—perhaps the consumer or the employee—that really loses the essence of the democracy which people seek to achieve by this process. So I have certain criticisms to make. I suggest that Amendment No. 45 is not sound, for the reasons I have given, because it produces on the Regional Heath Authority a mixture of people accountable to the Secretary of State for the management of the Health Service and other people accountable to local authorities for representing the views of the community as a whole.
Turning to the Area Health Authority, I criticise the Bill because in Schedule 1, paragraph 2(1)(d), referring to those who shall be members of the Area Health Authority, it calls attention to the fact that it shall be:the specified number of members appointed by the specified local authority or local authorities.So if the Government resist Amendment No. 45 they can scarcely support the maintenance in the Bill of paragraph 2(1)(d) in Schedule 1 to which I have just referred, because in principle they are both moving in the same direction. 18 Personally, I should prefer to see paragraph 2(1)(d) removed and the whole of the Area Health Authorities appointed by the Regional Health Authorities or by the Secretary of State, always, of course, after taking soundings among the various bodies as to who would be suitable appointees.
In this Bill the interests of the patients and the community at large and the local health authorities are looked after, first, by Parliament itself and its servant, the Secretary of State, second, by the Commissioner (a most important innovation), and third, and perhaps most important of all, by the community health councils in each district. The powers of these councils are extensive. They can call for reports, they can insist on visiting hospitals, and so on. The powers are set out quite clearly. But the extraordinary thing is that if one looks at the way in which these community health councils are to be formed one is left with the impression that instead of being elected by local authorities, or even by elections in the towns and districts, they are apparently to be appointed. So one has the extraordinary situation in this Bill that here is my noble friend on the Front Bench moving in a direction which would put upon the Regional Health Authorities a mixture of representatives and managerial personnel, which no doubt the Government will resist. There are clauses in the Bill which, as they stand, insist that this mixture shall obtain on the Area Health Authorities, and when one comes to the community health councils one finds that whereas one would expect to follow through the principle that they are to look after the interests of local authorities and of the patients, apparently they are to be appointed by the Area Health Authority.
§ LORD ABERDARE
I hesitate to interrupt the noble Lord, but we shall soon come to the subject of the community health councils. I think he has it slightly wrong; at least half the community health councils will be nominated by the local authorities.
§ LORD BROWN
I note what the Minister has said, but the word "nominate" does not satisfy me. It is true that the local authorities can nominate, but who decides whether these people shall become a part of the community health councils?
19 I am deploying my comments on the community health councils not because I particularly want to start a debate about them at the moment but in order to draw attention to the inconsistencies that arise in this Bill and the inconsistencies in some of the Amendments which we are discussing. I will close my remarks by suggesting that it is essential to keep representative persons and bodies quite separate from managerial bodies and that by so doing one will get more efficient management and more efficient representatives of local authorities, of patients and all the rest of it. Immediately one mixes these things one puts everybody on these mixed bodies in an extremely difficult position. I believe it is true to say, although I have no personal experience, that the hospital management committees have sometimes been confused because some of them have construed their role as being to represent the interests of the community in which their group of hospitals exists and some of them have presumed that they are there to represent the Health Service itself. I believe there is no question but that they are there for the latter function rather than the former. But this is a confusing situation and personally I have little doubt that it has led to some unfortunate situations in the Hospital Service which were probably attributed to personalities. So I have risen merely to draw attention to what I think is an extremely important principle which should be represented in every clause throughout this Bill which deals with management personnel or, on the other hand, with representative personnel.
§ LORD BROOKE OF CUMNOR
I could hardly disagree more with the noble Lord who has just spoken. It seems to me to be an extraordinary doctrine that on an executive body one should never have any representatives of the general public or the consuming interests, and that if you do have them there they will have divided loyalties and therefore will become ineffective. We must surely grant that there are people who are capable of rising above these difficulties and doing their duty as they see it. I simply cannot accept the idea that representatives of the public should be excluded from executive bodies which have to provide a service. This may be so in the 20 provision of gas or electricity, but the subject we are discussing now is far more sensitive than either of those, and far less uniform. I cannot accept the idea of having the National Health Service run by a body of managerial technocrats with no dilution whatever.
I warmly welcome the idea that we should have a general debate on the composition of the Regional Health Authorities and then of the Area Health Authorities, because I believe—and I hope the noble Baroness, Lady Serota, will agree with me—that what we want to do most of all is to elicit from the Government what their own ideas are for the membership of both these types of bodies. My principal anxiety in putting down my Amendments was to give the Government an opportunity to make clear what sort of composition of Regional Health Authorities in the first instance they were aiming to produce by this Schedule, because the Government would be the first to agree that it is not absolutely clear simply from reading the Schedule. Then we shall be in a position to discover whether there is a fundamental difference between the Government, on the one hand and those who are seeking to amend this Schedule. Frankly, I do not know.
The Government appear to me to visualise a Regional Health Authority as a small group of experts in management who, somewhat mysteriously, can be relied on to know what the public want, or ought to want. On the contrary, I visualise a Regional Health Authority as being ideally a rather larger body of people—rather larger than fifteen members—with a lot of practical and financial good sense, wider understanding and (if I may venture to put it this way) more compassion than experts sometimes have, and with a built-in channel of communication between itself and the public that it exists to serve. The main purpose of my Amendment is to keep that channel open.
The Regional Health Authorities will have responsibility for some health services which are now administered by elected local authorities. The Government will no doubt have noted that there is nothing in the Bill which ensures that there should be any local authority representatives at all on the Regional Health Authorities. If my Amendment were acceptable, that would be put right. I 21 am not yearning to move my Amendment or to press it to a Division; indeed, I have no intention of doing that to-day. I hope that between now and later stages of the Bill the Government will take into consideration the points that are being made from both sides and will produce their own plan in more explicit form; it may be better than the original Bill and any of these Amendments. I am not asking, as is the noble Baroness, that one-third, one-quarter or any other particular fraction of a Regional Health Authority shall be local authority representatives. I am merely seeking that at least five shall be, whereas in the Bill as it stands there is no guarantee that there will be any.
I repeat in passing that the suggested figure of 15 members on the Regional Health Authority is surely too small. The principal criticism of the Regional Hospital Boards has been their remoteness, and they were larger than 15. I do not see how the members of the Regional Health Authority can do their job unless they are able to make themselves reasonably familiar with what is going on in the National Health Service throughout the region. They will certainly have some social functions to perform. That is inevitable. They will certainly have some problems of local difficulties, tensions and conflicts to resolve. I should have thought therefore that a body of 15, even with a salaried chairman, would not be large enough to enable the members to know enough personally about the hospitals or other local health services throughout their region and to do all the other duties which will inevitably fall upon them. That is why I fear that these Health Authorities, while I agree with the Government in giving them executive rather than advisory powers, may be regarded as even more remote than the present Hospital Boards.
It may be that in the view of the Government that will not matter so long as they are successful management technocrats. But supplying the National Health Service is not on a par with supplying ordinary commodities. It is necessary that they should be sensitive to public opinion, and I would say that it was essential, if they are sufficiently to commend themselves to the population of the area for which they have responsibility, for them to include a material 22 number of elected local authority representatives.
I have no desire to bind the hands of the Government in these matters. I realise that an all-wise Minister might very well produce a Regional Hospital Authority better than any of us could contemplate, even though he had to carry out a certain amount of consultation. But it seems to me that we are leaving a great deal to the Secretary of State, and I should be most grateful if my noble friend would indicate whether he and the Secretary of State really are contemplating management expertise as being the first requirement of every member of the Regional Health Authority. If so, then although they may satisfy the noble Lord, Lord Brown, I do not think they will satisfy the general public; and it is because the general public is always anxious to ensure that there is somebody on the executive body who has the qualifications to understand local problems that I press these matters.
§ LORD BROWN
It is quite clear that before these appointments can be made by the Secretary of State he will, and rightly so, consult all kinds of local authorities, trade unions I hope, and the rest. There is absolutely no reason why people who have some knowledge of;management—who are competent and mature managers—should not also be familiar with local problems. The noble Lord, Lord Brooke of Cumnor, has suggested by inference that either one has people with knowledge of management or people with knowledge of local problems. He has suggested that it is not possible to combine both in the same person. With great respect, he is not right.
§ LORD BROOKE OF CUMNOR
I was not seeking to establish anything of that kind. I have been worried about statements emanating from the Government that managerial expertise will be the primary qualification for these people. I spent more than twenty years in local government and I met many people there whose managerial expertise was high but was equalled, if not surpassed, by their sensitivity to local public opinion. I shall be only too happy if the Government will make it clear that they want a substantial number of people on these Regional Health Authorities who will 23 amply fit in with the definition that the noble Lord, Lord Brown, has just given.
May I ask my noble friend Lord Aberdare to say what will be the likely attitude of the Secretary of State towards those who are at present serving on Regional Hospital Boards and hospital management committees. Is it likely to be the desire of the Government to get rid of all of those people unless they have medical or managerial qualifications? Or, after all the consultations that are laid down by Statute have taken place, is their attitude likely to be that they will seek to retain in the service of the National Health Service those who have fully justified themselves by the work they have done on Regional Hospital Boards and management committees? I am aware that the new responsibilities will go much wider than has previously been the case with these bodies. But I would have thought that there exist a considerable number of those people who are not professional people but who nevertheless would be of great value in the new régime.
My Amendment speaks of local authority members, but my main purpose is to ensure that there will be a sufficient number of people on these Regional Health Authorities who are not there simply because of their professional qualifications. I believe that these bodies should be a well judged mixture between the amateur and the professional. I should be fearful indeed if these Regional Health Authorities were to consist wholly of untried amateurs, but I should be even more frantic if I thought that they would consist entirely of medical or other professionals.
§ LADY RUTHVEN OF FREELAND
I rise to speak in support of something said by the noble Baroness, Lady Scrota, and repeated by my noble friend Lord Brooke of Cumnor. The noble Baroness spoke of "voluntary people" in the National Health Service. I think that by that both she and my noble friend had in mind those who have served on Regional Hospital Boards and hospital management committees. In my view, their knowledge of the Health Service is very great indeed and it would be the greatest pity if they were excluded from membership of the new Regional Health Authorities simply because they did not 24 have the technical qualifications that appear in the Bill. If they have given a number of years' good service to the consumer, the patient, they should not be forgotten when the constitution of the regions and areas is arranged.
§ 3.30 p.m.
§ LORD LEATHERLAND
I should like to say a word in support of the Amendment moved by my noble friend Lady Serota. I believe that on the whole this is a very good Bill. It is undeniable that the Health Service, having run for so many years, is in need of some kind of overhaul, but we must be careful to ensure that the overhaul is conducted on the proper lines. It may well be that every word in my noble friend's Amendment is not beyond question or dispute, but if the Government could come forward with an undertaking that something in the nature of the spirit of that Amendment will be incorporated in the Bill then I should be quite content. I have a nasty feeling, which has been growing in recent months, that this country is tending more and more towards the corporative state of Italy. Democracy is being squeezed out and bureaucracy is being injected at various levels of our administration and government, and if there are Services that ought not to be run by a bureaucratic machine, surely they are the Hospital and Health services.
As the noble Lord, Lord Brooke of Cumnor, with his long experience of local government has said, the representatives of the people in local government are very much closer in touch with the feelings and the aspirations of the ordinary people than are the people who are closeted in their offices administering the machinery of any particular piece of legislation. I sincerely hope that local government representatives will be brought in at all stages of this new Bill. I know that they are in at some stages already, but also it is essential that they should have a voice in the Regional Authority.
My noble friend Lord Brown is a recognised national and international expert on management science. I take off my hat to him in that respect. The thesis that he has put forward this afternoon would be admirable if we were planning to set up a factory. But we are not discussing nuts and bolts and pipes and tubes: we are discussing 25 people; we are discussing patients; we are discussing their families; and we are discussing the facilities that are available to all those people should their health break down. My noble friend rather criticised the idea of there being a mixture of people, a mixture of views and a mixture of attitudes on these authorities. Surely a mixture is desirable; it leads to argument; it leads to proposals being hammered out on the anvil; and it leads ultimately to a respectable and proper decision being arrived at.
§ LORD BROWN
The noble Lord is misquoting me. I have no objection to a mixture of attitudes, views or anything else, and I have never said anything that could possibly be inferred to suggest that I object to it. I simply suggested that to have a mixture of people on one body, differently accountable to different other bodies, is unsound. I am not even suggesting that they all should have managerial expertise or should all be managers or should all be all so sufficient, but to have a body accountable to the Secretary of State for running the Health Service and to have that body composed of people separately accountable in both directions is to put them in a very difficult position.
§ LORD LEATHERLAND
I am glad of my noble friend's brief interruption. He objects to mixtures! We have a mixture here, and it works. One side says one thing and another side says another thing; sometimes the two sides become a mixture in themselves, but ultimately we try to arrive at a consensus which may be right or wrong. Decisions are not always right in this world. I am quite sure that a mixture on this Regional Health Authority would be very healthy indeed. I am afraid that my noble friend, with his great expertise in matters of management, has come unstuck in one particular—a board of directors does not manage, a board of directors gives directions which are then handed down to professional managers who manage. The same kind of thing happens in local government. Aldermen and councillors sitting around a table do not profess to be managers (they are fools if they do, 26 and they do occasionally); they indicate the direction in which the policy of their particular council is to move and then they instruct their officials, who are the technical, professional, expert managers, to get on with the management and the implementation of that particular policy.
I know it is suggested in Clause 10 that at certain stages there shall be some kind of co-operation between local authorities and these professional, bureaucratic boards. But it is only a consultative committee that is being suggested, even at that level. I shall not call it an executive committee because that rather tends to get into the management level, but it is not a committee which will be able to give directions as to the line and the general attitude which is to be taken by that Health Authority. What is wrong with the principle of having elected people directing our public affairs? We have them in the Cabinet. That is one of the very foundations of our democratic system of government in this country. I dislike the particular complexion of this Bill which seems to have a mania for professional management and which seems to squeeze out the democratic attitude of mind. When all is said and done, during the last two and a half years I have not been especially enamoured of the management ability of Her Majesty's present Government. In this Amendment and those other Amendments touching on this same question which are to come later this afternoon, let us see that we do not say to the ordinary democratically elected people of the country: "The time when you can serve the community is gone. You have to make way for bureaucrats."
§ VISCOUNT AMORY
I should like to say how strongly I agree with everything that my noble friend Lord Brooke of Cumnor has said and with almost everything that the noble Lord, Lord Leather-land, has said, including perhaps his remarks on the Italian corporate State. One thing I would say is that perhaps his analogy with this House was a little strange, because looking round, to my knowledge, I cannot see any of your Lordships who have been locally elected. But my noble friend Lord Brooke of Cumnor at the beginning of his speech administered the stick rather sharply to the noble Lord, Lord Brown, for expressing the doctrine that there was no place for 27 locally elected representatives on a managerial, executive, directorial body. I have become so accustomed to acclaiming all the utterances of the noble Lord, Lord Brown, that I own I was shocked at the necessity for this reproof. But there are some occasions when the stick is justified—particularly when wielded with such a humane hand as that of my noble friend Lord Brooke of Cumnor—and this was one of them.
The case advanced in these Amendments is a powerful one. The fact that the principle behind them is supported by all four of the main local authority bodies I hope will lead my noble friend to attach appropriate weight to them. There is apt to be a danger inherent in this kind of authority and council, and that is the remoteness from the people they serve. The noble Baroness, Lady Serota, made this point and said that there is criticism of this remoteness even in the existing circumstances. Here I must own that I myself am not familiar in detail with the National Health Service having never sat on any of the bodies concerned, except on the county council side of the picture. Because of that danger of remoteness, every possible method must be adopted when passing legislation to make sure that the danger of this remoteness is reduced to the minimum. In the case of the proposals in the Bill, this danger seems to me particularly conspicuous. For reasons which no doubt the Government feel are good ones the organisation they are proposing is really a very hierarchical bureaucratic one. Power and authority are imposed from the top downwards. The Minister appoints almost everyone and approves almost everything. That in practice means that he does so on the advice of his officials. It will be an organisation run from the top and from the centre. Those of us who served in another place will remember the invariable reaction of Ministers on these occasions: "You need not worry; Ministers will exercise their power reasonably, after consultation." I think the noble Lord, Lord Brown, mentioned the point about consultation, but we know that when we are passing legislation we must not have our fears calmed down by that assurance.
Up to a point I think it is not unreasonable, when one remembers that the money is to come from central funds and 28 that a great deal of public money is involved, that the Secretary of State should keep reasonably tight hold on the purse strings and take an active interest in his responsibilities for accountability. But this is not a unique constitutional problem. The central difficulty confronting legislators in a Bill such as this is how to reconcile the responsibility of the Minister to control the public funds which have been allocated to the Service with the vital contribution which can and ought to be made to the administration by the democratically expressed voice of the users of the Service. It is the considered view of the local authority bodies —all four of them, I think—that in the proposals put forward in the Bill there is not enough democratic participation to be effective.
The noble Baroness, Lady Serota, made the point about the sharp distinction which the Government appear to draw between managerial responsibility and local representation, and if that distinction really were as sharp as they appear to think, it would be a very poor look-out for local government as a whole; I think it would be a very sad situation indeed. We believe that the arguments that have been adduced (and they will also, I am sure, come from other sources) do call for an amendment to the proposals in the Bill in respect of the Regional Authorities, the Area Authorities and the community councils—though at the moment we are debating only the Regional Authorities. That these Regional Authorities should be entirely composed of Government appointees I cannot believe is right or necessary.
It is true, as the noble Lord, Lord Brown, said, that appointments will be made by the Minister after consultation, but the choice of the members remains that of the Secretary of State. As regards the representation of the democratically elected members, the views of many of us in local government rather differ from that of Ministers, as we understand it. I think Ministers probably accept that the work of the Regional Authorities in certain particular matters, such as planning, will be of interest to local authorities, and therefore certain links are required, in particular perhaps between the Regional Authorities and comparable local authority services, so far as some aspects overlap. But many of us 29 look at it rather more widely than that. We believe that elected members of local authorities could bring to bear on the work of the Regional Authorities most useful knowledge and experience of what people want in general ways. That is to say, it will not be purely a technical view of one committee of the local authority about one matter, but will cover a very broad front. That seems to me rather a difference of outlook. I would urge the Ministers to try to check whether their view is not a rather narrow one in this respect. We feel that some local authority members will be a valuable element on all these decision-making bodies in the work of their decision making. We believe, therefore, there should be some minimum representation of local government on all these Authorities. Surely a sensible apportionment of the representation could be worked out. I strongly support the principle that runs through these Amendments, and I would urge my noble friend to look at them very carefully. If he finds something which will alleviate the anxieties we feel and give effect to that principle in a better way than any of these Amendments do, I am sure we shall be very grateful to him and shall be willing not to press our particular Amendments.
I should like to make only one point, which I believe has not yet been made in this interesting debate. In the arguments in favour of ensuring that there is full and proper local authority representation on all these bodies there is one point which I believe is very important. It is from these local authority members that originality is likely to flow. My experience of appointments made by Ministers is that they are very sound and capable men but all too often are safe men, because no official is going to recommend to his Minister that he should appoint someone who is going to be a nuisance. If anyone wants to make a career of Ministers' appointments on these and other bodies he must prove that he is competent and that he is safe. That sort of situation is not going to produce the originality of thought that an organisation like this must have at all levels. It can of course be said that some local authorities may send their awkward squad on to a body like this. But it is a risk that I think the Minister 30 must take, that there should be occasional local authority members who do not understand what it is about and who will perhaps press their own King Charles's heads. None the less, it is from the local authority members that this very important originality of thought is likely to come.
§ LORD VIVIAN
Before the Minister replies, may I say that I feel that the Amendment moved by the noble Baroness, Lady Serota, would be of help in improving the Bill. All noble Lords in this House know of, and are deeply grateful to the noble Baroness for, the tremendous amount of work which she herself performed for the National Health Service when in office as a Minister in this House. During that time I approached the noble Baroness on several occasions with regard to the position and standing of medical practitioners; and I received the greatest courtesy and encouragement from her on this and on several other matters concerning national health. I shall certainly listen to what the Minister, the noble Lord, Lord Aberdare, has to say, but I hope that when he replies on behalf of the Government he will very carefully weigh up the reasoning of the noble Baroness. I believe that if the noble Lord, Lord Aberdare, and the noble Baroness got together they could work out some measure that would be acceptable to both sides of the House and of benefit to this Bill. It is therefore my hope that the Minister will not turn down this Amendment but will take it away and look at it again to see whether he can meet the noble Baroness.
§ LORD DAVIES OF LEEK
I apologise to the Minister for having come in late, but due to the fog I could not make it earlier. Consequently I will be brief but shall try to be cogent. I should like to support the request of the noble Lord who has just sat down. I sincerely hope that the Minister will take this back and look at it. I was reading with interest of the World Health Organisation symposium which was held in Stockholm in April, 1970. The title of the symposium, and the papers from medical experts and others, was Stress and Disease in Society; and it dealt with The Psychosocial Environment and Psychosomatic Diseases in man. We know that 31 90 per cent. of all National Health Service patients first of all come to the base of the pyramid, the "P.B.I." of the Health Service, the general practitioner. He is down at the base. I think that it was Gould who wrote an article in the New Statesman a few months ago saying that we should get rid of the concept of "cottage medicine". We still have the general practitioner working in medicine like those in the old cottage industries before we had the Industrial Revolution in Britain.
I think he should have his place, and in view of the fact that 90 per cent. of the National Health Service depends on that pyramid I believe that he should have his say in the set-up of the Health Service. When using the phrase "cottage medicine", we must think of more and better health centres. May I appeal for a more democratic approach? God forbid this apotheosis of management! There is more in life than efficiency; there is living for the love of life. Nature is not just efficient; nature is erratic, with its abundance when it is producing. It is only man, through his ideas of efficiency and management, who thinks that he is making a better world. He is mismanaging his environment, so much so that probably 70 per cent. of the diseases we have today are psychosomatic: diseases of the mind and neuroses.
May I now quote from an article headed "The Human Factor—And The Inhuman", and say first, anent the symposium in Stockholm, that this kind of organisation is building up the inhuman side of it:When man becomes maladjusted to his physical, social and psychological environment, the blame is usually placed on 'the human factor'. Implicit in such criticism is the idea that the human organism, evolved more than 500,000 years ago, is now outmoded. Much of today's medical activity is concerned with the diseases induced by man's present environment and by his unsuccessful adaptation to it. Much less attention is paid to 'the inhuman factor', by which is meant environmental conditions, often arising from modern civilisation, that induce disturbances of a medical and/or social nature even in a perfectly normal biological organism.I will finish there because I do not want to trespass on the time of the Committee after having made my apology for coming in late for this important debate. I finish with this remark, without going into 32 it in depth because there is so much knowledge in this Chamber: this Part of the Bill is where all the power is concentrated. Even if a man were a genius and had the finest soul on earth, it would be too much power in one focal point. Therefore, I hope that after this debate —and I have heard quite a fair amount of it—the Minister, having heard from both sides of the House, will be good enough to reconsider this clause as it now stands.
§ 3.54 p.m.
§ LORD ABERDARE
I have listened with great interest to this debate, and we have had some notable speeches in the course of it. If there is one thing that has got slightly under my skin it is the complete misrepresentation of the sort of people that we hope to see on the Regional Health Authorities. I must say to my noble friend Lord Brooke of Cumnor that when he referred to "managerial technocrats" and to a "small group of experts in management" it was the most unkind cut of all. I felt like howling out, "Et tu, Brookie!". That is not our intention in any degree at all. Perhaps the simplest thing to do would be to read out, for those of your Lordships who may have failed to read the passage, paragraph 96 of our White Paper.The work to be done by the members calls for general ability and personality. They will need to be interested in the NHS; to have an unbiased, questioning yet constructive approach and good judgment; to set high standards and provide vigorous leadership. A diversity and a proper balance of relevant ability and experience are also called for. These needs can best be met if, in the main, members are chosen for their personal qualities after appropriate consultations, not elected as representatives reflecting the views of particular interests.There is nothing in that paragraph that mentions management, or managerial technocrats, or anything of that sort.
§ BARONESS SEROTA
Would the noble Lord allow me to interrupt for one moment? It is not really for me to defend the noble Lord, Lord Brooke of Cumnor, but I must point out to the Minister a sentence that appeared in the Consultative Document, when it said quite categorically:The authorities will be kept small and management ability will be the main criterion for the selection of members.
§ LORD ABERDARE
It is no good quoting the Consultative Document, because that is what we were consulting about. We have now put down in the White Paper what we are going to do, and that is much more relevant to what we are discussing now.
May I turn to the Amendment itself? I dislike the Amendment, and I am sorry to say that I could not possibly advise your Lordships to accept it, first of all on the grounds of principle and secondly because I do not believe that it is practicable. Schedule 1 proposes that appointments to Regional Health Authorities should be made by the Secretary of State after consultation with interested bodies. The Amendment would have the effect of making the Regional Health Authorities bodies representative, in the main, of local authorities and of some of the health care professions. I would ask your Lordships which approach is the more likely to enable these Regional Authorities to carry out effectively the important functions that they will have entrusted to them.
They will be responsible for the expenditure of many millions of pounds; some of it for allocation to the Area Health Authorities in their region, and some of it on the provision of regional services and specialties. What we are looking for is a good mix of people from various walks of life, but all united in the one aim of providing a comprehensive Health Service and putting the available resources to the best possible use. We believe that this will be best achieved if the Secretary of State is free to make the appointments to the Regional Health Authorities, just as he does now to the Regional Hospital Boards—and they are bodies that represent all sorts of different interests. They are all appointed by the Secretary of State and I know of no serious criticisms of what they do at the moment, although there has been mention by the noble Baroness, and I think my noble friend Lord Brooke of Cumnor, of their remoteness. But under the set-up that is proposed in the Bill, the Area Health Authorities will be much closer to the people who are using the Service, and these authorities will come between the Regional Health Authority and the hospitals and health centres themselves. Therefore, that remoteness, I suggest, will be of slightly less importance.
34 I found a good deal of sense was spoken in the words of the noble Lord, Lord Brown. I certainly do not think that one wants only people of managerial capacity. I think that one wants to have a body at regional level who have one aim in mind. There were at one time two alternatives for the new Health Service. It could have been organised under the local authorities, but that was not the solution accepted by the last Government, nor is it the solution accepted by this Government. But those who criticise the proposed organisation on the grounds that it pays insufficient heed to the needs of the patient would be the first to accuse the Secretary of State if those needs were not being met. He is responsible under this Bill for the provision of the Service. How can we hold him responsible, unless he has at least the necessary powers to run the Service for which he is responsible?
The Amendment which we are considering would allow him to appoint only one-third of the members of the Authority which is his principal agent. I do not see how he could be held responsible for the Service if he appointed only one-third of the members at the Regional Health Authority level. I can see the dilemma in which members might be placed if disputes arose at some point between their appointing bodies and the Secretary of State, and it seems to me wrong to build tensions of this sort into the Regional Health Authorities. I believe that the Secretary of State must be able to determine the choice of people who are to be his direct agents in the National Health Service for which he is responsible, although I agree that he must consult wisely before making his choice. He will certainly appoint members of Regional Health Authorities from the local authorities and from the professions, but the Amendment would weaken the Authorities' accountability since no single appointing source could make changes in membership sufficient to remedy weaknesses in performance. Each group would be a distinct entity and, in effect, it would be a collection of minorities rather than a team and no one could be held responsible.
As for the practicalities, I very much doubt whether what is proposed in the Amendment could work. It would require 35 one-third of a total membership of between fifteen and twenty-five to be appointed jointly by the local authorities and the Health Authorities wholly or partly within the regional boundaries. What would this mean in one of the larger regions, such as the present Sheffield region? Between five and eight members would have to be chosen by all the Area Health Authorities, provincial counties, metropolitan counties, metropolitan districts and non-metropolitan districts. In Sheffield, that would be a total of some fifty separate authorities competing for from five to eight places. How would they make the choice? How would a balance be struck between members from the Area Health Authorities and members from local government? How would the separate categories of local authority determine their total and separate shares? I know that later the noble Baroness has down Amendment No. 59, to provide a means for resolving disagreements, but I really cannot see it working and I can only think that under Amendment No. 59 we should come back to the Secretary of State making all the appointments because the others could not agree.
Then the Amendment calls for one-third of the members to be appointed jointly by six of the health care professions—doctors, dentists, nurses, midwives, pharmacists and opticians. If we take the Sheffield region again, there are about 25,000 people from those professions: and how are they to select their five, six, seven or eight representatives? Further than that, would each profession choose a specified number of candidates? If there were only five places, this would seem to mean just one place per profession, if one put the nurses and midwives together. And would the doctors be satisfied with only one place on the Authority? There are also other professions providing health care which may not feel happy about the set-up. So I really feel that the Amendment as it stands at the moment is muddled and impractical.
But on general grounds of principle, I do not feel it to be right that for the Regional Health Authority, which is the main agent of the Secretary of State for the running of the Health Service with which he has been charged, the majority of the members should be 36 appointed by interests other than himself. I fully recognise the tremendous contribution that can be made by local authorities and, as I have said, there will be members of local authorities appointed to the Regional Health Authorities by the Secretary of State after consultation with them. But we have built into this Bill the closest possible relationship with local authorities at the Area level. It is there that we have the most intimate working arrangements with local authorities, and deliberately so. One of the main reasons for having Area Health Authorities was to link in as closely as possible with local authorities.
But there are certain aspects of the composition of the Regional Health Authority which have been mentioned this afternoon, which I certainly wish to look at and think about again. My noble friend Lord Brooke was on to an important point when he mentioned its size and I shall certainly look at that aspect, because we want to keep it small and manageable. We do not want large committees which are very often unwieldy but there is nothing rigid about the figure of 15. I am equally convinced, as is my noble friend Lord Amory, that there is a great contribution to be made by local authority members and we see this coming at Area level. Again, I have no reason for not thinking very carefully about this aspect in relation to the Regional Health Authority.
May I make one point in answer to the question which the noble Baroness, Lady Serota, asked me about participation and collaboration arrangements between local authorities and the Health Service? First of all, the joint consultative committee of the Area Health Authority and the local authority will consist of members, although it will be supported by a group of the appropriate chief officers of the authorities. The proposal is that the Regional Health Authority should be represented in the Area Health Authority's membership of the joint consultative committee, so that they would partake with the appropriate Area Health Authority in consultation with the matching local authority. I think I have given the reasons why I am afraid that I find this Amendment unacceptable, both in principle and in practice. But I have said that there are certain points with regard to the composition 37 of the Regional Health Authority that I will look at, if I may, and in those circumstances I would ask the noble Baroness whether she is prepared to withdraw this Amendment.
§ 4.10 p.m.
§ BARONESS SEROTA
I must first apologise to the noble Lord, Lord Aberdare, if I have been both muddled and impractical this afternoon. I have been seeking only to ventilate some of the issues of principle which I think all Members of the Committee are anxious to consider, before we come to any final conclusions on what we regard as a very important part of the Bill.
May I say straight away that I welcome the offer of the noble Lord, Lord Aberdare, to look again at the size of the Regional Health Authorities; and I was also glad to hear his, I thought, somewhat qualified undertaking that he might possibly consider including some element of local authority membership. That part of his reply was not quite clear, and I should like to have something rather more categoric from him before we come to a decision on some of the issues involved. Until now the Government have not been able to accept any element of this kind in the membership of the authorities, and before coming to a decision I think we should be a little clearer in our minds as to what is intended here now.
I should also like to make it quite clear—and I think I can say this on behalf of all noble Lords who have spoken in the Committee to-day and who believe that the representative function and the directional management function are not incompatible—that we all of us, on all sides of the Committee, are just as concerned with the good management of the Health Service as those who take the other point of view. Indeed, on the contrary, our anxiety to see efficient management and the most effective use of resources in so vital and expensive a Service as the Health Service is such that it inclines us even more to the kind of proposals we have been putting forward as regards membership than to the proposals put forward by those who have been determining the policy of the Government.
It is strange that the only ally that the noble Lord, Lord Aberdare, has found to-day is in the powerful support of my 38 noble friend Lord Brown. So far, in three days of Committee stage, my noble friend is the only person who has supported the Government positively in this definition and delineation of the role of the manager and the role of the consumer, of the professional and the public service interest in the policy-making processes of the Health Service. Like my noble friend Lord Leatherland, I too fully recognise the long experience of my noble friend Lord Brown as a practising manager in the engineering industry; his great concern with the social organisations through which the manager works; and, above all, the value of the action research studies which he has undertaken in co-operation with Professor Elliot Jaques. But that does not mean that one must agree with all the experts in the field of organisational theory. Indeed, they very much differ as between themselves; and I take the view—and I think those noble Lords who have spoken to-day hold a similar view—that the major factors which affect the management of the engineering industry (such as development, production and sales) are not quite the same as those with which we are concerned in a social service like the Health Service.
There is, I think, a growing concern that lies behind much of our thinking—and I tried to make this point on Second Reading—that as organisations increase in size and complexity the needs of society and of individuals within it should not become subservient to the needs of the organisation, and that loyalties to organisational goals—and I felt this particularly while reading through the Grey Paper—should not supersede loyalties to social goals; again, above all in a service like the National Health Service. What we are trying to say to the Government to-day, I think, is that social services and their organisational structure must react to information that feeds through from the environment, from the consumer and from the public if they are to provide truly sensitive social services.
The noble Lord, Lord Aberdare, was quite right: there are very deep differences between us on this matter. There are deep differences of principle and there are deep differences of approach, although I welcome the offer that he has made in relation to the size of the authorities and to the possible inclusion of 39 local authorities. But these differences exist, and I think it would be unwise in a Committee stage debate to attempt to paper them over. Indeed, I hope the Committee will be prepared to express its views on this particular Amendment in the light of all the cogent arguments that have been advanced. I am not going to pretend for one moment that the wording is perfect. I take some of the points that the noble Lord, Lord Aberdare, made, although I am not sure that I quite agree with the numbers that he gave the Committee. This is Committee stage, and if your Lordships were to accept the principle I would be more than willing to come together with other noble Lords, and indeed with the Government, as the noble Lord, Lord Vivian, has suggested, in order to produce a better, a more practical and a less muddled answer. But the principle is important, and I very much hope that the Committee will support it.
§ LORD BROWN
Perhaps I may make a comment to my noble friend Lady Serota. I am very much obliged to her for the generous references she made to me, but I wonder whether the Committee fully realises the implications of this Amendment. There are very many Government services, and I do not know of one which adopts the principle that is involved in this Amendment; because all these Government services are in the last analysis responsible to some Minister who is indeed accountable to Parliament itself. If this Committee were to put on a Regional Health Authority a majority of people who are not appointed by the Secretary of State, and if that majority of people were to decide to do something with the resources which did not meet with the approval of the Secretary of State, then the Secretary of State would cease to be accountable to Parliament. So that in effect this Amendment could interfere with the accountability of Ministers to Parliament. This is not a question of opinion: this is a question of fact. I think the Committee ought to be fully aware of what they are doing before they move in this direction if they are going to vote on this Amendment, because it is a very serious principle indeed.
Great emphasis has been laid on the democratic results which would flow from this Amendment. Perhaps I may point 40 out that Parliament itself is a democratic assembly, and that Members of Parliament can raise issues about the Health Service quite freely, that members of the public can raise them with the Commissioner and that they can raise them with the community health councils. They can do all these things. I really think it would be a great mistake in principle to put a Regional Health Authority in a situation the result of which would be that the Secretary of State himself could not be held accountable by Parliament.
§ LORD BROOKE OF CUMNOR
Before your Lordships come to a decision on this matter, may I be allowed to say two things? I could not support the Amendment of the noble Baroness, Lady Serota. I do not think that this tripartite method of appointment is the right one. I prefer, in general, what the Government have proposed, though I do not think that that is ideal, either. But I certainly hope that the Amendment moved by the noble Baroness, Lady Serota, will not be carried. I am grateful to my noble friend Lord Aberdare for what he said in reply to me. He very aptly quoted paragraph 96 with an implicit suggestion that I had not properly studied that paragraph. I think I had, but I had been influenced, I confess, also by paragraph 106 of the White Paper, and I hope he will give further consideration to that between now and the next stage of the Bill, because in that paragraph it says:The expression of local public opinion can be catered for in one of two ways. It can be done indirectly by including in the membership of the health authorities local people serving in a representative capacity. Or it can be done more directly through bodies specially set up for this purpose, with direct links to the authorities. The Government prefer the second course. It allows each of the interests—management and the community—to concentrate on its own special function".et cetera. From that I certainly gained the impression that those who are members of a Regional Hospital Authority are to concentrate on management and are to await the reactions of the community health councils, the local authorities, and so forth, to represent to them the interests of the public. I think the interests of the public must be represented from the very start on the executive body. That is what I am seeking to establish. I hope that the Government will withdraw from the somewhat rigid position that they have taken up in paragraph 106.
§ 4.20 p.m.
§ BARONESS WHITE
Before we leave this point, I should like the Government to consider the strategic planning functions of these Regional Health Authorities because it is extremely important that anyone undertaking this particular function of theirs (and I know they have others) should be very well aware of what is in the minds particularly of the major local authorities. Elected regional authorities may possibly come about, but we do not know, out of the Kilbracken deliberations. When we are going to receive their report, Heaven knows! But in default of that, surely the noble Lord, Lord Brooke, is right, that there should be some correlation between the great local authorities who are responsible for all the other social planning in their areas and the Regional Health Authorities. If one does not have some provision for that there will be difficulties in having common thoughts on these matters which affect the totality of social planning in the areas of which health planning is one part.
On the point made by my noble friend Lord Brown which, from what he has said, I am quite sure is much in the mind of the noble Lord, Lord Aberdare, and certainly is in the minds of the Treasury—this business of the accountability of the Minister to Parliament if persons appointed to these bodies are not all appointed by him or are even necessarily predominantly appointed by him—if the Minister through the Treasury is the source of supplies, of course he has one very simple sanction. If he thinks they are acting improperly he can withhold the supplies. It is unlikely that such a situation will be reached; but as a matter of political theory one ought at least to keep in mind that the Minister does have the whip hand in so far as ultimately he is the person who finances the service concerned.
Therefore no matter what such an authority might wish to do, they know that ultimately the Minister has this overriding sanction of finance. I do not feel that we should be unduly frightened by that in the way suggested by my noble friend Lord Brown. Had the Government decided that this was a completely reprehensible doctrine, I assume that they would not have included paragraph 106 42 in their White Paper; because they put it in as a reputable alternative, but one which on balance was less desirable than the one they proposed. I do not think the Committee should be frightened by the figure of a Minister who will be completely helpless at the hands of a body that he has not entirely appointed himself.
§ LORD GARNSWORTHY
Before the Minister replies, may I say that I have listened to the debate and have been impressed by the fact that with one exception there appears to be unanimity on the part of those who have spoken. I have the feeling that they have considerable support in the Committee that the Bill is not right and that the Government are showing too little inclination to give consideration in depth to the views that have been expressed here this afternoon. The Minister in his reply indicated that he would give some further thought to what the noble Lord, Lord Brooke, had to say. I wonder whether he could go further. I am sure that we on this side do not want to divide if that can be avoided; on the other hand, if we are forced, we may have to consider that course. Would the Minister indicate that he would have consultations with those who can speak in representative authority? The noble Viscount, Lord Amory, for instance, knows very well the views of the county council associations; the noble Lord, Lord Brooke, knows the views of the A.M.C., and my noble friend Lady Serota is recognised by everybody as an expert in this field, not only as a consequence of Ministerial office but from a lifetime of service in the public field. Would the noble Lord, Lord Aberdare, go so far as to say that he would be willing to have a meeting before Report stage, to see whether it is possible to reach some compromise which would give some satisfaction to those who have spoken so strongly and who feel as deeply as they have indicated?
§ VISCOUNT AMORY
My noble friend may be able to respond to Lord Garnsworthy's suggestion in some way because it will be a pity if we have to divide on this Amendment about which I think many of us have some worries—worries about the wording and about some of the proposals, though not about the most important part.
§ LORD ABERDARE
I am quite ready to go ahead to try to help the Committee if I can. I am completely convinced that the Amendment is wrong. I cannot accept that the Secretary of State should appoint only a minority of the main agents in a service which is necessarily centrally organised. I do not agree with the noble Baroness, Lady White, that the financial sanction is really a valid one because the Secretary of State will be giving them a large budget and you cannot expect him to fine them because they have done something he does not approve of. It is more normal where a Minister is responsible for a service for him to have a majority on the agency which is responsible to him.
So far as the strategic planning functions go, the difficulty is that there is no corresponding local authority that embraces the same area as the Regional Health Authority. I have no doubt that the Regional Health Authority will wish to be in the closest possible touch with the strategic planning of the local authorities within its region. But there is no reason thereby to say that of right those local authorities should have their members on the Regional Health Authority. Two bodies can co-operate satisfactorily, I should have thought. But I am impressed, and always have been impressed, by what my noble friends Lord Amory and Lord Brooke say. I will certainly see whether I can help in any way to satisfy them and to satisfy noble Lords opposite who have expressed the need for closer co-operation at regional level with the local authorities. If we could have conversations on that point I will certainly see what I can do. But I am afraid that I cannot accept the Amendment as it is.
§ BARONESS SEROTA
The Committee has given a considerable amount of time to this issue which I only opened up on Amendment 45. I am grateful to the noble Lord, Lord Aberdare, for the way in which he has received the comments made on what I realise is his "baby" which we have been, so to speak, tearing to pieces in public in front of his eyes. I know that for Ministers this can be a painful process. I hope that he will appreciate that we believe we are doing this in the most constructive way possible. In view of what he has said, and subject 44 to the agreement of my noble friends who have also put their names to this Amendment, I should be inclined to withdraw it at this stage on the basis that we can talk between now and Report stage and come back with other proposals. I, myself, do not move one inch from the general principles that I have enunciated. I accept that there are drafting difficulties with this Amendment and that from some of the views put forward it would be helpful to come together for talks. On that basis I am prepared to withdraw the Amendment. I hope that my noble friends who have put their names to it will agree that I should do so.
§ Amendment, by leave, withdrawn.
§ 4.30 p.m.
LORD BROCK moved Amendment No. 47:
Page 49, line 9, at end insert ("and not less than one-quarter of these other members shall be medical practitioners").
§ The noble Lord said: I beg to move Amendment No. 47 which is in my name and the names of my noble colleagues. With the permission of the Committee, I should like to take with it Amendment No. 50, as the two Amendments are essentially similar. They are concerned with ensuring that there is adequate medical representation on governing and advisory committees of the new Administrative authorities. There is nothing in the Bill to limit the number of doctors even to a quarter, but the White Paper suggests that the number of doctors could be quite small. For example, on page 23, paragraph 99, it is stated that the professional members will not be prescribed and may indeed differ from area to area, but it implies that the format could be, or need be, only two doctors in a committee of 15. The Amendment prescribes that such a committee should have double that number.
§ The medical representation should be at least as strong as it is on the present authorities of the National Health Service. The present practice is that on the board of governors of a teaching hospital a quarter are medical, and on a Regional Hospital Board one-fifth are medical. This, therefore, is a good and acceptable precedent; but it is not in the Bill. The proportion of medical members dates from the Guillebaud Report of 1950 which recommended it then, and has been 45 adhered to since. I hope the Minister will be willing to insert some prescription of the proportion of medical members on governing and ordinary committees.
§ LORD PLATT
My noble friend Lord Brock has made the purpose of this Amendment perfectly clear and there is nothing difficult to understand, so I will not elaborate it. I should like to point out one thing, though I am sure that it will not have escaped the noble Lord, Lord Aberdare. It is that this Amendment does not dispute the principle of the appointment by the Secretary of State, which Amendment No. 5 would have replaced by another mechanism, because its place, if accepted, would be after the words which give the Secretary of State the appointment of such other members as he thinks fit.
§ LORD ABERDARE
I appreciate the reasons that actuated the noble Lords to move this Amendment but it does not appeal to me very much because I would reiterate that what we want at the Regional Health Authority level is a number of people of different backgrounds, different interests, different talents. Although these will certainly include medical practitioners we feel that it would be wrong to tie the hands of the Secretary of State to appointing a specific proportion of the Regional Health Authorities from medical practitioners. It is not true that in the case of the present health authorities there is a requirement that there shall be a minimum of 25 per cent. medical practitioner membership. The present position is that in 1956, in Hospital Memorandum 111, it was announced that the Minister would not normally appoint more than 25 per cent. doctors on to a Regional Hospital Board, and he asked the Boards to follow this same practice in appointing their hospital management committees.
The boards of governors have one-fifth (I think the noble Lord said a quarter) of their members appointed after consultation with the senior medical and dental teaching staff. Executive councils with a membership of 30 have eight members appointed by the local medical committee, and this will continue to be the practice with family practitioner committees; and of course, local health authorities do not necessarily have any medical members on their boards, 46 although doctors may be elected as councillors in the normal way. But the Regional and Area Health Authorities will not be the same as the present hospital authorities. They will have wider responsibilities and functions and will be composed on a different basis. We believe that it would be wrong to specify a particular number of medical practitioners on either the Regional Health Authority or the Health Authority, although we give the assurance that there will be doctors on both bodies.
I should like to make clear that in this Bill we are bringing the doctors even closer into the management, into partnership, with the Service than has ever been the case before. I have said that there will be doctors at both Regional and Area Health Authority level. At all levels, regional, area and district, there will be strong medical advisory committees. I am sure the noble Lord will know that we are in close consultation now with the medical profession and discussing just how those medical advisory committees can best be set up to ensure that essential medical advice is available at all levels.
Under the management study proposals the regional and the area medical officers will be members of the regional and area teams of officers. At district level, the district management team is to contain two elected members from the district medical committee, one being a consultant and one being a G.P., as well as the district community physician; so that will be three doctors out of a total of six on that team. We are also confident that doctors will play a full part in the proposed health care planning teams studying various aspects of the Health Service within a district. I do not think that anyone can accuse us of not having taken due account of the need for doctors to be an integral part of the proposed management structure. But, just as I have been trying to defend the position that we do not want to allocate specific numbers of places on the Regional Health Authority to the, local authorities, I equally hope that it will not be thought wise to specify a certain number of places on the Regional Health Authority for the medical profession. I would ask your Lordships to leave it in the hands of the Secretary of State to make sensible decisions on how the Regional Health Authorities should be constituted, taking 47 into account the fact that there will be medical members after consultation with the profession.
§ LORD BROCK
I thank the Minister for his reply. I do not wish to divide the Committee on a matter such as this. I must trust to the good sense of the Secretary of State, and that he will pay attention to the inevitable value of the medical profession in the various committees and consultations. I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ BARONESS SEROTA
I beg to move Amendment No. 49B, if only to ask the Minister to reply to the question that I put to him on this part of the Schedule when I spoke earlier. I realise that he was then concerned with the wider issues of a major Amendment but I hope that this will give him an opportunity to tell the Committee that the Government are prepared to accept this Amendment.
Page 49, line 25, after ("bodies") insert ("including trade unions, and voluntary organisations").—(Baroness Serota.)
§ LORD ABERDARE
Yes, I am sorry; I meant to answer that matter earlier, but perhaps it will be more convenient to do so now. It is certainly our intention that the Secretary of State shall consult the Trades Union Congress rather than trade unions as referred to in the Amendment. It has been the practice hitherto that Regional Hospital Boards consult the T.U.C. (and I hope that the noble Baroness would think that the right thing to do in the future) and voluntary organisations before making appointments to Regional Health Authorities. The reason why these bodies are not specified in the Schedule is simply that they are one of a number of organisations which will be consulted, such as the C.B.I. for example. It seemed invidious to mention some but not all bodies, yet to attempt to mention all would import a certain rigidity. The Scottish Act certainly makes no such provision. However, I agree with the substance of the Amendment. I should not like to accept it as it stands, because I would rather see "T.U.C." than "trade unions". If the noble Baroness will allow me to consider it, I will see whether before the next stage 48 of the Bill I can find some wording that will satisfy what she has in mind.
§ BARONESS SEROTA
I am grateful to the noble Lord for his offer, and without taking up any more time I will ask leave to withdraw the Amendment, looking forward to hearing further from the noble Lord at Report stage.
§ Amendment, by leave, withdrawn.
§ 4.41 p.m.
BARONESS SEROTA moved Amendment No. 51:
Page 49, line 43, leave out from beginning of line 43 to end of line 8 on page 50, and insert—
(b) the Chairman or a member of the Family Practitioner Committee for the area of the Area Health Authority;
(c) a specified number of members, which shall be not less than one third of the total number of members, to be jointly appointed by all the local authorities for the area of the Area Health Authority;
(d) a specified number of members, which shall be not less than one third of the total number of members to be jointly appointed by persons representative of the following categories, namely:
§ (e) as to a specified number, members appointed by the Secretary of State, after taking into account recommendations made to him by the relevant Regional Health Authority after consultation by that Authority, except in prescribed cases, with the bodies mentioned in sub-paragraph (2) of this paragraph; and
§ (f) a specified number of members to be appointed by the Secretary of State on the nomination of the university or universities specified as being associated with the provision of health services in the said area.")
§ The noble Baroness said: I beg to move Amendment No. 51 standing in my name and those of my noble friends Lord Garnsworthy and Lady White. I know that my noble friend Lady White is most anxious to speak to this Amendment, particularly because of the views that she holds about the proposed composition of the Area Health Authorities. As she appears to be elsewhere at the moment, I wonder whether I might begin 49 the debate, which of course affects a number of other Amendments that appear on the Marshalled List, by making special mention of the proposal in the Amendment which refers to the inclusion of the chairman or a member of the family practitioner committee as a member of the Area Health Authority as of right. That is a matter that we touched on at Second Reading. I hope, having put the Amendment down early, that the Minister, when he comes to reply, will be able to say something about this proposal.
§ As the noble Lord knows, there has been criticism of the appearance that we are creating not an integrated Service out of our present tripartite Service, but one that will integrate the hospital and the local authority services, leaving the vital contribution of the community-based general practitioner services separate from the other two parts. We are fully aware of the thinking behind the Government's proposals to establish through the Bill the special statutory family practitioner committee to preserve the independent contractor status of the general practitioner; but we believe that there would be a danger of their working in isolation if they were too rigidly segregated in that committee, and we are most anxious that they should participate in the wider policy planning and the day-to-day provision of service considerations of the Area Health Authority. That was the reason behind the inclusion of the chairman or a member of the family practitioner committee on the committee of each Area Health Authority. As I have said, I hope that when the noble Lord comes to reply he will let us know the Government's reaction to this suggestion. As I said at the outset in moving this Amendment, I know my noble friend Lady White wishes to speak to it in Committee, and therefore I will sit down to enable her to put forward her views. I beg to move.
§ BARONESS WHITE
I think my noble friend Lady Serota has put clearly the kind of considerations which we had in mind. We are concerned to some degree with the same sort of considerations as arose on the previous Amendments in relation to the Regional Health Authority. We recognise that the Area Health Authorities have more specific local functions, and we are anxious, as the Amendment plainly indicates, that the 50 other parts of the local health services, namely, those which will come under the family practitioner committee and those which are now being taken over from the elected authorities, should all be drawn together and that those working in the services and in similar capacities professionally should have some say in the working of the services. We are also much concerned, as we were previously, as to the kind of consultation which may take place, including consultation with trade unions and voluntary organisations. I have another Amendment down later on which applies only to Wales, but I think that we should take it as a separate Amendment and I will not elaborate on it now.
Before we press this Amendment further, I think it would be desirable to hear what the reaction of the Government is to these propositions. Not a great deal is said in the documentation that we have in the White Paper and so on about the principles on which the Government propose to order the membership of the Area Health Authorities. We in Wales, again, are in a particularly sensitive situation, because we shall not have a Regional Health Authority to carry out the function of appointing the Area Health Authorities: we shall be directly dependent upon the Secretary of State for Wales. Therefore, for us, I think there is a particular interest in the composition of the Area Health Authorities. We want to be doubly certain that the various elements at area level are adequately included in the proposed membership. If, in making his comments, the noble Lord, Lord Aberdare, is able to say something further about our particular Welsh concerns, in addition to the important but minor one in Amendment No. 57, I and others who have Welsh interests shall be particularly obliged.
§ LORD BROOKE OF CUMNOR
If it is acceptable to the noble Baroness, Lady Serota, and to my noble friend Lord Aberdare, I think it might save the time of the Committee if I were to speak to my Amendments Nos. 54 and 55, thus widening the debate on this Amendment into a general debate on the composition of the Area Health Authorities, rather than to move those Amendments separately, because there is a certain amount of overlap. There are two 51 separate points made in my Amendments. The first is that there should be not less than five local authority members appointed by the local authorities to the Area Health Authority. Even on the Government's plan, I think that at least five will be needed, because the Government look on these people as making links with the local authority services. In paragraph 98 of the White Paper the Government say:Because of the need for close decision-making links with the local authority services, local authority members who are active in the management of the personal social services, education and other relevant services, should have places on the Area Health Authorities and four members of it will therefore be appointed by the corresponding local authority.I do not quite follow that word "therefore", because if in fact these people are to be active in the management of the personal social services, education and other relevant services, at least five will be required: there are at least three other relevant services. In addition to the personal social services and education, which are mentioned here, there are planning, housing, and environmental health; and you could not gamble on the possibility that any one of the local authority people would be adequate as links with more than one of those services. So it seems to me, on the Government's own argument, that there should be at least five local authority people on the Area Health Authority. I would say again, if I may, that the number of 15 will prove to be too small in the normal case for the membership of one of these authorities. I know that the Area Health Authority can co-opt to committees and so forth, but it will be the members themselves who will need to be seen visiting hospitals and other units, as described in paragraph 95. That in itself will be a considerable burden on the small number of members of the Area Health Authority. I cannot see any reason why one should not have an efficiently-composed membership and yet go somewhat beyond the figure of 15. I am not pleading for a particular percentage to be local authority nominees; I am anxious that there should be more than four, which it seems is the figure chosen by the Government.
My second Amendment raises a different point. It does not accept the 52 argument in the Government White Paper that the need for having local authority people on the Area Health Authority is not because they will be representative of the public but because they will establish links with the relevant social services of the local authorities. I do not think one can have local authority nominees confined to this sort of function. If you are elected to a local authority, you may become interested in a particular service and become highly knowledgeable about it, but you cannot put away from you the fact that you have been elected and that you are a representative of the view of the public.
I do not want to repeat the speech that I made on the previous Amendment, but really find it very hard to accept that representation of the views of the public should be kept away from these health authorities. I appreciate the Government's argument that there will be quite enough of them in the community health council and that the Area Health Authority will do its work more quickly, sensibly and effectively if it does not have representatives of the public on it. That is a view that I cannot accept and that is the purpose of my second Amendment. If my second Amendment were accepted by the Government, it would mean that these local authority representatives on Regional Health Authorities would not be confined in their work there to one particular function; that is, acting as links with the relevant local authority services. They would do that, but in addition they would be an extra channel of communication of local opinion to the Area Health Authority. I cannot help thinking, despite the rigid views of the noble Lord, Lord Brown, that the Area Health Authority would be the better for it, provided that the representatives are sensibly chosen—and I think one must assume that in general, though there may be mistakes, the individuals will be sensibly chosen.
The purpose of my two Amendments—and, as I say, I will not take up the time of the Committee by moving them separately—is, first, that there should be at least five local authority representatives on the Area Health Authority; and, secondly, that they should be there in their own right as people representing the views of the public and not simply in the more technical sense as links with the services 53 of the local authority with which they are particularly familiar.
§ THE DEPUTY CHAIRMAN OF COMMITTEES (LORD CHAMPION)
In putting Amendment No. 51 I ought to have indicated that in the event of that Amendment being carried I would not be in a position to call Amendments Nos. 54 and 55.
I am sorry that I missed the beginning of my noble friend's speech. I feel, as my noble friend does, that there are two reasons why local authority representatives should be on these area committees. I do not pose as an expert on this matter, but I should like to give the experience I have had with a small hospital which I know well. It is well equipped for minor operations, though not for major ones. These small hospitals are, I know, a bane of the hospital administration; they have been trying to close this particular one for some years. But public opinion is very much roused on this matter, not only among the lay public but also among the local doctors. Local doctors have formed a society of friends of this particular hospital and have collected something over £12,000 so that this hospital may be properly equipped and maintained. This may be the sort of story that has nothing unusual about it, but it seems to me somewhat extraordinary that the hospital administration should want to close a hospital without, apparently, any reference to local opinion, and that only when local opinion develops and there is a row do they withdraw and change their policy.
My noble friend Lord Aberdare said he did not think it so important that the area committees should be liaising, as it were, with those committees of ordinary local government that were not concerned with medical services. But I think it is important that they should so liaise Take the question of the old I have always understood that the health of the old depends a good deal on the sort of accommodation they have. If they live in purpose-built accommodation with their own belongings round them, they live very much longer in much happier circumstances than if they are herded together in geriatric wards, or even in Part III homes. The position under this Bill is somewhat different, but hitherto 54 in rural areas these old people have come under three different authorities, according to their condition. If they were fit they would come under the district council as the housing authority; if they needed care and attention they would come under the county council, and if they were in need of medical services they would come under the hospital board. The system has worked in a sense, but only because, fortunately, we have a number of very sensible people in this country—sensible representatives, sensible doctors, and sometimes a sensible civil servant. But the system itself is not one which leads to proper liaison. It will be somewhat different under the present dispensation, because the people in need of care and attention and of medical care will come under the same authority. I am not saying that this whole question can be solved just by having on the area committee some representatives of the local authority, but I think it will go some way to helping with that liaison. I am quite certain that without it there will be a number of people who will suffer from being, as it were, nobody's child. I hope that this idea may appeal to my noble friend Lord Brooke.
§ LORD HYLTON
I should like very briefly to support my noble friends Lord Brooke and Lord Gage. It has been notorious for many years that because of the very great shortage of purpose-built accommodation for the very elderly it is difficult to discharge elderly patients from hospital when they have recovered. I feel that if there are local representatives on these Area Health Authorities they themselves will be brought face to face with their own responsibilities, and this will be most helpful.
Before my noble friend replies, may I say that I feel, as with the last Amendment, that we need to be rather careful of being too specific about the different people who will have powers of appointment. In all different areas you will probably find that the medical practitioners will be carefully chosen. But if we are going to give a power of appointment to the dental practitioners, the nurses and midwives, the registered pharmacists, and the opthalmic and dispensing opticians, we shall get into rather deep waters, because in smaller areas this will be difficult, and in larger 55 areas they will be fighting each other as to whom is to represent them. Let us keep it as open as we can. We have discussed the question in principle; my noble friend has said that he will watch to see whether he can find sonic way round the principle of these Amendments. Let us be careful not to be too rigid with those who will have the power of appointment.
§ VISCOUNT AMORY
The case my noble friend dealt with in his Amendment is to a large extent in line with the discussion we held on the Regional Authorities. I should like to add one or two words. Looking closely at this organisation, one feels that the area level is perhaps the most important of all inasmuch as the decisions reached there will most strongly reflect on the local users of the Service. So that seems to be the level where it is most important that there should be locally elected members of local government authorities, and where they will have most to contribute. Therefore, whether the provision for representation in the Bill is adequate or not is important.
In discussions that I have had with people who are very knowledgeable about the Health Service one of the fears that is felt is that under the organisation proposed there will be proportionately too much emphasis placed on the clinical and remedial treatment as against preventive and safeguarding measures—that is, on treatment of illness as against the safeguarding of health. Under the new organisation there will be no one who is quite as independent as are the existing medical officers of health. The School Medical Service is an aspect which is of vital interest to local authorities. The joint consultative committees may be effective and useful—and we hope that they will be—but they will be only consultative and advisory. Several speakers, including myself, when discussing Regional Authorities, mentioned that the considered view of all the local authority bodies is that a sufficiently strong representation of elected local representatives on the area committees is absolutely essential, and they should participate fully in the policy decisions that are reached. I should like to support the Amendment proposed by my noble friend Lord Brooke of Cumnor.
§ 5.4 p.m.
§ LORD ABERDARE
I am grateful to your Lordships who have spoken in this debate, and to my noble friend Lord Brooke for having included his Amendment in it. It has made the matter much tidier and more comprehensible. Many of my objections to the main Amendment that we are discussing, Amendment No. 51, are similar to my objections on the previous Amendment with regard to the setting up of the Regional Health Authority. In my view it would be wrong at this second level for the Regional Health Authority, in turn, not to appoint a majority of its agents on the Area Health Authority. On the other hand, so far as concerns the Amendments of my noble friend Lord Brooke and those who have supported him, we are much nearer together, because we have made specific provision for the appointment by the local authority of members of the Area Health Authority. I will justify that to the noble Lord, Lord Brown, in the course of my remarks.
The Area Health Authority will be the major operational tier of the new Service. We see it, like the Regional Health Authority, as a relatively small body of about 15 members. This is not a magic figure; we want a small body which will not be too unwieldy to take decisions. But in the case of Area Health Authorities we recognise that there may well be particular areas where we shall have to have more than 15 people. This will arise, for example, where there is a teaching hospital, because we have already undertaken to put extra people on the Area Health Authority in that case. It will arise in London in areas where there is more than one London borough in the area. We have suggested that there should be more local authority representatives on those Area Authorities so that each borough has a member of the Area Health Authority as a representative.
At the same time we hope that none of the 15 or so members will feel themselves to be representative of particular interests, because we wish them to take a comprehensive and unbiased view of the total health requirements of the area. That would be the way in which we should hope to meet some of the points which have been put by my noble friend Lord Amory regarding the need for total 57 health care for preventive medicine, and community care, which my noble friend Lord Hylton mentioned. That does not mean that its members will not include people from the local authorities, or from the main health care professions or relevant universities. On the contrary, we suggest there should be four members directly appointed by the matching local authority; that is, the authority administering the services complementary to the health services provided by the Area Health Authority, particularly personal social services and education. We think it is this link with the matching local authority which needs particularly to be reflected on the Area Health Authority, and not the less intimate link which there will be with other local authorities in the area.
As to the professions, we suggest there will be doctors and at least one nurse or midwife on each Area Health Authority. In addition there may be other members, drawn from other of the health care professions. As I said regarding the last Amendment, the particular strength of the role of the professions in the new structure will lie in the advisory machinery which we are anxious to be sure is strong, and which will be in a position to bring their views forcefully to the Area Health Authority, just as we see it right for the community health councils to bring the views of the users of the services to the Area Health Authority.
§ BARONESS WHITE
Before the noble Lord leaves that point, could he, in order to clarify the position, say whether it is still the intention of the Government that those persons from the health professions should not be active within the area of the authority?
§ BARONESS WHITE
There are two quite different conceptions between our proposals and what we think are the Government's proposals. We should like to be quite clear about this matter.
§ LORD ABERDARE
Our view is that it would be wrong for members of the Area Health Authority to be in the employment of that Authority. The noble Baroness said "active". There is no reason why they should not be active 58 in the area. We think it would be wrong, if they are in the employment of the Authority, to be, at the same time, members of it. So far as sub-paragraph (f) is concerned, we have provided in the Bill for a university member, or members, to be appointed by the Regional Health Authority on the nomination of the university.
The noble Baroness, Lady Serota, asked me about the family practitioner committee. We have met, I think, her basic point in requiring the Area Health Authority to appoint at least one of its members to the family practitioner committee. It is not quite the same as having the chairman of the family practitioner committee necessarily on the Area Health Authority, but it is the fact that there will be one member of the Area Health Authority on the family practitioner committee. However, we do not feel it would be right if two-thirds of the members of the Area Health Authority were appointed by local authorities and some of the health professions. These are very important bodies. They will be handling budgets of some £14 million and upwards per annum, and they will be accountable to the Regional Health Authority. We do not believe that the accountability could be effective unless the majority of the Area Health Authority members were appointed by the Regional Health Authority.
The noble Baroness will perhaps not wish me to go into all the practical problems set by this Amendment, just as they were by her Amendment on the Regional Health Authorities. They are less serious and less daunting, but there still would be grave difficulties in rationing out the shares of the various local government members and various professional members as proposed in the Amendment. Our plans are based on an ideal. We want to inspire the Service with enthusiasm for a new approach. We see great hopes for better results in an integrated National Health Service, but as well as unification there must be leadership. I am sure we are all agreed on the need for integration, and we are agreed that there must be a more conscious choice between health in the community and in health institutions. We believe that a new impetus is required from smaller, more positive management bodies at the A.H.A. level, properly advised by professional committees, 59 properly advised by the representatives of the local community, yet still free to take positive decisions for the better health care of the citizen. That is why we see the Area Health Authority being established as we have suggested with the chairman nominated by the Secretary of State and the members appointed by the Regional Health Authority.
If I may turn for a moment to the Amendments of my noble friend Lord Brooke of Cumnor, I think we are pretty close together, except that we have suggested four local authority members on the Area Health Authority—4 out of 15, which is just over 25 per cent.—and my noble friend is suggesting 5, which is a little more. I do not say that there is any great significance in one more or less, but I would emphasise (this is what I was going to say to the noble Lord, Lord Brown) that our proposal is not altogether illogical. Naturally, we want to find bodies that will be effective and give a lead, and take the right decisions on priorities. But above all it was borne in upon us that, so far as we were able, we must not allow there to be any lack of liaison and co-operation between the Area Health Authority and the matching local authority. It was for that reason that we have established innumerable bodies. We have had Working Parties. We have laid it down statutorily that these two Authorities must co-operate; we have laid it down statutorily that there shall be a joint consultative committee, and we have gone so far as to concede, in this case only, that the local authority should nominate at least four members of the Area Health Authority. It may not meet my noble friend's pure management doctrine, but I think that in practice it really is an essential if we are to get the right sort of co-operation between the two bodies.
I found myself in some difficulty when my noble friend Lord Brooke of Cumnor was talking about the functions of these four or five members. It certainly would not be our idea that they should be in any sense confined to the function of being the links with the social services or the other particular services of the local authority. We would think it right that, of the four (or, as he suggests, five), 60 there should be those who have experience in the very relevant opposite matching services—the social services, and maybe education. But what our wording tries to establish is that they are there as members of local authorities—as my noble friend Lord Brooke says, as elected members—who will give that link with the relevant other services who will also, I am sure, speak as representative of the people who have elected them. But what we want to avoid, if we can, is anybody on the Area Health Authority actually representing a specific interest. We hope that the doctors will not represent just the views of the doctors; we hope that they will be people with medical experience looking at the problems of the health position in the area. Equally, we hope that members who are drawn from the local authority will not just be putting the view of the local authority but will be people with experience of local authority work, who have been elected by their constituents and who will contribute to the overall solving of health problems that present themselves in the area.
There is only one other point that I would briefly mention to my noble friend. There are many pressures upon us, of course, for the right to appoint members of Area Health Authorities. The noble Baroness's own Amendment is one example where other bodies—the medical profession, for example—are brought in and given the right of appointment. Obviously, we must find the right balance of membership. We believe that there is a very special exception to be made in the case of the local authorities, but if one is going to raise their representation from just over 25 per cent. to what might be 33⅓ per cent.—or, at any rate, 5 out of whatever the number may be—it may mean that other bodies will feel they should equally have strong representation. Then we should move away from what we want, a single-minded Area Health Authority applying its mind to the problems of the area, and we should find it again made up of a number of different representative members.
So I very much hope that the noble Baroness will withdraw her Amendment. I hope that I have satisfied her to some degree. I hope my noble friend will 61 withdraw his Amendments. I am certainly prepared to think further about the matter; although here again my difficulty is my fear of upsetting the balance of membership and my own belief that four members actually nominated—and they are the only ones to be nominated—on the Area Health Authority probably ought to be able to bring the necessary skills and experience to the work of the Authority.
§ 5.18 p.m.
§ LORD BROOKE OF CUMNOR
If I may speak before the noble Baroness, I am grateful to my noble friend for what he has said, and assure him that I am not going to press my Amendments; indeed, I shall not move them. I am quite certain that it is more effective if we can have a general debate of this kind on a group of Amendments and give the Government something to think about between now and later stages of the Bill. I still hope that my noble friend will reach the conclusion that four is too small a number of local authority persons (I avoid the word "representatives") on the Area Health Authority. I am glad to have his assurance that these persons will not be confined in the work of the Area Health Authority to representing the linkage between the Health Authority and the relevant local government services. I am sure that everybody who has served on a local authority and is trained in that hard school will realise that in public affairs he is not speaking just for a local authority, but is speaking for the public in general whose views may or may not be channelled through a particular local authority.
My real difficulty, and the point that led me to table my second Amendment, was the troublesome sentence in paragraph 106 of the White Paper which I have already quoted. The Government wish to avoida confusion between the direction of services and representation of those receiving them…I do not really see how local authority people appointed by local authorities to an Area Health Authority can stop short of making representations for those who are receiving the services. If those words are allowed to stand in the White Paper and that is to be taken as the principle, then what my noble friend has said cannot stand because it is contradicted by 62 those words. The more I think about the whole subject of the composition of these bodies the more I believe that the trouble—and, it may be, the misunderstanding of the Government—have flowed from that sentence in paragraph 106. I know that that sentence gives pleasure to the noble Lord, Lord Brown, but it gives very little satisfaction to anybody else on either side of this House and I hope my noble friend and the Secretary of State will consider matters from that point of view when they are reviewing all that has been said from two different quarters in these two debates.
§ BARONESS WHITE
We have great sympathy with the sentiments expressed by the noble Lord, Lord Brooke of Cumnor. I must confess that when we first saw his Amendment No. 55 we were a little dubious about "representatives" because it could have meant "delegates" who might be mandated, and I am sure that none of us wanted that sort of relationship. But as the noble Lord properly pointed out, there is of course an inconsistency in the phrase in paragraph 106 of the White Paper compared with what the noble Lord, Lord Aberdare, has stated to be the philosophy of the Government in relation both to the area and to the regional bodies.
In all the circumstances, I think the sensible thing for us to do would be not to press our Amendment at this stage but to hope that in the discussions which the noble Lord, Lord Aberdare, promised on the Regional Health Authorities, any points we have to raise on the Area Health Authorities might be subsumed in those discussions. On that understanding, with which I gather the noble Lord, Lord Aberdare, is in agreement, on behalf of my noble friend I beg leave to withdraw the Amendment.
§ THE DEPUTY CHAIRMAN OF COMMITTEES
I think the mover of the Amendment must seek permission to withdraw the Amendment herself.
§ BARONESS SEROTA
On the basis of the conditions which my noble friend Lady White has just stated to the Committee, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.63
§ 5.23 p.m.
BARONESS WHITE moved Amendment No. 57:
Page 50, line 19, at end insert ("but including, in Wales, the Health Committee of the Welsh Council.")
§ The noble Baroness said: I beg to move this Amendment which stands in the name of my noble friend Lord Watkins and myself. As the Committee will appreciate, in Wales, because there is to be no Regional Authority, the appointments to the Area Health Authorities will be made directly by the Secretary of State for Wales. Plainly, he will wish to consult a number of bodies in the Principality but in Wales we have the Welsh Council, which is different from any body that exists in England, and this Council has a health committee, or health panel as I believe it is more normally called.
§ BARONESS WHITE
That makes it all the better, because one has there a body of persons in Wales who are closely interested in and concerned with policy in the field of health and social services, and we feel that it would be entirely appropriate in our conditions in Wales that the Secretary of State should be under some obligation to consult. He would not necessarily have to take their advice, but we hope that normally he would do so. In any case, we feel it only right that people who are asked to serve on this all-Wales body in relation to health and social services should have some say in making suggestions, at any rate, as to persons who might well be appointed to the Area Health Authorities in Wales. This seems to us to be entirely reasonable.
The Welsh Council itself, as at present constituted, is of course appointed by the Secretary of State for Wales. Many of us hope that the time will come when it will be an elected body. We cannot foresee exactly what will happen because, as I said at an earlier point, we still do net know what the recommendations of the Crowther-Kilbrandon Committee may he and we do not know what developments may ensue. But, whether or not the Council remains, as it is at the moment, an appointed body or, desirably, an elected one, we still feel that in Wales 64 it is a body of some consequence and ought quite specifically to be brought into the consultations which will be held under the provisions of the Bill by the Secretary of State before he makes his appointments to the Area Authorities. Accordingly, I beg leave to move this Amendment.
§ LORD ABERDARE
The noble Baroness will know with what sympathy I look upon a Welsh Amendment, but I am afraid I am not able to accept this one. I believe it would be invidious to single out the Welsh Council for mention in a provision under which other important bodies will be consulted. For example, the T.U.C.'s regional advisory committees for North and South Wales; the Council for Social Services for Wales and Monmouthshire, the Welsh Council of the C.B.I., and a number of Welsh bodies representing the major voluntary organisations—for example, the National Society for Mentally Handicapped Children. Obviously, it would not be practicable to list them all in the Bill and it would be invidious to single out the Welsh Council alone. There is also the point that the noble Baroness herself made: that whatever the future may be, the present situation is that the Welsh Council is a non-statutory body set up administratively by the Secretary of State for Wales and it would be most unusual in legislation to require consultation with a non-statutory body by name, as opposed to generically. But it would be even more odd to require statutorily that the Secretary of State should consult a body which he had himself appointed at his own discretion.
However, I can give to the noble Baroness the absolutely firm assurance that the Secretary of State for Wales will consult the Welsh Council, among other bodies, some of which I have mentioned, before making appointments to the Welsh Area Health Authorities. I think the noble Baroness will probably agree that it would be more appropriate to consult the Welsh Council and then to leave it to that Council to refer to the Health and Social Services Panel. I hope that, with that assurance, the noble Baroness will feel able to withdraw this Amendment.
§ BARONESS WHITE
We have the assurance on the Record, which is the object of the exercise. I appreciate the 65 point about the Welsh Council not being at the moment a statutory body: we hope that it will become so. In any case, I think the Council is in a different position from the more sectional organisations referred to by the Secretary of State, important as they may be. It is an all-embracing body, on an all-Wales basis, and does not represent sectional interests. However, as we have had the assurance from the noble Lord, which I am sure will be observed by his right honourable friend and his successors, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ 5.30 p.m.
BARONESS WHITE moved Amendment No. 60:
Page 53, line 27, after ("including") insert ("attendance allowance or")
§ The noble Baroness said: The purpose of this Amendment is to make it possible for the Secretary of State to pay attendance allowances as well as travelling expenses or compensation for loss of remunerative time—for "loss of earnings" as it is more usually expressed. We feel that this is a very important Amendment because it is not long since we had in this House a Bill regarding local government. As we know, the basis of allowances for members of local authorities was changed in that Bill from what it had previously been. In earlier days the basis for payment to members of local authorities was the same as is now proposed in this Schedule for members of the new Area Health Authorities, but it appears to us that the same considerations which apply to allowances as of right to members of local authorities when they attend for official duties apply to the new Area Health Authorities which we are setting up under this Bill.
§ It is not always the loss of remunerative time involved in service on bodies of this kind that is important. Service is likely to be extremely onerous, not so much at the regional level, although the work there will be of great importance because it will include the allocation of resources—a task which, if conscientiously done, will involve a great deal of work—but at Area Authority level. It is plain, from the work which will fall to be done at the Area Health Authorities level, more particularly if the members of those 66 bodies are restricted in number to the 15 or so proposed by the Government, that the members of those authorities will have a very heavy task to perform.
§ Included on the Area Health Authorities, as we have been discussing, will be at least four persons—some of us hope more—who are themselves members of local authorities. When they are doing their work on local authority committees they will be remunerated in one way. If, on the other hand, they are performing their duties as members of Area Health Authorities they will be remunerated on a different basis because, presumably, they will be remunerated as members of Area Health Authorities and not as members of the local authorities by whom they are nominated. I feel that there is bound to be dissatisfaction among people who, having moved under the Local Government Act to a new basis of remuneration, find that although they are nominated by their local authorities for public duties on Area Health Authorities they do not have the same sort of right to an attendance allowance; and this seems to me in itself to be unsatisfactory.
§ There is another matter which I have raised before in your Lordships' House, and that is the position of women. Women who serve on these Authorities can often not legitimately claim compensation for loss of remunerative time for the simple reason that many of them are not remunerated for all the work they do.
§ BARONESS WHITE
My noble friend is absolutely right. Thus, if they are not in full-time paid employment (I believe I am correct in saying that one has to be in full-time paid employment before one can claim loss of remunerative time) and are only in part-time employment, or are working in the home, then according to these arrangements they may not get adequate compensation for the indirect expenditure which may fall on them and for which it is almost impossible to account.
Women in public life know very well —I see the noble Baroness, Lady Young, smiling in an understanding way—that we are put to all sorts of expenses in our domestic lives for which one cannot possibly account. After spending a very 67 long day at an Area Health Authority meeting—and when I think of the distances one will have to travel in Wales it will be a very long day indeed—one usually comes home to a husband and family who expect to be looked after; and we know that it is very much quicker to cook the more expensive meats and fish than the cheaper varieties. It is quicker to use the so-called convenience foods, and these are much more expensive. This is something for which one can never account in any acceptable way, but we all know how important an aspect it is.
Similarly, if arrangements are made to pay for domestic help—for example, to look after children if the mother is not certain whether she will be home in time to meet them from school—if it happens to be on that direct day, then I believe that there are arrangements whereby she can claim something. If, however, she rearranges her domestic life in such a way that she does not have domestic help at the actual moment when she is engaged on the work of the Area Health Authority or regional body, she will not be in a position to claim because the accountants in the Department will say, "You cannot prove that the fact that you had domestic help on Monday had a direct connection with the meeting you were attending on Wednesday." Nevertheless, one knows from experience that there is in fact a direct connection, and therefore it was of tremendous advantage to women members of local authorities when the Government decided to change the basis of remuneration for attendance at local authorities and to give an attendance allowance by right and not simply payment in terms of loss of remunerative time. We are anxious that if the fullest range of people is to be available for service on these bodies, what has been accepted as right and proper for service on local authorities should also be accepted as right and proper for service on Area Health Authorities.
I am aware that there are some differences, so far as local authorities are concerned, between elected members and people who are co-opted on to certain committees. However, I do not believe that that difference is in the least relevant where service on these Area Health 68 Authorities is concerned. As I say, they are major bodies in the National Health Service structure and are taking very great responsibility—quite as great within their own fields as any in local authorities—and we therefore wish to press our belief that there should be the possibility included in the Bill of paying attendance allowance and not only, as we understand it, compensation for loss of remunerative time. I beg to move.
§ 5.40 p.m.
§ BARONESS YOUNG
The Government have given very careful attention to this important point about allowances and the present system of reimbursing members in the National Health Service, but feel that they cannot accept this Amendment. It is the intention of the Government to continue the present practice, which is that members attending Area and Regional Boards should receive travelling expenses, subsistence allowances and the financial and other loss allowances. The precedent was set over the National Health Service (Scotland) Act when it went through your Lordships' House last year, and the Government consider that this principle is right. A special exception has been made in the Local Government Act to pay allowances to the newly elected members of the new local authorities, and their position will be much more nearly comparable to that of Members of Parliament. The new allowances, as Lady White has said, will not apply to non-elected members of local authorities. They do not apply now to non-elected members of Development Boards and Councils, and this distinction between elected members of local authorities and non-elected members of Boards has been drawn.
The noble Baroness raised a number of quite specific points about women members, and as I felt that this matter might well arise on this Amendment, I re-read what was said at the time of the Scottish Bill. I think it is fair to say that the question of financial loss allowances for women members, which is a very real point, has been quite generously drawn, and the Department have agreed that the allowances should be paid where, for example, expenditure has been incurred on, say, baby-sitters while a woman is at a meeting; in special circumstances for home helps. In this way some of the very basic and necessary expenses that 69 many women members will have to meet when attending these area board meetings are covered. It is for these reasons that the Government feel unable to accept this Amendment.
§ BARONESS WHITE
I can only say that that is a very unsatisfactory and—particularly coming from the noble Baroness —extremely disappointing reply. On the Scottish Health Bill the noble Baroness, Lady Tweedsmuir of Belhelvie, was the spokesman for the Government, and we now have the noble Baroness, Lady Young. If I may say so, I think both are traitors to their sex, because they both know perfectly well that the kind of allowances which are given do not fully cover the situation. In any case I have always thought that service on the Health Authorities as they now exist is grossly unfair. We have the Regional Hospital Boards, for example; some of the chairmen put in a tremendous amount of work and receive no remuneration at all. It is true that in this Bill some remuneration is now to be offered to chairmen. But one can be a part-time member of a new town corporation, for example, and one can be a member of an advisory body on gas, electricity, or what-have-you, and it is taken for granted that some payment will be made, because it is said: "We could not get businessmen unless we did". But when it comes to something really important, like the Health Service, the labourer is not considered worthy of his hire.
Coupled with this Amendment is my feeling that the social services have been exploited in this way by comparison with any public service which is even remotely connected with industry and matters of that kind. I watched this very particularly when I was the Minister responsible for some of the health administration in Wales, and I felt that it was grossly unfair that someone who served part-time on our mini new town corporation, for example, had remuneration. There are various other people I could mention. For example, the Chairman of the Welsh Committee of the Countryside Commission gets paid. But when it comes to somebody who is going to serve on a Health Authority compensation for loss of remunerative time is all that is considered necessary for service of this kind.
70 This is an important principle. As I say, the Goverment took a great step forward so far as the local authority members were concerned in their own Local Government Act. Some of us were extremely dissatisfied with the response we had on the Scottish Health Service Bill. We are equally dissatisfied with the response we have had so far from the Government on this point, and I would ask my noble friends at least—and I would hope also for some sympathy and support from Members on the other side of the House and on the Cross Benches—to support us. What is good enough for the new local authorities should be good enough also for the new health authorities.
§ BARONESS EMMET OF AMBERLEY
I feel that I must support the noble Baroness on the Opposition Bench. I do not think that this matter has been sufficiently thought out from the male point of view so far as women members are concerned. There is a very real case here for re-considering the matter.
§ LORD AUCKLAND
May I also say a word supporting the opposite sex. It seems to me essential that we should get women of high calibre on these committees. After all, women are very closely involved with the National Health Service. In any case, the Schedule is rather vaguely drafted and I was not quite certain from my noble friend's reply who would get the allowance for baby-sitters, and so on, and who would not. It seems that the whole matter is rather vague and I am quite sure that the Treasury could afford to pay proper compensation for this very vital work.
LADY RUTHVEN or FREELAND
I should also like to support this Amendment because having served on a Regional Board and on a number of hospital management committees I have seen the amount of time given up by people, particularly, as my noble friend Lord Auckland said, the women who serve on those committees. It is true that they were coming from their homes and therefore had no claims to make, except for travelling, but it is most unfair that other organisations set up by the Government should be allowed to get this attendance allowance yet not the Health Service. I entirely support the Amendment.
§ LORD ABERDARE
Before the noble Baroness decides what to do on this Amendment, may I point out one or two difficulties that have not emerged in the debate. There would be repercussions. If you pay an attendance allowance to members of these authorities, there may well be voluntary members of other authorities who equally feel that they should also be entitled to the same treatment. There is also a very real tax difficulty. I daresay the noble Baroness is aware of this. It is frightfully complicated, as are all income tax matters, but if an attendance allowance is paid to a member of a Health Authority that would mean that his or her travelling expenses were taxable, whereas at the moment he or she gets his or her travelling expenses free of tax. It is not as easy as it appears on paper.
§ BARONESS WHITE
May I interrupt the noble Lord to ask what happens to the expenses of the local authority members?
§ LORD ABERDARE
The local authority members are looked on differently because they are said to have not only a place of work in the local council offices, but also a constituency place of
§ work where they live. Therefore their travelling expenses are free of tax for that reason, just as an M.P.'s are. This is a real difficulty. We have studied this matter extremely carefully because all of us are very conscious of the amount of work put in by our members of Health Authorities. It is a very tricky subject. If the noble Baroness likes, we could look at it again, particularly from the point of view of the woman member but for the reasons I have tried to explain it is not easy. Also, we should be out of line with Scotland.
§ BARONESS WHITE
Scotland could catch up with us, but that does not worry me! I recognise that there may be some difficulties about tax, but I do not believe that they could not be overcome somehow. I should like to get on the record that in principle we believe that something of this sort should be done, and therefore, on this occasion—we have been very cooperative so far—I must ask for an expression of opinion.
§ 5.50 p.m.
§ On Question, Whether the said Amendment (No. 60) shall be agreed to?
§ Their Lordships divided: Contents, 71; Not-Contents, 61.73
|Addison, V.||Hayter, L.||Ruthven of Freeland, Ly.|
|Amulree, L.||Henderson, L.||St. Davids, V.|
|Archibald, L.||Hereford, L. Bp.||Serota, B.|
|Ardwick, L.||Hoy, L.||Shackleton, L.|
|Arwyn, L.||Hurcomb, L.||Shinwell, L.|
|Auckland, L.||Hylton, L.||Slater, L.|
|Avebury, L.||Inglewood, L.||Somers, L.|
|Bacon, B.||Jacques, L.||Stocks, B.|
|Beswick, L.||Janner, L.||Stow Hill, L.|
|Blyton, L.||Kennet, L.||Strang, L.|
|Brock, L.||Leatherland, L.||Strange, L.|
|Brockway, L.||Llewelyn-Davies of Hastoe, B. [Teller.]||Summerskill, B.|
|Champion, L.||Taylor of Mansfield, L.|
|Chorley, L.||Lloyd of Hampstead, L.||Vivian, L.|
|Clancarty, E.||Macleod of Borve, B.||Walston, L.|
|Davidson, V.||Maelor, L.||Wells-Pestell, L.|
|Davies of Leek, L.||Masham of Ilton, B.||White, B.|
|Diamond, L.||Milford, L.||Williamson, L.|
|Elliot of Harwood, B.||Northchurch, B.||Willis, L.|
|Emmet of Amberley, B.||Peddie, L.||Wise, L.|
|Evans of Hungershall, L.||Platt, L.||Woolley, L.|
|Foot, L.||Popplewell, L.||Wootton of Abinger, B.|
|Gaitskell, B.||Rhodes, L.||Wright of Ashton under Lyne, L.|
|Gardiner, L.||Roberthall, L.|
|Garnsworthy, L. [Teller.]|
|Aberdare, L.||Berkeley, B.||Brooke of Cumnor, L.|
|Albemarle, E.||Bessborough, E.||Brooke of Ystradfellte, B.|
|Amory, V.||Bethell, L.||Coleraine, L.|
|Balerno, L.||Bradford, E.||Colville of Culross, V.|
|Belstead, L.||Bridgeman, V.||Conesford, L.|
|Cottesloe, L.||Gowrie, E.||Monck, V.|
|Courtown, E.||Grenfell, L.||Mowbray and Stourton, L.|
|Craigavon, V.||Grimston of Westbury, L.||Orr-Ewing, L.|
|Cranbrook, E.||Hailes, L.||Pender, L.|
|Daventry, V.||Jellicoe, E. (L. Privy Seal.)||Rankeillour, L.|
|Denham, L. [Teller.]||Killearn, L.||Redesdale, L.|
|Drumalbyn, L.||Lauderdale, E.||Rowallan, L.|
|Dudley, E.||Limerick, E.||St. Aldwyn, E. [Teller.]|
|Dundonald, E.||Lloyd, L.||Sandford, L.|
|Eccles, V.||Lothian, M.||Sudeley, L.|
|Ferrers, E.||Mansfield, E.||Swansea, L.|
|Fortescue, E.||Massereene and Ferrard, V.||Templemore, L.|
|Gage, V.||Merrivale, L.||Tweedsmuir, L.|
|Gainford, L.||Mersey, V.||Windlesham, L.|
|Gisborough, L.||Milverton, L.||Young. B.|
On Question, Motion agreed to.
§ Resolved in the affirmative, and Amendment agreed to accordingly.
§ 5.58 p.m.
LORD GARNSWORTHY moved Amendment No. 61:
Page 53, line 39, after first ("regulations") insert ("(after consultation with the staff representative body)").
§ The noble Lord said: Paragraph 10(1) of Part III of Schedule 1 enables a Regional Health Authority, an Area Health Authority and a special health Authority to employ officers "on such terms as it may determine in accordance with regulations". Amendment 61 would require those authorities to consult with the staff representative bodies. If one is asked what is a staff representative body, I have endeavoured to set that out in Amendment 124 to Clause 54, which we shall be coming to somewhat later. It surely is desirable that this consultation should take place before these authorities exercise their powers.
§ I think that at this stage I need not take very much of your Lordships' time, because it seems to me that this is a very sensible Amendment and one that ought to commend itself to the Government. I appreciate that these authorities are anxious to do what they can to meet the staff organisations and see that the role they play in the National Health Service is recognised in the Bill. I very much hope that the Minister, when he replies, will say that he is able to accept this Amendment, which does not seem to me fundamentally to alter anything in the Bill.
§ 6.0 p.m.
§ LORD ABERDARE
The principle behind this Amendment is one that we touched on before Christmas when we 74 were discussing Amendment No. 42. It was then that the noble Lord, Lord Garnsworthy, suggested, in effect, that the Statute should make it plain that the Government attach great importance to their relations with the staff interests, and recognise the necessity of consulting them fully. Since then, as I undertook to do, I have taken a second look at this matter, and I should like to make it clear once again that the principle of consulting staff interests on all appropriate matters is fully accepted by the Secretary of State. Certainly in the circumstances of Amendment No. 42, as in the circumstances of this Amendment, staff interests would most certainly have been consulted.
Although the inclusion of a statutory duty is not necessary from a practical point of view, we have concluded that in order to make our intentions perfectly clear we should accept the principle of this and various other Amendments standing in the name of the noble Lord. As I said when we were considering Amendment No. 42, we are not particularly happy about the phrase "staff representative body" and its definition in a later Amendment, and in the Government Amendment which I will put down at a later stage concerned with consultation we shall be proposing a rather different approach. This definition of the body to be consulted would allow the Secretary of State, if necessary, to sound out staff interests generally on the question of what would be the most appropriate channel of consultation in any particular case. This would accord with the practice that has been successfully followed in the past, and I hope therefore that the noble Lord will be prepared to accept my undertaking. In its present form the Amendment, as drafted, is ambiguous on the question of which 75 activity should be the subject of consultations, and I am afraid that I cannot accept it exactly as it stands. However, I give the noble Lord an assurance that I will introduce a Government Amendment at a later stage to cover this most important point.
§ LORD GARNSWORTHY
I am most grateful to the Minister. I moved the Amendment with brevity because we have had an earlier discussion, as the noble Lord, Lord Aberdare, has said. May I thank him for the full reply that he has given and say that I fully, and indeed gladly, accept the assurance that he has given. With your Lordships' permission, I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ 6.5 p.m.
LORD GARNSWORTHY moved Amendment No. 62:
Page 53, line 45, after ("experience") insert ("and in the case of an authority, being an Area Health Authority, to employ, after consultation with the relevant Local Education Authority, a medical practitioner, a dental practitioner and a person engaged in the nursing service, being in each case of senior status and having experience in the provision of school health services, who shall serve as whole or part-time officers of the authority and be available to advise the relevant Local Education Authority and to undertake such executive and administrative functions for the purposes of the school health services in the area of the authority as they may be reasonably called upon to undertake.").
§ The noble Lord said: I beg to move Amendment No. 62. This Amendment is of a somewhat different nature, and would write into the Bill firm guarantees that Area Health Authorities would not only employ particular categories of officer but would ensure consultation with local education authorities with a view to securing people of the calibre and quality likely to fit in with the service of education.
§ The noble Viscount, Lord Amory, touched on the extremely important consideration of the continuance of the school health services. I think that it may be helpful if we remind ourselves of the role that the medical service plays in the field of education. First of all I mention the assessment and management of handicapped children. This covers a very wide range, and it is extremely important that local education authorities, 76 in dealing with and providing for the needs of handicapped children, have at their disposal all the expert advice and assistance that they may require. There is the issue of subnormality. Assessing an educationally subnormal child is not a purely educational matter. The medical man needs to come in, and local education authorities are accustomed to having the advice of senior medical officers in this field, as they are in regard to maladjusted and handicapped children. The medical officer is of assistance not only in regard to the advice and help that he gives to the local education authority regarding the educational needs of the child or children, but is of tremendous service in helping to counsel parents. Without question, the doctor is an essential member of the staff of a local education authority. May I make the point that the early assessment of a child's needs is not the only matter of concern. Assessment is a continuing process, and the local education authority needs to have continuing consultation and to receive continuing advice from the medical officers who are needed if the work is to be properly undertaken.
§ I could go on instancing where the medical officer comes into the area of the education service, but I hope that I have said enough to persuade your Lordships that this really is a vital role and that adequate provision ought to be made for it in the Bill. The Amendment lays it down that these officers would be available not only to give advice and fulfil executive functions and administrative duties for the running of the school health services such as may be reasonable to expect, but that they would be there constantly, readily available as and when the need for consultation arose. It seems to me that the Amendment is in line with paragraph 60 of the White Paper, and I trust that the Minister will be able to indicate in his reply that the Government take a sympathetic view with regard to it. The Amendment may not be too well drafted, but that is a difficulty that the Government, if they accept the principle, could quite easily put right. I beg to move.
§ LORD BELSTEAD
May I say, in reply to the noble Lord, Lord Garnsworthy, that it was only to be expected that noble Lords opposite would put down an Amendment to this effect. 77 In fact, I welcome it, because it presents an opportunity for the noble Lord to point out to the Committee the importance of the medical advice and the medical administration which local education authorities will continue to expect to receive, so that the good work of the school health service shall in essence continue. Paragraph 21 of the Report of the Working Party on Collaboration stated that it did not envisage an exact replica of the current usual pattern, whereby the principal school medical officer is also the M.O.H. with a full-time deputy or senior medical colleague responsible for school health. That Working Party recommended that a senior doctor with appropriate experience and training should be appointed, with advisory and executive responsibility for the transferred school health service.
The Report went on to describe the Working Party's expectations of the coordinating role of an area chief dental officer and an area chief nursing officer, but I think it is fair to say that that Working Party on Collaboration did not recommend that such arrangements ought to be put into legislation, and, clearly, sub-paragraphs (1) and (2) of paragraph 10 of Schedule 1 provide ample scope for administrative guidance to be given by regulations. There is a genuine difficulty over this Amendment. If the noble Lord, Lord Garnsworthy, sought to press it, I should have to point out that there are other fields—for instance, social services and environmental health—where the Working Party on Collaboration regarded it of the utmost importance that there should also be arrangements for seeing that the health skills and staffs of the Area Health Authority were available to the local authority, and I understand that these recommendations are still the subject of consultations.
May I outline the intentions of the Government which lie behind sub-paragraphs (1) and (2) of paragraph 10 of Schedule 1? Under sub-paragraph (1)(b) of paragraph 10, an Area Health Authority could by regulation be required to appoint officers having prescribed qualifications or experience to perform prescribed functions. Obviously, these functions could be to advise a local education authority and to undertake other specified tasks on its behalf. Incidentally, I can give a specific assurance to the 78 noble Lord that it most certainly is intended either to make new regulations or to carry over the existing regulations, which prescribe qualifications for those medical practitioners who examine children for the purpose of deciding whether special education is required. Then, in accordance with sub-paragraph (2) of paragraph 10 of Schedule 1, professional officers now employed by local education authorities for the purpose of the school health service will be transferred and available to the Area Health Authorities. As stated in another place on July 13 by the Secretaries of State for Social Services and for Education and Science, staff in the school health service will continue with their present work after reorganisation, and it is intended that each Area Health Authority will have on its staff a senior doctor and a senior dentist advising the local education authority as the principal school medical and dental officers do now, and similar arrangements will be made for nursing staff.
The Government recognise, as does the noble Lord, Lord Garnsworthy, the importance of the school health service and the essential need to ensure its continuity and further development. They also recognise the important part to be played by professional officers, doctors, dentists and nurses experienced in that service. I assure the Committee that guidance on the professional staff arrangements for child health and the school health service will cover this. Consideration will be given to the need for prescribing relevant qualifications and experience. Although I am resisting the noble Lord's Amendment, I hope that what I have said gives him the assurance which he is seeking.
§ LORD GARNSWORTHY
I am grateful to the noble Lord, Lord Belstead, for his lengthy reply to the case which I put very briefly and, perhaps, inadequately. I hope he will not be too surprised if I tell him that he is encouraging me to think of putting down Amendments about social services generally, since he has drawn attention to the fact that they might as easily have been tabled as this Amendment about the school health service. However, that is something for further thought. I am indeed grateful for what the noble Lord has said about this 79 Amendment, but both he and the Committee will appreciate that since he has spoken at some length there is need to study very carefully what he has said. I have no wish to press this Amendment for the sake of having a Division. I am much more concerned with getting recognition of the need at all times to have full-time specialists in all the fields where a doctor is essential, if the service is to provide for the needs of all children, particularly those who suffer from any form of handicap. Again may I say that I appreciate what the noble Lord has said and, while reserving the right to come back at Report stage if it is thought that the position is not satisfactory, I do not wish to press this Amendment. But I hope the Committee will feel that, having got the noble Lord's statement on the record, at least some service has been rendered by the discussion on this Amendment. I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ 6.17 p.m.
§ LORD GARNSWORTHY moved Amendment No. 63:
Page 54, line 29, at end insert—
("(6) No officer shall be transferred and no employee placed at the disposal of another authority, under or by virtue of the foregoing provisions of this section, except with his consent")
§ The noble Lord said: This Amendment is concerned with paragraph 10(2) in Part III of Schedule 1, which would permit the making of regulations for the transfer of officers from one authority to another, and for the secondment of officers. It is intended to ensure that no such arrangements would be implemented without the consent of the officer concerned. When the Local Government Bill was going through this House, we spent some time discussing Amendments which were somewhat similar to this one in their intention. I was present yesterday at a meeting where there were a number of representatives of people in the service of local government. Many of them are at present working in health departments, and I wish I could convey to the Committee the anxiety which some of them feel. It may well be said, again and again, that nothing unreasonable will 80 be done; but these men and women are in a situation which they themselves have not brought about, and they feel threatened in a way which they never anticipated. I should like to feel that we shall at least get something on the record indicating that they will receive a degree of consideration sufficient to allay their anxieties. That my Amendment would do. I doubt whether it will be acceptable to the Government, but I hope that when he replies the Minister will go as far as he possibly can to accept the principle.
May I say that I have been talking to some representatives of a very small group in the Health Service who are worried about being transferred from the hospital service to local government. They drew attention to subsection (5) of Clause 18 of the Bill, and it is interesting to see how that reads. If the noble Lord, Lord Aberdare, is going to tell me that it applies equally in reverse, again I think it will be useful to have this statement. The subsection reads:
A person transferred by virtue of the preceding subsection to the employment of such a body as is mentioned in that subsection shall not be required in the course of that employment to perform duties otherwise than at or in connection with a hospital unless he has consented to perform such duties.
It would give a great deal of satisfaction to many people who have anxieties if that could be put in reverse. Personally, I do not see how it can be put in quite that form in reverse, but I may be wrong about that. However, may I say that the people who have drawn my attention to this safeguard, as it were, are not satisfied that it goes as far as they would like it to go because they do not want to be transferred. But in regard to people who are being transferred from local government to the hospital service, I feel that at the moment nothing has been said that indicates that they will have quite the degree of consideration that Clause 18(5) seems to indicate will be meted out to those who are being transferred the other way. If I am wrong, I shall be very pleased indeed; I have no wish to be proved right on this one. But I hope that if in reply the Minister says that he cannot accept the Amendment, he will, as I say, be able to go sufficiently far to allay some of the anxieties of those who undoubtedly are extremely disquieted at the present time. I beg to move.
§ LORD ABERDARE
Again, I can well appreciate the noble Lord's interest in staff matters, and I share them with him. The Secretary of State would certainly wish to consult fully with staff and other interests about the arrangements for staff transfers or secondments envisaged in this subsection, and procedures would be fully discussed with staff interests. But I have to say that the service to the patient is paramount, and one cannot exclude the possibility of occasional situations in which there might be difficulty in securing the full consent of an officer whose services in a particular post were of importance to the public interest. The arrangements for consultation have, however, been looked at again since we discussed this matter in December last, and again I propose to put down an Amendment at Report stage to the effect that no regulations or directions would be made under this subsection without suitable prior consultation. In the case of arrangements concerning the movement of individual members of staff, we feel that we should follow the precedent, which the noble Lord himself has mentioned, of Section 113(1) of the Local Government Act, on which we both spoke not so very long ago. This does not go quite as far in obtaining individual consent as the noble Lord himself would wish, but I hope that what I have said and the Amendment which I propose to put down at the next stage of the Bill will, as he asks, allay most of the anxiety that is understandably felt by certain members of staff.
The noble Lord made reference to subsection (5) of Clause 18. I am sure that we shall have a debate on that when we reach it. He is quite right, of course, in saying that this is a very special case; and it refers to the transfer to local authorities exercising functions under the Local Authority Social Services Act 1970 of staff of prescribed descriptions employed wholly or mainly for the purposes and functions which stand referred to social services committees by Section 2 of that Act. The noble Lord will appreciate that this is a very special case. It is one with which we are all deeply concerned, and it is one where we hope that at least this concession will help on this difficult problem that we have to resolve. But I do not think this special pleading should determine the general rule. I hope, therefore, that the noble Lord will 82 feel that I have gone some way to meet him, and will see his way to withdrawing the Amendment.
§ LORD GARNSWORTHY
I am grateful to the noble Lord, Lord Aberdare. I think he made a very fair point with regard to the use that I made of subsection (5) of Clause 18. But I used it to try to lend emphasis to the case I was endeavouring to make. I am grateful to him for what he has had to say, and perhaps I may say that I have the feeling that it will give satisfaction to those who speak for the people who are most concerned in the subject matter of this clause and of this Amendment. What he said will be studied with interest. I am pleased to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ LORD ABERDARE
Amendment No. 64 is a small drafting Amendment. The word "so" in this context can be construed only as referring to the opening words of paragraph 11, which refer to regulations, and it is not desired that the bodies to be approved should have to be specified in these regulations. I beg to move.
Page 54, line 45, leave out ("so").—(Lord Aberdare.)
§ Schedule 1, as amended, agreed to.
§ Clause 7 agreed to.
§ 6.28 p.m.
§ Clause 8 [Local advisory committees]:
LORD BROCK moved Amendment No. 66:
Page 7, line 28, leave out ("a Regional Health Authority") and insert ("the Secretary of State").
The noble Lord said: This Amendment deals with local advisory committees, and I should like the Committee to take with it the consequential Amendments, Nos. 67 to 70 and No. 72. Section 32 of the 1946 Act says:
Where the Minister is satisfied…
The recognition is the function of the Minister. Section 16 of the Scottish Act says:
…the Secretary of State is satisfied…",
and the recognition of local consultative committees lies with the Secretary of
State. The English Act should say the same. Yet again we have this unexplained differentiation, to which I referred on an earlier occasion in this Committee, between England and Scotland. If the medical representation on the new Health Authorities is to be less than hitherto, as appears probable, it becomes all the more important to have a strong medical element on the advisory committees. A Regional Health Authority or Area Health Authority might well be influenced by some non-medical factor; for example, a purely political factor. It is suggested that the Secretary of State should be the one in whom the ultimate authority rests, and not the Regional Health Authorities or Area Health Authorities. Unless there is some satisfactory explanation for the differentiation between the mode of recognition in England and Scotland, the same mechanism should be followed and the ultimate authority should rest with the Secretary of State. I beg to move.
§ LORD ABERDARE
We have great sympathy with the noble Lord's intentions in his Amendment, but we feel that to accept it as it is at the moment would result in a very unnecessary centralisation of work which would lay an impossible task on the Secretary of State. Moreover, if the advisory machinery is to be fully effective there must be confidence between the Authority and its committees. It would provide a poor basis for such mutual trust if the Authorities, which have such wide responsibilities, cannot be entrusted with the functions under this clause. Certainly, the local bodies (the Regional Health Authorities and the Area Health Authorities) are in a much better position to assess whether a committee is fully representative than is the central Department. However, if I correctly understand the noble Lord's intentions, he wishes to give the Secretary of State ultimate control of recognition arrangements. We think that there are merits in this proposal.
As subsections (1) to (4) of Clause 8 are drafted the Secretary of State is given no standing in the matter of dealing with this matter and could not issue a directive to an authority about it; he could not intervene directly if there were disagreement between the Authority and the profession. We should expect that if the 84 proposal were accepted the Secretary of State would very rarely use the power of direction in this sort of way, and then only in the most exceptional circumstances. But it may be that such a power would, nevertheless, provide a safeguard for the profession against the possibility of arbitrary action by a Health Authority, however unlikely that may be. However, we cannot accept the Amendments as they stand; they have certain technical defects. If I may, I shall be pleased to consider this point further on the lines that I have indicated.
§ LORD BROCK
I thank the Minister for those encouraging words. Perhaps he will find a way of improving the situation. I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ 6.32 p.m.
LORD PLATT moved Amendment No. 71:
Page 8, line 42, at end insert ("and it shall be the duty of the Authority to consult with the committee on such occasions and to such extent as may be prescribed;").
§ The noble Lord said: I should like to speak to Amendment No. 71. It might be thought that the wording of the Amendment is unnecessary, but even if it is proved to be unnecessary it seems to me to be desirable, which is a slightly different thing. I propose it with a certain amount of assurance because these words are incorporated in the original Act, and the very wording used here occurs in Section 16(7) of the Scottish National Health Service Act. I beg to move.
§ BARONESS SEROTA
I should like to support the Amendment moved by the noble Lord, Lord Platt. Earlier in our deliberations the noble Lord, Lord Aberdare, was concerned lest we should be ahead of Scotland. In this particular situation Scotland is ahead of us. I hope that he will agree that we should put the matter right.
§ LORD ABERDARE
I never like to be behind Scotland and I certainly hope that I can assure the Committee that we will try to help with the point put by the noble Lord, Lord Platt. As I have said previously, we attach the greatest importance to strong professional advisory machinery. That is why Clause 8 provides for 85 the statutory recognition of advisory committees. It is essential that the Authority should develop a close working relationship with their advisory committees if this new machinery is to work properly. We do not think that such a relationship can or should be controlled by legislation. We think it would be wrong, therefore, to list in detail all the matters on which the advisory committees should be consulted. This would not only be wrong in principle but in practice it might lead to argument and delay where urgent action was required, and could lead to doubts about the vires of an Authority's action.
With regard to the imposition on the Authority of a general obligation to consult the advisory committees, these objections do not apply. I am aware that the medical profession attaches great importance to provisions of this kind and, as the noble Lord has said, there is a precedent in Section 16(7) of the Scottish Act. Therefore, if the noble Lord will withdraw this Amendment I will undertake to move an Amendment on Report stage which will put a general duty of consultation on the Authority.
§ LORD PLATT
I thank the Minister for his reply and I feel sure that those of my colleagues who have subscribed their names to the Amendment will allow me to propose that it now be withdrawn.
§ Amendment, by leave, withdrawn.
§ Clause 8 agreed to.
§ LORD ABERDARE
Perhaps at this moment, since we have made excellent progress, as we are about to embark on Clause 9 and as there is other business for the House to tackle, it might be convenient for me to move that the House do now resume.
§ Moved, That the House do now resume.—(Lord Aberdare.)
§ House resumed accordingly.