HL Deb 23 January 1973 vol 338 cc96-149

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.)

House in Committee accordingly.

[The VISCOUNT HOOD in the Chair.]

Clause 9 [Community Health Councils]:

BARONESS WHITE moved Amendment No. 73: Page 10, line 5, leave out ("each Area Health Authority") and insert ("the Secretary of State").

The noble Baroness said: We now reach what will be generally agreed is one of the most important and controversial clauses in this Bill, because it deals with the community health councils, on which we had considerable discussion at Second Reading. It would be fair to say that on that occasion the Government did not have a friend in the House. There are different views as to the ways in which these councils might be constituted, and different views as to the scope of their functions. What is plain to all the world except, so far as one can understand, those at Alexander Fleming House, is that if one is to have a body whose business it is to act as a watchdog on the operations of the Health Service, then it simply passes comprehension how one can suppose that it can be an effective watchdog if it is to be appointed by, staffed by, possibly housed by, and its expenses met by the body which it is its business to watch. This is the simple proposition. If the Government are in earnest in this matter, and are sincere in their protestations that they genuinely wish community interests in the operation of the Health Service to have an effective voice, it appears to noble Lords in every part of the Committee that the propositions in the Bill as it now stands simply could not bring about that desired state. Therefore some Amendments to this particular clause of the Bill are imperative if we are to have effective community participation in the Health Service.

In our earlier discussions to-night on the managerial structure of the Health Service the point was made by the noble Lord, Lord Aberdare, that the Government were standing by the philosophy of keeping management and representation separate, except for the anomaly (if one might suppose it to be that) at the Area Health Authority level of having at least four persons nominated by local authorities. The corollary to having the hierarchical and self-contained managerial structure which is proposed in the White Paper and in the Bill is that public participation, if it is not to be brought in at management level, must have an effective vehicle alongside or out-with the management structure. It is for that reason that we have literally pages of Amendments proposed to this clause. It is going too far to follow The Times, which made a very good start to the year on January 1 by referring to the proposed structure as a "bureaucratic monster". That was going a little too far. When the article, which no doubt the Minister has read, went on to say that arrangements for giving the public an effective voice were hopelessly inadequate there we have reached common ground.

I find it difficult to suggest precisely how we can proceed with this debate because, in the nature of things, the three main groups of Amendments are scattered throughout the clause, yet they each have a consistency within themselves. The Amendment I am proposing, which is the opening Amendment, would substitute the Secretary of State as the appointing person for the Area Health Authority. A number of otherwise rather obscure Amendments which follow are consequential on this proposition, and try to express in the later parts of the clause what would have to be written in were one to accept this particular principle.

For the assistance of noble Lords, may I say that, in addition to the Amendment I am now moving, one might fairly suppose that Nos. 74 to 80 and Nos. 83 and 84 all hang together with this initial Amendment. Amendments Nos. 81 and 82 are separate, and so are Amendments Nos. 85, 86, 89 and 91 which stand in the names of my noble friends and myself. I will come back to the substance of the Amendments in a moment. The other two main groups of Amendments, as is plain from the Marshalled List, are those standing in the names of the noble Viscount, Lord Amory, the noble Viscount, Lord Bridgeman, and my noble friend Lord Pargiter, on the one hand. Those Amendments, broadly speaking, represent the views of the local authority associations. The other Amendments, standing in the names of the noble Lady, Lady Ruthven of Freeland, and the noble Lord, Lord Amulree, which are not so numerous, deal with one or two very important matters. The Amendments standing in the names of my noble friend Lord Garnsworthy and others are separate issues of great importance to the functioning of the community health councils, but do not go into the root matter of who is to appoint, who is to pay for and who is to staff these bodies.

I should make it plain that we are not necessarily wedded to our own proposition that it should be the Secretary of State throughout. When we considered this matter and began our consultations, which we have been pursuing during the Recess, with various interested organisations outside the House, and particularly those concerned with consumer matters, we reached the conclusion that everybody wanted to delete the Area Health Authority—there seems to be no dubiety at all about that in this context—as the body responsible for appointing the community health council. We did not find a single person who was in favour of the Area Health Authority appointing the community health council, financing it or staffing it. Those who have considered the matter were also generally of the opinion that, so far as practicable, such a body should be housed separately from the health authority that it was meant to be supervising—not in the managerial sense of supervising, but supervising in the interests of the general public.

There is far less agreement as to what should take its place. It is for that reason that I hope that in this long series of Amendments we may have a broad discussion of the possibilities which are open to us if we accept as a guiding principle that we do not want the Area Health Authority to be responsible, as is provided for in the Bill. I shall listen with particular interest to the propositions put forward by the noble Viscount, Lord Amory, and his friends because, while we may not go all the way with them, we feel there is substance in their proposals. The more one thinks about the functions of the community health councils the more one wants to be certain that they are linked with the community and are not just appendages of the Health Service.

Our own Amendments start, as I say, by substituting the Secretary of State as the appointing authority; and from that would flow that he should also meet the expenses of the body concerned. It is open to argument whether he would attempt to do this directly or by using the Regional Health Authorities, but certainly not the Area Health Authorities—that, I think, would be clear to most of us. The other Amendments which we have put down are in some respects germane to those of the noble Viscount, Lord Amory, in so far as we believe, as I said on Second Reading, that if the real purpose of the community health councils is to express public opinion, there is much to be said for trying to adjust their areas to coincide with those of local authority organisation under the revised scheme. I believe (and one of our Amendments is addressed to this point, and I have found a good deal of support for this view in the discussions we have been having) that it should at least be possible under the Bill for there to be direct elections. I gathered from the comment that the noble Lord, Lord Aberdare, made on Second Reading that this procedure does not necessarily commend itself to the Government, but the way in which we have worded this Amendment would, as I say, make it possible rather than mandatory. I think one cannot solve some of these problems (this is the one point on which I agree with my noble friend Lord Brown) on this side of the Health Service without an element of direct responsibility to people, if one is going to presume to speak for the people. But all these matters will be taken in due course as we reach them. I thought it was proper to point out the elements in our policy.

I expect the Government to say that they are not necessarily much enamoured with the idea of making the Secretary of State responsible for the appointments to what we grant will be a pretty large number of community health councils—I think, in round figures, about 200 is the order of magnitude so far as England is concerned. One fully recognises that this might be a difficulty. One of the problems which have arisen in our discussions is that, whereas in the Bill it is proposed that half the membership of the community health councils shall be from the local authorities and the other half from the voluntary organisations, the voluntary organisations themselves are not certain just how they wish to proceed. I do not know whether there are other noble Lords in the Committee who can give some further guidance on this matter, but we have done what we could in the time available to consult with, for example, the National Council of Social Service, National Organisations Division, and other groups who have been meeting to discuss this particular matter. Their strong wish, as I understand it, is that the voluntary organisations should be able to select from among themselves their own representatives on the community health councils. But when one puts to them precisely by what mechanism they think this would be brought about, there is a good deal of uncertainty.

I have before me a letter from the National Council of Social Service, dated January 12, in which they say that they would very much wish to be able to select the membership representing the voluntary organisations, but the mechanics of this would not be entirely straightforward and would take some while to work out". They go on to suggest that for an initial period of three years the appointments should be in the hands of the Secretary of State and that that time should be used so that not later than the end of the first two of those three years schemes might be put forward for dealing with the representation of voluntary organisations on the community health councils. I have no doubt the Government will be making their own contacts with the people concerned and I shall he very much interested to know what is their view on this matter.

I think there has been a general feeling that a 50/50 division is not entirely satisfactory. Again, we feel that one-third/one-third/one-third is a better proportion: in other words, one-third from local authorities, one-third from voluntary organisations, and we should like the other third by direct election, but there are alternative Amendments in the names of other noble Lords which suggest that the community health councils might co-opt persons whom they thought desirable. There are other propositions that the Secretary of State might himself nominate names from persons who were not put forward by the voluntary organisations which have a direct concern with the Health Service but might nevertheless be persons active in other walks of life who would make valuable members of such bodies. We ought to discuss all these proposals because what we are trying to do in what is a departure front the existing pattern in the Health Service is to try to lay down guidelines, at least, as to the most effective way of giving real voice to public concern with the way in which the Health Service is run at the community level in the localities.

I repeat that if the Government are taking the attitude which in general they are taking on the managerial structure, then it really behoves them to make certain that this particular vehicle of expression for public interest and public concern shall be as effective as it possibly can be. No one looking at the Marshalled List could suppose that it is satisfactory as it is now, because if it were we certainly should not have this very large number of Amendments. The earlier Amendments deal mainly with the composition, method of appointment and financing of the community health councils. There are one or two later Amendments, including that in the name of my noble friend Lady Llewelyn-Davies of Hastoe, No. 90A, and several others, which are more concerned with functions. But if we could get the appointing authority and the method of financing these councils clear in our minds first, then we might be in a better position to consider functions. Accordingly I beg to move the Amendment standing in the name of myself and my noble friend so that we may open the discussion on this extremely important clause.


The noble Lord, Lord Amulree, and I did not move Amendment No. 58 as it appeared to be more appropriate for discussion when we came to Clause 9, where there are many Amendments on the setting up of community health councils, but I should like to draw the attention of the Committee to the fact that there is nothing in the Bill about the composition of the community health councils. If they are to play an important part in the new National Health Service in representing the consumer (in other words, the patient) this omission ought to be rectified. That was what I had intended to try to put over in moving our Amendment No. 58, and the Minister has kindly allowed me to intervene in order to say what I had then intended to say.

Our Amendment No. 58, accepted the suggestion in the White Paper that there should be not less than twenty or more than thirty persons on each council and that the councils should appoint their own chairmen, but we think that the local authorities can provide sufficient expertise with fewer than half the members. Therefore we propose that they should make do with one third of the members. We suggest that three members might be co-opted by the councils themselves or appointed without consultation by the Secretary of State, the remainder to be appointed by the Secretary of State and not by the area (as the White Paper says) after consultation with bodies interested in health matters. In the last line of our Amendment we indicated the sort of people these nominees should be. We thought that really it was the voluntary organisations that had actually worked in the hospitals—speaking for my own association, the League of Hospital Friends, and there is also the W.R.V.S., the British Red Cross and the St. John Ambulance and many others who actually have worked in the Hospital Service with the patients and with the staff—who should make nominations. We are particularly anxious that those people should be considered, and we thought appointment should be by the Secretary of State.

We did not agree with some of the Amendments on how the people should be appointed. We think the councils ought to correspond with the health districts and not with the local authority districts, which are different. We do not see that the councils will be any more independent as the creatures of the local authorities than they would be if they were the creatures of the Area Authorities. We feel most strongly that the councils should be set up by the Secretary of State with only a few nominations from the local authorities. That is what I meant to say if we had moved Amendment No. 58 and I am glad to have had the opportunity of saying it now.


I should like to say a few words in support of the noble Lady, Lady Ruthven of Freeland. I am sure it is important that the community councils should not be thought to be in any way dependent upon or really connected with the Area Health Authority, and I should like to support what the noble Lady has just said. I hope that when the Minister replies he will be able to give us not only a friendly answer but also an understandable answer that we shall be able to accept.

8.4 p.m.


I think we are all grateful to my noble friend Lord Aberdare for welcoming the idea of a general discussion on the various proposals covered by the Amendments dealing with the community health councils. I am afraid he may feel a little impatient with us for continuing to plug this one aspect of local democratic participation, but the reason we are doing it is really because of the structure of the Bill as it is at present drafted.

If I may, I should like to speak to the Amendment standing on the Marshalled List in the name of myself and my noble friend Lord Bridgeman and the noble Lord, Lord Pargiter, No. 73A. There are many other consequential Amendments: Nos. 77A and 78A, 80A, 81A, 81B, 82A, 82B, 86A, 89A and 91A. In fact, the Amendments set down in our names seem to proliferate over the next two pages of the Marshalled List. It looks as though we have tabled every Amendment that has not already been pre-empted by the noble Baroness, Lady White, and my noble friend Lady Ruthven of Freeland. The aim of all these Amendments stems from the same basic cause. We think it important that the proposed community health councils should be given and should have, and should appear to have, a clearer independence than they have under the Bill at present. The proposals in these Amendments are supported, once again, by all four local government associations who have given great thought to this matter and I hope that this fact will lead my noble friend to think carefully about this matter.

We recognise that the intention behind the proposals for these community health councils is a worthy one: to afford an opportunity for advice from local users to the Area Authority, and criticism of them when the need is felt. But the proposal that half of the council members should be appointed by the Area Authorities, that the staff should be appointed and paid by the Authorities, and that accommodation should be provided by the Authorities—those same Authorities whose work will be subject to the council's criticism—surely cannot be right. The importance of these bodies being at arm's leneth from the organisation whose operations they are ready to scrutinise has been recognised in the Report of the Select Committee on the Nationalised Industries and also in the White Paper on the nationalised industries' relations with the public. It seems astonishing that this principle does not seem to be given effect to in this case. Local authority members, because of their own responsibilities for personal social services, and because of the knowledge they have of local needs and wishes, will have a deep interest in the work of these councils. The principle behind all these Amendments is the same: to ensure that the council shall be seen to be as separate as possible from the Area Committees whose operations they are going to scrutinise.

The Amendment standing in the name of the noble Baroness, Lady White, provided, as I understand it, for the councils to be set up by the Secretary of State rather than by the Area Authorities, and for the expenses to be paid by the Secretary of State, the local government members being elected by local government. The Amendment standing in the name of my noble friend Lord Bridgeman, the noble Lord, Lord Pargiter, and myself proposes that the members should be appointed by the local authorities and that the staff should be appointed and paid by local authorities. We believe, again, that the voluntary organisation members should not be chosen by the Area Authorities, but should be chosen in some other way by the voluntary bodies concerned. One thinks particularly of those voluntary organisations such as my noble friend Lady Ruthven, who knows so much about these things, has mentioned to us. I believe that these Amendments would render the councils entirely independent. It is this principle of independence that seems to be so essential, and I hope that if my noble friend does not like the precise proposals put forward in our Amendment he will agree that the principle of independence, and clear independence, seen to be there, requires to be enshrined and to be safeguarded in the Bill, and that he will make some proposals of his own to that effect.

Clause 9(4) says that membership shall be prescribed by regulations, whereas it seems to us that the Bill should itself provide specifically that district councils should appoint members, as is provided in the case of Area Authorities. It also seems to us that it should be laid down that every district in an area that is covered should have a representative. While we agree that the majority of the members should certainly be appointed by districts, we see possible advantage in one or two of them perhaps being members of county councils; apart from the value to the community council, it would be of value to a county council to have one or two of its members able to speak from first-hand knowledge of the working of the Health Service.

As regards districts, it seems to us that there is probably some difficulty in ensuring that these districts for this purpose should coincide with the local government districts; so that we feel that the Health Service districts might be the best guiding factory, provided that every local government district has a member on the council which covers any part of its area. Here we are a little out of agreement with the Amendment proposed by the noble Baroness, Lady White.

We know from our experience of other legislation that these sort of consultative bodies and bodies for channelling complaints can fail and be ineffective. They represent in a way a second best alternative to the principle of direct participation in executive decision-making. But if the Government are as determined as they seem to be to keep to a minimum direct participation by elected local government members on executive bodies, we really must press them to adopt some means of stressing the absolute independence of these community councils. I suggest to my noble friend that any reluctance to do so must be interpreted as confirming still further the fears that some of us mentioned at an earlier stage in the discussion to-day—the fairly widely held fears that the proposed set-up will be hierarchical, bureaucratic and insulated against the democratic expression of local opinion and need. The appointment of members and staff by anyone else seems to be preferable to their appointment by Area Authorities.

I trust that my noble friend will look favourably on the principle behind these Amendments and will accept, as I am sure he will, that we are not out to wreck the efficiency of this Service in any way but are anxious to make it still better. If he accepts that principle and looks favourably on it, I hope that he will choose some way of giving effect to the principle.


I do not wish in any way to curtail the debate or to prevent any noble Lord who wishes to speak from doing so. I feel from what I have heard so far that it might be useful if I were to say something now about how our thoughts have moved since we discussed this matter on Second Reading. It seems that the Committee is being a little difficult over this.




Where it is appropriate that the Secretary of State should make the appointments to management bodies we are being told and advised that other arrangements are preferable. Now, when we are talking about appointments to community representative bodies, the noble Baroness's Amendment seems to indicate that the Secretary of State should make these appointments. I should have thought that that was the very last thing he should do. There would be grave difficulties if that were to happen. The noble Baroness made a most realistic and entirely helpful speech about this. We are all trying to tackle this problem in the same spirit, namely, that of finding independent community health councils. However, as she said, there will be some 200 of them, and it would be an impossible burden to lay even on Alexander Fleming House to have to appoint these 200 local representative bodies which must, one would have thought, be appointed with the utmost local considerations in mind.


I hope that the Minister will forgive my interrupting him at this point. He will appreciate that in the course of my remarks I tried to indicate that if our suggestions were accepted one-third would in fact be local authority nominees, and therefore the Secretary of State would not have to worry unduly about them; and we should like one-third to be directly elected, so that he would not have to worry about them either. The voluntary bodies would like to choose their own but they are not sure how to do so. They regard the Secretary of State, as it were, as an interim person, one holding the line until they have worked out their own mechanism for doing this job, which means that in the end the Secretary of State would not have to worry about any of them. Nevertheless, we appreciated that something about this matter needed to be put in the Bill.


That would be on the assumption that we accepted all the other proposals of the noble Baroness about direct elections. The important matter on which we are all agreed is that the community health councils should be representative of local opinion; and it has been our thought hitherto that it would be easiest and more effective if the appointments were actually made by the Area Health Authority—although we are open to suggestions about this—simply because within the Health Service, which is the body in which these community health councils will be engaged, this is the most local body we can find who will know the local conditions.

Having said that, may I put on record some of the thoughts we have had since Second Reading because it is clear to me, as it has been to others, that these proposals are not universally approved of. To begin with, we accept the proposal of my noble friend Lady Ruthven of Freeland, that provision about the composition of community health councils should be in the Bill rather than in regulations. That point was also made by my noble friend Lord Amory. We will put forward Amendments on Report in the light of the further discussions we may have to-day on what the composition should be.

Secondly—and I am including in this Amendment No. 58, which my noble friend Lady Ruthven of Freeland and my noble friend Lord Amory did not move—we would prefer to leave the number of members of the community health council flexible rather than lay down a figure in the Bill. This would allow for local circumstances.

So far as the composition is concerned, we intend that not less than one-half of the members should be appointed directly by the district councils or by the London borough councils. We also intend—this will meet the point made by my noble friend Lord Amory—that each district and each London borough council concerned should be represented on the community health council. This immediately means that the Area Health Authority cannot have a majority of members on the community health council—because of this 50 per cent. minimum representation by the district councils, and we chose the district councils because they were the nearest to the ground in relation to the local authority council.


Did I hear the Minister aright? Did he say that 50 per cent. of the members would be appointed or elected by district councils and not by Area Authorities?


That is correct. That is why I would ask the Committee to consider carefully whether they really mean that the Area Health Authority should not be responsible for making these appointments, because the appointments, as I shall go on to explain, will all be nominees of other bodies: 50 per cent. of them by the district councils.


Did the noble Lord use the words "a minimum of 50 per cent. by local authorities"? Could he enlarge on that? Does he really mean that it will be a minimum, and that there is a possibility that there will be a majority who are not appointed by the Area Health Authority?


Yes, that is what I am saying. If the noble Lord will listen for a little longer, that is what I am trying to explain. I have already said that 50 per cent. will be appointed on the nomination of the district council. We go further and propose that of the remaining 50 per cent., two-thirds should be those nominated by the voluntary bodies. I appreciate, as does the noble Baroness, the difficulty of the voluntary bodies doing this themselves, so what we were suggesting was that the Area Health Authority, which knows its area and knows which voluntary bodies are most active in its area, should obtain from them the names of people they would like to see serving on the community health councils. A further two-thirds of the remainder would be those people who would be nominated by the local voluntary bodies. That means that one-third of the total would be drawn from people on the nomination of local voluntary bodies. Taking the whole of the community health council, that leaves a further one-sixth, and we were proposing that these again should be appointed by the Area Health Authority, which knows its locality, after consultation with other local bodies—for example, the churches, and perhaps former members of present hospital management committees. What we have in mind—and I am only covering for the moment the composition of these bodies—is that the Area Health Authority should make the appointments, because it is the nearest to the ground that we can get on the health side and because these bodies will be operating directly to the Area Health Authority, but that the composition will be such that the Area Health Authority itself will really have very little say in who the members are because 50 per cent. will be local district members, two-thirds of the remaining 50 per cent. will be voluntary body nominees, that is one-third, and one-sixth will be other local people from various organisations with interests in the Health Service. I thought I ought to put that on record.


I realise that the noble Lord has a difficult task. This is a long job of work he has in hand. When I rose earlier he asked that I should be patient. I have listened very carefully to what he has had to say and as I understand it—and it is important that we should get the picture clearer—what he has said since my earlier intervention is that 50 per cent. are to be appointed by the Area Health Authority. That a proportion is to be nominated by voluntary bodies is neither here nor there at the moment; they will be appointed from a list of nominees put up by voluntary organisations. That is the only possible meaning to be given to what he has to say. So when he referred to a minimum of 50 per cent. representing local authorities and appointed by them, the word "minimum" has no significance whatsoever because it would appear to me to be a maximum. If I am incorrect I hope the noble Lord will put me right.


The point I am trying to get over is that the Area Health Authority itself will not be putting on its nominees. It will have 50 per cent. of the names from people put on from the local district. The difficulty is, who else is going to appoint from the voluntary organisations? I do not think it is right that the Secretary of State should make appointments at district level to a community health council. It makes nonsense of it. If your Lordships' Committee can find some other suitable way of finding one-third of community health councils from among the voluntary bodies, I shall be the first to listen to it. We do not look at the Area Health Authorities as quite such an ogre as some noble Lords opposite do. We think that they will be perfectly responsible. They will go to the voluntary organisations such as those which the noble Lady, Lady Ruthven of Freeland, represents and others, and say, "There are so many places on our community health council, will you please suggest names for them?" And they will accept those names.


May I ask the noble Lord, Lord Aberdare, whether the Government have had consultations with the voluntary organisations on these proposals? It seems to me, and particularly the bodies which the noble Lady, Lady Ruthven of Freeland, has mentioned, that they are quite adult, mature and grown-up. Some would almost say that they are too stable for this kind of activity—and I am sure the noble Lady, Lady Ruthven of Freeland, will understand me when I say that. Have there been consultations? If so, has it been put to the voluntary organisations that they themselves are mature and stable enough to elect their own representatives. I should not have thought it was beyond their ability to come together and elect as from among themselves.


I agree very much with what the noble Baroness has said. It occurs to me that there is more machinery available for this purpose than anybody has said so far in this debate. What is the National Council of Social Services for; or the community councils in every county? I know the disadvantage: that they are sponsored by the Department of the Environment. That, of course, would be a very serious disadvantage in the eyes of a civil servant. But having said that (and no doubt my noble friend will come back to that in a moment), while I am on my feet I wonder whether I can say more about what my noble friend has said in reply to the various suggestions. Nobody who has listened to this debate can have failed to notice that there have been three different methods of approach, three different ideas of what should be done to get this right. But, unless I am wrong, there is complete unanimity about what should not be done; that is, that the Area Health Authorities should have the ultimate control of the community councils and should have the servicing of them.

That is a point which I thought was very clearly made not only by other noble Lords and Ladies, but by my noble friend Lord Amory. That is a point which, so far, my noble friend Lord Aberdare has not met in any way, because my noble friends and I in putting down this group of Amendments felt very strongly that the community councils should be, by constitution, entirely independent of the health councils and that in order to achieve that they should not have the nomination nor should they be responsible for the servicing, because the damage that can be done to the effectiveness of a council by secretaries who send things out too late has to be seen to be believed. If my noble friend could include that aspect, rather more positively than he has done up to now, in the points which he is prepared to listen to and talk about between now and Report, I think that noble Lords who are associated with me in this group of Amendments would be very pleased. But unless we can feel that, I do not think we shall feel satisfied that our point has been mot; and we feel it as strongly as ever.


I do not want to take up much time but I was very pleased when I heard my noble friend say that a large proportion—I believe it was 50 per cent.—of the members were to be nominated by members of local councils. May I follow that up by asking him whether the provision to be made in regulations will say that they "shall be" so appointed or that they "may be" so appointed, because that is important. We are here dealing only with the first stage. Its actual implementation comes when the regulations are laid before Parliament.

My second point, which I think is worth considering between now and Report stage, is that when it comes to overcoming some of the difficulties of finding appropriate members from the hierarchy of the voluntary societies my noble friend should consider the social services committees of the county councils or their successors, who are in fact in touch with all these bodies and have very close contact with the work which we all have in mind. I do not recall having heard him refer to the social services committees of the county councils during the whole course of this debate. As they are, as it were, in the middle of the road, their help may very well be valuable to him when he is thinking how he can modify these proposals before Report stage.


May I support my noble friend who has just spoken? During Second Reading debate the noble Lord, with his great experience of the borderland between health and welfare, explored this subject at some length very fruitfully, and I feel it is really most important that the county councils, as the social service and welfare authorities, should be represented on the community health councils.


There seems to be some confusion about the voluntary organisations. I would suggest that the people who really know what the voluntary organisations do in the appropriate locality are, first of all, the director of social services, for the community work, and the organisers of volunteers in hospitals. As obviously from district to district—and I mean from district to district—the work of the various voluntary organisations will vary, they are the people who would be most capable, in my view, of recommending to whoever they are to recommend to which voluntary organisations could give the best service on the community councils.


The noble Viscount, Lord Amory, said that these councils should be seen to have greater independence. I think that what is wanted is that they should be seen to have complete independence of the A.H.A.s and the R.H.A.s That is the point that needs putting across and that the Government needs to grasp. A situation should at no point be seen to exist where the A.H.A.s could be suspected of choosing who served. The councils ought to be independent in the manner in which they are appointed. They ought to be quite independent in regard to finance and the appointment of officers serving them. If community health councils are not going to be so independent then they might as well be forgotten, because the public will have no confidence in them. If the Government would give a little of their time to thinking out how these councils might be appointed, taking into account the views that have been expressed here this evening, I think they would be spending their time more wisely and to better purpose than in thinking out why they cannot meet the points of view expressed here to-night.

The pity of it is that those who have put Amendments down on this matter have not had a meeting and consultation before this debate took place, because there is an underlying unity of purpose so far as the movers of the various Amendments are concerned. I should have thought that the Government would appreciate that they are coming up with an answer that is completely unacceptable to this Committee and I believe unacceptable to public opinion—certainly unacceptable to the local authority associations. I should have thought that they would have welcomed the opportunity to call together those who have concerned themselves with these Amendments this evening, so that the way forward might be found to ensure that these community health councils were in fact, and were seen to be, completely independent. If they are not so independent, then the Government are wasting everybody's time in proceeding with their appointment.


I have had some experience of this subject and I am deeply worried about one situation. I think one can put these community health councils in the category of a hospital management committee without teeth; in other words, they have no monetary teeth; they have to get through everything by the charm of their hearts. They have the right of entry, and the right of entry can be a very dangerous thing. You call it a right of entry, but that immediately labels you as a snooper. We want to avoid that to the best of our ability They must work as a team. If they are nominated by the local authority or by the Secretary of State, they then get further and further away from the hospital, or whatever it is; they are more aloof, and they have to find their way in to the chairman of the Area Authority. Having regard to what my noble friend has said, that 50 per cent, of them will come from the local authorities, would it not be wise for at least the chairman or some of the members to be nominated by the Area Authority, who will know them and who will know the district? I cannot help feeling that the more remote we make these people the more difficult their job is going to be. These are not people who can go in and say, "You will do this and do that". They can only come in and say, "Please, we have noticed so-and-so", and the Area Authority under the Bill must take notice of what they say. But please do not let us make them too remote. Otherwise, I fear they will be out on an island of their own and find it very difficult to get in with the team.


I was taken to task at Second Reading for doubts I expressed about the whole of the administration of this new Bill. I think it is true to say that some of those doubts have been expressed by others, particularly in relation to these community health councils. Before we come to a decision, if indeed we can do so at this stage, it is good to ask ourselves what we expect the community health councils to be doing. Some light is shed on this in the White Paper. It is said: The council's basic job will be to represent to the A.H.A. the interests of the public…". One asks how are they going to do that. Councils will have the right to visit hospitals…and will have access to the area authority and…its senior officers. How are they going to do that—a body of 20 or 25 people? Conversely the Area Health Authority is expected to consult the community health councils on plans and variations of plans, new services, the closure of hospitals and the closure of departments. How is an Area Health Authority going to do that in relation to this community health council? There is a delightful phrase: that they are going to meet once a year, all together. I like that. The White Paper goes on to say that this is in addition to the regular less formal meetings between the Area Health Authority and its officers on the one side and the community health councils on the other. How is that going to be organised?

The point I should like to make is that we must devise, in addition to the constitution of the councils, a method of communication between the Hospital Service and the community health council. For my own part I should feel much happier if I knew that one member of the community health council—it may well be the chairman—would sit on that Area Health Authority. At least he would be privy to some of their thoughts, and they would know what the community health councils thought about the Area Health Authority's affairs.

My second point is one that has been running right through this debate: that the community health council must not in any circumstances be appointed by the Area Health Authority. I have written down a note, "If anything, rather the other way round". My business instincts prompt me to think that the shareholders should elect the directors rather than the directors elect the shareholders. My last point on the finance side is that, as I understand the Department's views at this moment, there seems to be an impression that, in addition to the finance which naturally has to be provided to these community health councils, the best person to be the staff representative would be somebody from the Department itself or from the National Health Service. This strikes me as being absolute nonsense. Again, when it comes to the question of the offices which these community health councils are to occupy there seems to be a suggestion that these would be in the Area Health Authority's offices. This, too, would be nonsense. For anybody who had a grouse or a grumble to complain to the community health council about some element of the hospital service and then to find that the very telephone number he rings up is that of the Area Health Authority would make him extremely doubtful of what was going on.

My last point—and I imagine that here I shall be on common ground with the Minister—is that I do not think that there should be any direct responsibility at the community health council for complaints. Once such a position got under way in a serious context we should feel that these community health councils were nothing but grousers. I feel that the community health councils are, in effect, a citizens' advice bureau, but to be a good and efficient citizens' advice bureau they must know what is going on in the hospital world. The difficulty at this moment in this Committee stage is that it is very easy to turn to each of the individual thoughts that have been expressed here and say, "Since it is difficult to put into effect what noble Lords are trying to achieve, why not leave it as it is in the Bill?" I am sure that that attitude is wrong. There has not so far been one person who has spoken in favour of the Area Health Authorities' making these appointments. We must find another way. We must ensure the independence of the community health councils; and, at any rate to start with, we must leave a flexible situation that can be improved on as time goes by. Personally, I shall not be content until I hear the Minister say that the Area Health Authorities have nothing whatever to do with the election of the members of the community health councils.

8.43 p.m.


It has been interesting to hear your Lordships' views on these matters. I can certainly undertake to do what the noble Lord, Lord Garnsworthy, seemed to think I had not already undertaken to do; that is to listen to this debate and see what comes out of it. I think I said that at the beginning, and I was rather surprised that he turned such a hostile face towards me and thumped the table.


I do not want the noble Lord to misunderstand me. I said that it was a pity that we had not had conversations before those Amendments were tabled. I am sure that the noble Lord, Lord Aberdare, is one of the last people towards whom I should want to adopt a hostile attitude, because he is always as conciliatory as he possibly can be and unfailingly courteous. I should have thought that it was clear that I was suggesting that the Government might invite all those interested to come together to find a positive answer to a very difficult problem, and a problem to which the Government themselves do not have a satisfactory solution.


May I say that I was sitting immediately behind my noble friend and I was looking full at the noble Lord, Lord Garnsworthy, and I could not see any hostility in his face at all. It looked to me extremely benign.


I am very glad to hear that. I am sorry if I imputed the wrong motives to the noble Lord, but he was rather banging the box and I thought that that was an indication of his wrath. I am certainly open to any sort of persuasion. Although I have been plugging the Area Health Authority as the appointer, it has been only within the restriction that they would be appointing people nominated by others, so that they would not be able to appoint a majority of people on to the community health council. If there should be another suggestion that we can seriously look at and that makes sense, I am all for considering it.

I do not think it has emerged from this debate as to who is going to make these appointments. I can assure the Committee that we have been in touch with several voluntary bodies but have not yet come up with an answer. The Director of Social Services was mentioned: well, we could think about that. The noble Baroness, Lady Hylton-Foster, mentioned the organisers of volunteers in hospital, but I dare say that it would be thought to be too prejudicial if they were given a say in what people should be put on the community health council. If the local authority were to do it I think there is a danger that they would be dominating this body to too great an extent, just as the other objection is that the Area Health Authority would be dominating, although I do not think that that case has been fully made out. However, I shall certainly think very hard about this matter. We have our own stages to go through, and the Bill has still to go to another place, and I am sure that in the end we shall emerge with a solution that is sensible and that meets your Lordships' wishes.


Could my noble friend say a word about finance?


I was rather sticking to the composition at the moment. May I say one more word about the composition to my noble friend Lord Inglewood. The question of the appointment by the district council will now form part of the Bill. The constitution will come in a new clause in the Bill, so it will definitely be written into the Bill.

Finance, premises and staff are again matters which we wish to look at. I think we have not got those quite right at the moment. I certainly cannot accept that the Secretary of State should pay the expenses of the community health council. Again we are putting him into a difficult position in dealing with local bodies, and we again would have thought on the lines of the Area Health Authority as being the local body best charged with this responsibility. We foresee a fruitful partnership between the community health council and the Area Health Authority.

When we come to the matters of staff and expenses in general, I am not sure that the Bill is flexible enough at present with staffing and premises, which all need consideration in the light of local circumstances in each district. I will undertake to ensure that the regulation-making power is in wide enough terms to enable a variety of arrangements to be made both on staffing and premises according to local wishes and circumstances. If an Amendment is needed to secure this flexibility I will move it at Report stage. So far as accommodation and staff go, I think that it would be a pity to forbid the use of Area Health Authority staff, because that would be very inflexible. The staffing and accommodation of individual councils needs consideration in the light of local circumstances in each district. Again I will undertake to ensure that the regulation-making power is in wide enough terms to enable a variety of arrangements to be made according to local wishes and circumstances. I feel that it is best if we think about what has been said in the course of the debate today, and see whether we can meet some of the points that have been made by your Lordships. Perhaps as we go through the Amendments there may be more detailed points that will arise on them.


All I can do is to extend my deepest sympathy to the noble Lord, because it is clear to all of us that he is batting on a fairly sticky wicket. He has made one or two promises, that there shall be more specific provision in the Bill and that we shall not leave everything to regulations: but, on the other hand, towards the end of his speech he said that matters should be left flexible so that a variety of arrangements could be made according to local wishes. And by "local wishes", I presume he means the wishes of the community health council.




I am sorry to have to press the noble Lord on this point, but if we do not get at least some sort of declaration of principle at this stage, we shall be in difficulties when we reach Report stage because, while we are all entirely in sympathy with the view that we are not in a position to reach finality on details—I would not for one moment deny that— I feel that we ought to attempt to go through the intellectual exercise of getting our minds a litttle clearer on what seems to be the best possible way of dealing with at least the major points.

We have been having a little private consultation on our Bench while the debate has been proceeding, because we were considering very carefully the point made by the noble Lord, Lord Aberdare, that, according to his doctrine, the Area Health Authority would not really be doing anything in the way of effective interference, because its choice as to two-thirds of 50 per cent.—if I have his statistics correctly—would be limited to nominations made by voluntary organisations connected with the Health Service, and it would have consultations with other bodies unspecified, except so far as the churches are concerned, about the remainder. If the Area Health Authority is not to be a deciding body and is only to take nominations, that is something one can contemplate with greater equanimity. But surely there will be more nominations than places, and therefore the choice will be made by the Area Health Authority. I find it very difficult to envisage any other situation. Thus, the Area Health Authority will be doing what we are all objecting to, and choosing its own watchdog. It will have a limited pack from which to choose its watchdog, because it will be depending on nominations by various bodies but it will nevertheless be making the effective choice of individual persons. So I am very much afraid that the suggestion put forward by the noble Lord really does not meet the objections which have been voiced from all quarters of the Committee.

We have been trying to transfer this situation, as described by the noble Lord, Lord Aberdare, to Amendment No. 73A in the name of the noble Viscount, Lord Amory, and his friends, in which they suggest that a specified local authority (this might be one of the new county councils; obviously, the district councils already have very much say and would need to take a somewhat broader view if they were dealing with voluntary organisation nominations) might have the responsibility of choice. On the principle put forward by the Minister, that the choice would be limited to a selection from the nominations of groups of organisations, would it not be desirable to put this responsibility on to a specified local authority? The noble Lord spoke of the possible domination of the local authority; but the local authority is not the institution that is being criticised. This was the whole gravamen of the criticism of the noble Viscount, Lord Amory, and of the noble Viscount, Lord Bridgeman, that we cannot have people setting up their own jury to try their own cause. But if this responsibility is circumscribed in the way outlined by the Minister, so that they would not have a completely random choice but would be as much or as little confined as the Area Health Authority in the area from which they would choose individual persons, then it seems to me that a democratically elected body, which, after all, is responsible for the welfare of the community in its area, would not be inappropriate for this purpose. Such a body would have just as great a local knowledge as, and possibly somewhat wider than, the Area Health Authority of people who should represent public opinion, which is, after all, the function of the community health council.

In the light of all this, and after consultation with my noble friends, we are prepared to withdraw our Amendment No. 73 in favour of Amendment No. 73A. It was not our original intention to do this, and we have been persuaded by the weight of argument in this debate. We ourselves proposed the Secretary of State partly, as I tried to explain, as a sort of holding operation, because we felt that the voluntary organisations were not fully ready to come forward with the sort of scheme for self-selection which I think they would, on balance, prefer. But there is no reason why they should not work out some self-selection scheme and put forward their nominations to the local authority, if they are able to do so. On balance, I think that, of the possible ways of dealing with what is admittedly a difficult matter, Amendment No. 73A is the most satisfactory, because it contains a genuine democratic principle and is also circumscribed, in the way described by the Minister, as to the area of choice that would be open to the local authority.

In those circumstances, if the noble Viscount, Lord Amory, is prepared formally to move his Amendment (which he has not yet done because we have been discussing the earlier Amendment), I shall be happy to beg leave to withdraw our Amendment. But until I have heard from him about what his intentions might be, we must reserve our position.


May I ask a very stupid question? I do not know what is meant by the term "local authorities". I have read everything on this subject, but I cannot find out who they really are. Who are they and where do they come into the National Health Service?


May I refer my noble friend to Amendment No. 91A for the answer to her question?

8.58 p.m.


I am attracted by what the noble Baroness, Lady White, has just said. It offers possibility of finding another body which might appoint those drawn from voluntary bodies, and it meets the objection that they should not even be appointed mechanically by the Area Health Authority. So I should very much like to think about it. I hope that my noble friend Lord Amory will not press his group of Amendments from No. 73A onwards this evening, because there are various bits and pieces which we ought to think further about. We must think very carefully about which of the various local authorities should be charged with this duty. It seems to me that there might be difficulties with the district, which is already nominating 50 per cent. of the community health council, but we might have found the answer in leaving it to the county authority to deal with the other 50 per cent. of nominations from local voluntary bodies, or in adopting some such way as that. I am extremely grateful to the noble Baroness, Lady White, for putting forward that constructive proposal, and to my noble friend Lord Amory. I hope, however, that he will not press his Amendment, because I shall look very sympathetically at the position in the light of what has been said.


My noble friend has been very patient with us, and he has had to play a very lone hand indeed. I think that not one single speech which has been made has come out other than strongly against the Area Health Authority having anything to do with this matter at all. I think my noble friend will feel it is probably significant that not only my noble friends and I but the noble Baroness, Lady White, and her noble friends think, on consideration, that there may well be weight in the method which has been suggested here.


May I interrupt the noble Viscount for one moment—and I must apologise to the Committee; I should have made this clear. It is the definition of a local authority which is contained in Amendment No. 91A with which we are concerned—at that level. That is what we are really working towards. The districts put up their own people, but the others should be selected by the authorities mentioned in No. 91A, which are the non-metropolitan counties, the metropolitan districts, the London boroughs, the Common Council and so on. It is that group of authorities.


I accept that that is the noble Baroness's point. I am quite sure that my noble friend will not fail to point out to his right honourable friend the views which have been expressed, if only the negative one we have expressed, which is that the Area Health Authority really must keep its fingers out of this matter altogether and have nothing to do with it. I am sure my noble friend will look at this broadly to meet the view which has been expressed by everybody who has spoken in this Committee; and while I do not want to introduce any element of threat at this stage, (though really, I suppose, that is what I do want to do) I would leave my noble friend in no doubt that if he is unable to find a way of taking the Area Health Authorities out, then those of us who have been responsible for these Amendments would have to set up a kind of ad hoc, temporary consultative council together, with a view to producing an absolutely terrifying Amendment, so formidable that it will unquestionably receive the approbation of the Committee or, if it is at the Report stage, of the House. But if, as I think is the case, my noble friend is going to set out to try to find some way of meeting our main point in this matter, then I should be willing not to move at this stage the Amendments which stand in my name and those of my noble friends.


We are in a great difficulty, because we are very much worried at having to wait until Report stage before getting any declaration of opinion as to something on which I think the vast majority of us are agreed. Naturally we take in absolute good faith what the Minister has said to us, but I must confess that we should be much happier if the noble Viscount, Lord Amory, would move his Amendment. After all, if something better turns up we can drop his Amendment on Report and adopt the better proposition. We can have our consultative council, by all means; we should be most happy to join the noble Viscount. But it seems to us rather a pity to leave this Committee stage without having any firm declaration of the view of your Lordships. I wonder whether the noble Viscount would reconsider this matter, on the full understanding that if, on further consideration, the Government come up with anything which appears to both of us preferable, he would then not object if this particular Amendment, if we adopted it now, were then eliminated in favour of the something better. Could the noble Viscount not consider that?


The course of action which the noble Baroness proposes is very tempting, but I feel in this case that my noble friend has gone as far as he probably can go this evening in giving us the assurances we want, and that he has taken on board our views. I believe he will come forward with the answer, but if that does not happen then I think the course is clear before us. But I personally should like to give him the chance now to produce the answer which he thinks would meet the views which have been put forcibly in so many parts of the Committee.


May we perhaps have a further assurance from the Minister? I know it may not be easy for him to give this, but we are in a difficulty. We shall have a reasonable time—and I am not in any way complaining—between Committee and Report, but if an Amendment by the Government is not put down until nearly the end of that period it gives us little chance to consult either with other Members of your Lordships' House or with organisations outside with whom we are in contact. We have put pretty clearly to the Government a possible way out here. We have thought about it carefully, and we have been persuaded, in a way rather against our earlier thoughts, that in all the circumstances this is probably the best thing. I am wondering whether the Minister could assure us—it obviously cannot be any kind of binding agreement, but a gentleman's agreement—that he will make this an urgent priority in his own Departmental consultations and with his Ministerial colleagues, so that we have fair play on this one, which is really a very important thing. We should like to have a reasonable period before we actually reach the Report stage, which I understand is likely to be on February 12 or so, so that we shall not be, not by evil intent but just by effluxion of time, caught short on an Amendment of such importance.


I should like strongly to support what the noble Baroness has said there. I am sure my noble friend will not run this up too tight, but will enable us to take what action we think fit if it becomes clear that my noble friend has failed in what I am sure he will try to do, which is to produce something which is acceptable. If that does not happen, it is quite clear we shall want time to consider what action we take.


Of course I will do my best with what urgency I can. But these are very difficult subjects, and certainly none of the Amendments on the Order Paper is perfect. Therefore I have gone as far as I can in saying that I will look at it, and I hope that your Lordships will accept that. I really will go and look at it. I do not think I can do very much more.


In all the circumstances, I think the only course open to us is to ask leave to withdraw Amendment No. 73, but I hope that from the exchange which has taken place all the occupants of the Government Front Bench appreciate that this subject is something of real seriousness, and that we must have a genuine alternative put before us in reasonable time. With that understanding, to which we have witnesses all round, I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

9.8 p.m.

BARONESS WHITE moved Amendment No. 81: Page 10, line 14, leave out from ("includes") to ("parts") in line 15.

The noble Baroness said: Without prejudice to what may happen later, I think that on Amendments Nos. 81 and 82 we ought to draw attention to a point which, though perhaps not of major importance, occurred to us in studying the Government proposals. As we understand the Bill as drafted, if it were left without these Amendments it would be possible for a community health council to cover not only the area of one area authority but part of another area authority. What I want to ask for clarification upon is whether this is what the Government really mean: because if these community health councils are to be the grass roots organisations surely it should not be possible under the terms of the Bill for a community health council to cover the area of the Area Health Authority plus some extra territory. This is our reading of it—though we may be mistaken. But if it is so, I am sure the Minister will appreciate that this would not he our conception of a community health council if it covered such a large territory. I wonder whether the Minister may care to comment on this.


I had some doubts as to what the noble Baroness had in mind; but the position is as she says. The idea is to make provision where there is an overlap situation between two Area Health Authorities. It could happen in certain cases that an Area Health Authority was made up of one health district only, with one district general hospital. May I say that it does not even have to have a district area hospital? I am thinking of Solihull, an area of Birmingham, which does not have a district general hospital and depends on another district general hospital for its health provision. Therefore there will possibly be an overlap arrangement which links the district general hospital in Birmingham with the area of Solihull. In that case, if there is to be a community health council which matched that district it would cover not only Solihull but part of Birmingham as well. In other words, where you get a health district which is, as we have defined it, coterminous with a health district, it may overlap two A.H.As, and in certain cases may include the area of one A.H.A.


I should like to support my noble friend. It is a good provision that there should be some recognition of this overlap. It may be that people living in one area are more likely to go to hospital in the next area than in their own. In those cases it is important that the community health council of the area where they go to hospital should include representatives of the area from which they are drawn, provided that the number likely to come from this area is significant. There is one area in the north of England where that happens; and I am told (though I have not checked it) that there is an area either in or near Somerset where that could happen in a big way.

Taking the matter further, I imagine that as the Bill is drawn if there is an overlap between England and Wales there would be no difficulty in appointing a member from one side of the Border to sit on a community health council which lies on the other side of the Border. But the England/Wales Border is not the only line; there is another between England and Scotland. Scotland is not mentioned very frequently in this Bill. Germs might find it no more difficult to cross the Border between England and Scotland than to do so between England and Wales. I hope that, before leaving this clause, my noble friend will tell us how he proposes to deal with this particular problem as regards the overlap in an area between England and Scotland.


I think my noble friend is anticipating his Amendment No. 93A; but if I may, I would rather leave this until we reach his Amendment. As I think was made clear when the Scottish Act was passing, there are good liaison arrangements which crossed the EnglishFrench—I mean the English-Scottish boundary, and these will certainly continue.


That was a nice "Freudian slip". We have not got that far yet—thank goodness! These Amendments were really probing Amendments. The point we wanted to make was that in one's anxiety to fit these councils to suitable district hospital responsibilities one should not make the areas so large that they lose the real "grass roots" character. I do not want to press the Amendment. We felt that it was a point which ought to be made. In the circumstances I beg leave to withdraw Amendment No. 81 and I do not propose to move Amendment No. 82.

Amendment, by leave, withdrawn.

9.15 p.m.

BARONESS WHITE moved Amendment No. 85: Page 10, line 28, after regulations") insert ("separately for England and Wales").

The noble Baroness said: Here we come to a point where I hope that, for once, the Minister may be ready and prepared to meet us. We are asking here that if so much of the provisions in this Bill are to be dealt with ultimately by regulation—I think that this will still apply even if, as the Minister has indicated, we do have something rather more specific in this clause—we should have a possibility of separate regulations for the Principality. After all, the administration of the Health Service in Wales is separate. The Secretary of State for Wales is responsible for its administration in Wales. The people concerned are answerable to him for administration and not to the Secretary of State in London. And there are certain different conditions not the least of which is that we have no regional tier in Wales. The Secretary of State for Wales and the Welsh Office under him will have a far greater part to play, relatively, in Wales in the administration of the Health Service than the Department of Health and Social Security will have in the direct administration of the English system. Therefore regulations which might seem appropriate in the English context may not be entirely satisfactory in the Welsh context. In addition to that, in the other place there are only 36 Welsh Members out of a total of more than 600, and as we know very well regulations cannot be amended; they can be accepted or rejected.

In those circumstances, we do not think it would meet the very natural democratic desires of the Welsh people that if there is something that concerns them particularly it should be so completely decided by a majority of people who are not concerned with the affairs of the Principality. I hope I need say no more to convince the Committee that this concession in the Bill would be much appreciated in Wales. I cannot see that it could cause any serious difficulties for the Government, in the light of the fact that the administration of the Health Service in the two countries is different in certain important respects and is carried on separately. So I hope very much that this Amendment will be accepted.


Under Clause 55(4) any power to make regulations or orders or schemes may be exercised so as to make the same provision for all cases, or different provisions for different cases or different classes of cases. I am advised that there is no doubt that the provisions of Clause 55(4) would permit regulations under Clause 9(4), which we are now considering, which made separate provisions, in whole or in part, for community health councils in England and Wales. So I think that the point the noble Baroness is making is already met under the present provisions in the Bill. But, of course, community health councils are intended to serve the same purposes in England and Wales, and in most, if not all, respects the provisions for them should be the same in the two countries. There might be differences if they were to take account of different circumstances, and any particular differences could usually be dealt with satisfactorily in a joint instrument for England and Wales. I suggest that it would be somewhat cumbersome to be obliged always to make altogether separate regulations. Nevertheless the power is there.

The noble Baroness made some very interesting suggestions about community councils in Wales during the Second Reading of the Bill. At the moment we have not found any way through this aspect. There are 1,000 community councils in Wales and we have not found a way satisfactorily to associate them with membership of the community health councils. But in a case like that, were there to be a separate provision for Wales, one could have separate regulations.

9.20 p.m.


I am aware that it is possible under the Bill, but what we are suggesting is that in this particular area, which is a sensitive area from the point of view of public opinion and public representation, a gesture might be made to Wales. The Minister is well aware that there were considerable complaints that Wales did not have a separate Bill. That, I agree, certainly in your Lordships' House, would have been a cumbersome procedure, and we have not made a great point of it. But there has been considerable feeling about this. Circumstances in Wales, as the Minister has recognised, are not in every respect the same as they are in England. I should have thought that it was well worth while making a gesture in this particular area. We are not asking for regulations throughout the Bill to be subject to this procedure. This Amendment deals only with community health councils and, as we have already decided to-night, this is a particular area of the Bill in which public feelings are engaged.

I am not now an elected Member in the Principality, as I was for many years, but I know enough of public opinion in the Principality to realise that the Government would do themselves nothing but good (I offer them some free advice on this) if they showed in this respect, which I do not think would be cumbersome, that they were taking account of the fact that the Secretary of State for Wales does have particular responsibility for the Health Service in Wales. I should have thought that they might give way on this.

Again, I do not like putting everything off to the Report stage, and it seems to me that this is something that might easily be accepted without great difficulty. If it were to apply to the entire Bill, then I should have some sympathy with the noble Lord's point of view, because there could be circumstances in which it might be cumbersome all the time to have separate regulations. That I think would be against common sense. But where you are dealing with community health councils and with the expression of opinion of the people, and with nothing else—because they do not have executive functions of any kind—then I do not see what harm would be done; and, as I say, it would be a welcome gesture in the Principality if the Minister could agree that under this clause we should have an opportunity of discussing our own regulations. I think this would be a sound thing to do and, as I have said, it would do the Government no harm politically.


If I thought there was anything very important in this I would certainly look at it again, but there are so many regulations that are made jointly for England and Wales on matters which concern them both that to make an exception in this case, where one is dealing with regulations that might be entirely similar, seems rather an empty gesture. I would rather make more handsome gestures where they are important.


I would not reject any handsome gesture that comes this way. The Committee may wish to negative this Amendment, but I am not prepared to withdraw it, because I know what the feeling is and what the response will be in the Principality. On this I must stick to my guns.

On Question, Amendment negatived.

9.25 p.m.

BARONESS WHITE moved Amendment No. 86: Page 10, line 29, after second ("the") insert ("election by local government elections for the related district or the").

The noble Baroness said: I really had hoped for a concession on the last Amendment. I should very much like to suppose that there might be one on this, but I recognise that the Minister has made it fairly clear that the Government are not prepared, at this moment of time at any rate, to come out in favour of direct election. Nevertheless I very much hope they will look carefully at this Amendment, because it is permissive only. If it were mandatory it would be in line with Government policy to resist it, but it is very carefully drawn in such a way as to make it possible at some future stage to have direct elections for the community health councils. If a Government at that stage did not approve of this provision then they would not have to exercise their permissive power. But we all know that a measure of this nature is apt to remain substantially unaltered for many years. It is very difficult to get amending legislation of this kind, except by regulation—and this would not be a suitable matter for regulation without some authority in the main Bill. Therefore what we are really asking is: let us not tie our successors. Even if the present Government do not see eye to eye with us on the desirability of some proportion of the community health council members being directly elected, let us not make it impossible for future Parliaments or Administrations to provide for direct election if they think fit, without going through the full process of amending legislation.

We hear a great deal of talk about public participation in one way or another. I believe that direct election is the most satisfactory form of public participation for many purposes. I think it is very salutary if members have to report back and to answer to the people whose interests they are representing. If they are not directly elected it is very easy to coast along and perhaps carry their responsibilities a little lightly. I have always found it a very healthy experience to have to go back to my constituency and explain what I have been doing, or not doing, as the case may be. Similarly, I still believe there is a great deal to be said for having some members of the council—not necessarily all of them—in a situation where it is their duty to explain to the public what they are trying to do to improve the Health Service, what the genuine difficulties may be in the way of such improvements and how they have been dealing with any complaints from the public as to the way in which the Service was being conducted.

In addition to that, of course, the great advantage of election is that the person concerned becomes known as someone to whom people may go with problems. One of the difficulties one has had sometimes with various consultative bodies—for example, those concerning the nationalised industries—is that people simply do not know whom to approach. If they go to the local post office or the local council office and ask, they can usually find out; but the relationship with an elected councillor is quite different because the councillor elect has to circularise his or her constituents and say. "I am putting myself forward for election: these are my qualifications and my aims." Therefore he or she becomes known in the locality. I believe that we should be taking a very serious step if we did not make it possible under this Bill for such a process to take place.

If the present Government do not feel this is desirable, that is for them to decide. But do not let us tie posterity. That is what this Amendment is really about. The last big National Health Service Bill that we had was many years ago, and it will probably be many years before we have another one. A subject of this kind is not one which Governments normally bring forward as amending legislation on a minor scale, so one might have to wait many years, if it were not made possible in this Bill, if and when the time came that it seemed desirable to be able to carry these things out. I repeat, there is nothing to force the present Government to adopt this policy if they do not want to do so; but it would make it possible for future Governments or Parliaments, if they wished, to make regulations which could embody this principle. Though I fully understand that the noble Lord, the Minister, does not agree with this, and that his colleagues do not agree with it as a matter for action now, I am pleading with him to leave the field open for our successors in case they came to the conclusion that this was a sensible wav of dealing with matters. I should have thought that on that basis this Amendment might well be accepted.


The noble Baroness said, I think, that we should be taking a very serious step if we did not make it possible for our successors to have recourse to direct election to the community health councils. I take the view that we should be taking a very serious step if we did, because there are two points of some importance. The first is that direct popular elections are limited at present in the United Kingdom to Members of Parliament and local government representatives. The proposal represents an important departure from this rule and would require very careful consideration of its possible constitutional implications. It might mean the introduction of Party politics into a field which most of us would agree should not be connected with Party politics.

Secondly, a matter of this kind, affecting local government election machinery, is not suitable to be dealt with by regulations under a Health Service Act. It is for these two principal reasons that I cannot advise your Lordships to accept this Amendment which was so persuasively moved by the noble Baroness. It would require very careful study before an innovation of this sort was introduced, and we should have to consult with a great many interested organisations. I am not sure about the merits of the scheme. It has certain attractions in the way mentioned by the noble Baroness, of enabling people to find their local representative and making sure that everybody knows who he is. But just how much enthusiasm there would be locally for these elections in view of the fact that local elections are sometimes not well patronised, I am not sure. I could not advise the Committee to accept the Amendment on the principal grounds that it has considerable implications which it would be wrong to accept lightly.


I am not surprised, in some ways, that the Government should react rather cautiously to this Amendment. I must confess that when the noble Baroness discussed this matter with me when she was considering putting the Amendment down I, too, found this a very novel idea. Nevertheless, it is very difficult for the Government to plead that it would be an innovation and that at the moment the only direct elections that we have are for local government and Parliament. The Government have created a totally new kind of authority or council in the form of the community health council to represent public opinion to the National Health Service. This has prompted the thoughts that my noble friend has put forward and which I myself now, after fairly long consideration, have found to be not quite so revolutionary as they might sound at first consideration. I should like the Government to think about this matter. It is clear, from what the noble Lord. Lord Aberdare, said, that they have brushed it aside and are not prepared themselves to accept what might be a possible consequence of their own actions. By taking the representative function out of the administration of the Health Service and isolating it in the community health council they themselves have made it necessary to think of ways of creating truly independent councils which every member of this Committee finds essential to the workings of the new system. This is not quite such a "way out" idea as it might have seemed at first glance, and it is something to which serious consideration should be given for the future, in the permissive sense in which my noble friend put it forward and not necessarily for implementation to-day.


I think, as my noble friend has said, that the proposal has some attractions in itself, and the noble Baroness in her vigil way has put it forward with great moderation. But I find myself persuaded by what my noble friend has said. At this particular moment, at any rate, when local government is being reformed and it is all important that the electorate should be clear about the elections they are being asked to take part in—it is of great importance for parish councils, district councils, county councils, et cetera—it would be a serious mistake to introduce this innovation. It would take people's eye off the ball a little and encourage people who are inclined already to say: "I get so confused about all these elections. I don't really know who I'm voting for, or why." I do not think the case is strong enough for putting such a proposal in the Bill, as it were, to be kept in stock against some future use. So personally I find myself persuaded by the reasons my noble friend has advanced against the acceptance of this Amendment.


My democratic spirit does not allow me to withdraw this Amendment because I feel passionately, having been an elected member, that there are certain essential values in it. I still think this is an area to which those values should be extended. So I am not going to ask your Lordships for leave to withdraw my Amendment, because I believe in it.

On Question, Amendment negatived.

9.39 p.m.

LORD GARNSWORTHY moved Amendment No. 87: Page 10, line 32, at end insert ("such regulations shall make provision for the appointment to the Council of representatives of the Education Service, including teachers").

The noble Lord said: We have been discussing matters of considerable importance. The Amendment has some bearing on them, but I should not want to exaggerate its importance as compared with the larger issues with which we have been concerned. Nevertheless, we have on a number of occasions during the Committee stage of this Bill recognised the importance of the school health service. The noble Viscount, Lord Amory, himself said earlier to-day something to the effect that we must get that right; and a number of other noble Lords have indicated agreement with that view. The position of teachers in regard to the Health Service may very properly be limited in terms of statutory function. I had hoped at an earlier stage in the proceedings that the Committee might have agreed to define that function, to show its limitation, but the Government were not minded to accept that. There can be few who would question that community health councils would be the more representative and the better equipped to perform their function if there were on them representatives of the education service, including teachers; and because of the vital role of the School Medical Service I think there is indeed a strong reason for asking for special representation here.

The teachers, members of the education service, become aware very quickly when there is a breakdown or a failure at home. They acquire tremendous knowledge of local situations for they are indeed the recipients of many confidences and complaints, if only by way of reading the occasional diaries kept by pupils in the primary schools. I am told by friends in the teaching profession that it is quite amazing how much information teachers glean from these entries. As I have said before, teachers give service far beyond the limits of their professional obligations.

I hope the Committee will agree that their experience and their knowledge qualify teachers to bring understanding and a sense of public duty to this particular field. I have tabled the Amendment in the knowledge that its acceptance would be appreciated by those most concerned. I am not a teacher and I have no obligation to teachers, except that as a layman I have been concerned with education for a great many years; but I have considerable contact with them and with some of their professional organisations and I can say that it would be very much appreciated by those who speak for teachers if the Government were minded to accept this Amendment—or at least, if they do not like the wording of the Amendment, to accept it in principle and to bring forward something that would meet the situation. I should like to feel that if the Government were difficult about it the Committee might say that they really ought to do this. I take the view that if the Amendment were carried it would also encourage close co-operation (and we cannot have too much of that) between the services of education and health—if I may put it this way—at "grass roots" level, and if co-operation is going to be worthwhile, if it is going to be really fruitful, we ought to get this "grass roots" level of co-operation in this particular field of the Service.

I hope that the noble Lord, Lord Aberdare, will appreciate that I am trying to be constructive and that I am putting the Amendment forward in the friendliest way, with no degree of hostility whatsoever. I trust that in the circumstances he will have no difficulty in accepting it, at least in spirit. I beg to move.

9.45 p.m.


The noble Lord will know well the importance that we attach to the School Health Service and the efforts that we have been making, in conjunction with the local authority bodies, to ensure that we have the best method of co-operation in future. The noble Lord's Amendment would require the community health councils to include representatives of the education service, including teachers, and it seems to me that as the councils are intended to represent the public as consumers of the Health Service, it would not be right to add to them specifically representatives of any other interests.

I fear that if one were to give this right to teachers in this matter, there might well be other people who would feel that they, too, had something to give to the community health council. Certainly there is no reason why members of the public who are teachers should not become members of this body. I would have thought that they could well be among those to be nominated one way or another, but I do not think they should be there as representatives of the education service. If they are worried on the School Health Service side, there are plenty of other channels open to them for bringing their complaints to the notice of the Health Service; direct from the teacher to the doctor, from the local education authority to the Area Health Authority or through the joint consultative committees which there will be for that purpose.

So far as the community health council itself is concerned, I believe that we should stick to the proposals which I am hoping to bring forward on Report and which will be limited to the district council representatives and to people from local voluntary bodies and other organisations. However, if in our future consideration of who should be nominating the other 50 per cent. it were the county council dealing with this matter, maybe they would wish to include a teacher among those nominations; but I should not like to see it written into the Bill that teachers must be members.


I am grateful to the Minister for those comments and I will not take up too much of your Lordships' time at this hour. It is somewhat difficult at the moment to appreciate what the Government will come up with on Report. The Amendment was of course tabled against the background of the Bill as drafted. If the proposals of the Government on Report—I took the Minister to give a definite indication that we shall be getting Amendments covering the points that have been made—seem to meet the situation reasonably well, I am sure that everybody concerned will be content. It would, however, be foolish to overlook the fact that many local education authorities are concerned at what is happening in that the School Health Service is being transferred or taken from them. I am sure that they will give as much co-operation as they can possibly give in this instance.

It would go some way to meet the position if at this level there were provision ensuring a link making it clear that teachers will be able to play a valuable part. Perhaps the proposals of the Government on Report will completely meet this point; I hope they will. I stress that teachers are in a somewhat peculiar position as members of the community. I would not for a moment suggest that they should be there to represent teachers. I am suggesting that they have good service to give in that they have an understanding of what is happening in the community. They become more quickly aware of it than do many others and it would be a good thing to take advantage of this ability. I will not press the Amendment at this stage. Remembering that it is a matter to which we may have to refer on Report, I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.


Amendment No. 88.


The noble Lord, Lord Amulree, and I do not propose to move this Amendment or Amendment No. 90, because my noble friend the Minister spoke on these points earlier in the debate and said that they would be considered when we came to the full consideration of how the community councils are to be set up.

9.50 p.m.

BARONESS WHITE moved Amendment No. 89: Page 10, line 34, leave out from ("Councils") to end of line 36.

The noble Baroness said: Again, in view of our earlier discussions, I do not propose to press this Amendment, but perhaps I might take advantage of this occasion to say just a word or two about the question of staff, because one is disturbed at the thought of the Government which is being communicated in this House, and also to certain organisations outside the House, that the most satisfactory staff to service the community health councils would be persons from within the Health Service. I do ask the Minister to think again about this, because it goes back to the philosophy of the independence of the community health councils.

A number of noble Lords pointed out on Second Reading that if someone had to depend for his career prospects and his future promotion on his superiors within the Health Service, he was not at all likely to be over-critical of any defects or maladministrations falling within the interest of the community health councils. That is one of the reasons why I was interested in some of the local authority proposals. With the reorganisation of local government, for example, there may well be persons who know their localities extremely well, who could be effective officers servicing community health councils and who, incidentally, if they have been in one of the local authorities which at the moment provide an element of health service, probably know a great deal about it.

Therefore, without pressing the Amendment itself, I wish to stress the point that many of us are extremely apprehensive of what we take to be the Government's attitude on this matter: that the community health councils should be staffed from within the Health Service. We believe that they ought to be free to appoint their own staff but that there should be suitable arrangements—because of the limited opportunities offered by the community health councils from the point of view of career prospects and advancement—as there could easily be, for interchange with either Health Service or the local authority services, with a preservation of pension rights and so on. But the councils should be free to choose their own staff, and there should be adequate budgetary provision so that they can have at least one—probably not more than one—really experienced and sufficiently senior person on their staff as their main official in order to make their work effective.


I am sure that there is force in what the noble Baroness has just said. My noble friend has said that he will look into all these matters and I am sure that he will look at this one among them. I take comfort from the fact that he said just now that he did not feel that the Government have got the present proposals in respect of staff quite right.


I accept that. What we must find is some flexible arrangement. There may well be places where, as the noble Baroness said, there is a perfectly acceptable person who is not part of the National Health Service but is able to take on the work of being secretary of the community health council. In another area, however, as she says, it may be difficult to find somebody because there is no career structure there; and in that case it may be better to second somebody from within the Health Service. I must say it has not been my experience that people seconded from one organisation to another have been any less keen in the way in which they perform their job. I do not think this problem would necessarily arise. However, I have said that I should like to look at it, and I think perhaps all of us feel that what we really want is a flexible system which allows the community health council to have the sort of services it is seeking.


In view of the Minister's remarks, I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

9.56 p.m.

BARONESS LLEWELYN-DAVIES OF HASTOE moved Amendment No. 90A: Page 11, line 8, at end insert ("in particular, arrangements for advice to be made available to patients in the health service to enable them effectively to suggest improvements in or to pursue complaints regarding the operation of the service and for the council itself to pursue the suggestion or complaint if it thinks fit.")

The noble Baroness said: I beg to move the Amendment standing in my name and the names of my noble friends. Although the hour is getting late, I think it is rather important that I explain to the Committee what we mean by this Amendment. We have had a very remarkable debate, and there can be no doubt at all that the feeling of the Committee is that the community health councils should be a really positive part of the National Health Service. There is no doubt that in all parts of the House there is this belief that it is vital that they should play a positive part. What we have asked for is that arrangements should be made for advice to be available to patients in the National Health Service who would like to suggest improvements. I should like the noble Lord, Lord Hayter, especially to notice that we have put "suggest improvements" first, because we feel that this is just as important as complaints. Many people are too inexperienced and lacking in detailed knowledge to be able to suggest improvements themselves without advice. We believe that a lot of valuable suggestions for the Health Service—and I do not mean simply the hospitals but the whole Health Service—might well be lost without some form of expert advice. Although the noble Lord, Lord Hayter, did not care for the idea about complaints, in fact where complaints are concerned it is probably even more important, because it is often those people who most need help in this direction who find it most difficult to formulate for themselves just what the particular difficulty has been and are therefore unable to suggest things which will help patients who come after them.

What we want to ensure by this Amendment is that the responsibility for dealing with individual suggestions and complaints lies fully within the community health councils. The noble Lord, Lord Hayter, referred to citizens' advice bureaux. Noble Lords in all parts of the House know that there has been a tremendous multiplication of local authority advice services. Indeed, the right honourable gentleman—whose exact title I have forgotten; I think it is the Minister for Consumer Services—Sir Geoffrey Howe, has himself referred to this and to the necessity for some kind of rationalisation. If our Amendment is accepted, there should be people who would be capable of having a proper liaison with citizens' advice bureaux and organisations of that kind. Indeed, if necessary, they should have some form of training, perhaps even some minor form of honorarium, so that they would be available to maintain a two-way flow of information and assistance between those advice services which exist already and the new and quite vital ones which will need to be established when the community health councils come about.

It is always very difficult to discuss community health services without in some way getting into the sphere of the Ombudsman. I have heard it said that this kind of thing might conflict with his functions. We believe that this particular Amendment would in fact assist the Commissioner, because it would in a way divert from him to the community health councils matters which individuals could not always handle by themselves; and with the expert help of the community health councils a better result might well be achieved.

What we want to establish by this Amendment, and what we hope that the Government will accept, is the principle that if an individual made a suggestion which the councils thought had great substance, they might themselves have the right to pursue the idea, or the complaint, in a general sense with the expert advice that they would have at their disposal. We not only think this important in principle, but we think it important for a different reason: we must, and indeed do, believe that the Government really want these community health councils to succeed; but they will only succeed if they are composed of really first-class people. You are not going to have people coming on to these councils, sitting once a year, as the noble Lord said, unless they have adequate, vital and important jobs to do. It is no use thinking that someone who has served on an active hospital management board, or a board of governors, is going to look at this kind of work unless there is some substance in it. I am sure that the Government would like to have that, and we feel that this Amendment, which is not very complicated, will go a long way towards achieving what the Government themselves are after.

10.2 p.m.


If I may say so, I very much welcome the constructive view of the functions of the community health councils which the noble Baroness has expressed. She made one point just now when she said that the community health councils should be ready to take up ideas that might be mentioned by individual patients, or indeed complaints of a general nature that also emerge from their contact with patients; and we fully accept this. This is one of the functions that the community health councils will have. However, these are all matters that will be covered within the regulation- making powers provided in Clause 9(4)(g), which are quite wide enough to cover arrangements of the kind that she envisages. We propose to issue guidance in due course in the form of a sort of check list of the matters to which councils should pay particular attention. I think that this is the sort of matter which that sort of guidance should certainly cover. In fact, in the White Paper we specifically proposed that community health councils should, on request, provide information about complaints procedures to patients in hospital, and that members should act as a patient's friend where one is needed.

Of course, it is an important function of community health councils to seek ways of making the Service run more smoothly and efficiently, and they will certainly be able to take into account suggestions made to them by patients, and follow up general complaints with the health authorities. We feel that the community health councils themselves should be allowed to decide in the light of local circumstances exactly how they carry out the general duty imposed on them in the Bill, and we do not feel that we should write this particular Amendment into the Bill, although I will certainly take it into account when we come to the guidance to be issued to the community health councils.

We are talking here primarily of hospital patients; the situation is rather different for users of the Health Service in the community, who have access to various sources of information and help. The Davies Committee on Hospital Complaints Procedure is expected to report later this year and will make recommendations about the handling of hospital patients' suggestions and complaints; and this report may well carry implications for the role of community health councils. That is another reason why it would not be desirable at this stage to write into the Bill too rigid a provision which could possibly conflict with that Committee's views when they are made known. I think it would be wiser to wait and see what the Committee say, and then see what should be done to ensure that what they recommend fits in with the role of the community health council The Bill does not have to be amended to achieve the noble Baroness's objectives. As the clause stands, it already provides powers for regulations to be made covering the points referred to in the Amendment. I hope, therefore, that she will agree to withdraw this Amendment, on the understanding that her approach to the matter is fully shared by the Government.


Before my noble friend speaks again, may I ask the Minister for clarification? In paragraph 110 of the English Blue-White Paper, there is a reference to a "patient's friend", but for some peculiar reason there is no such reference in the Welsh Red-White Paper, and this has caused some comment. It is probably inadvertent, but it is a little odd that the English community health councils are expected to provide patients' friends where required in pursuit of difficulties or complaints, whereas the Welsh, apparently, are to get on without one. I wonder whether the noble Lord can comment on that.


I am afraid that the noble Baroness has caught me out on that point. I know that the Welsh are very competent and hardly need the assistance of a friend, but may I please be given a little time? I will certainly let the noble Baroness know the answer.


Between the Red Queen and the White Queen, I feel rather inadequate. The noble Lord is, as always, very disarming and I should like to thank him for the way in which he has looked at—I cannot say accepted—our Amendment. But it is precisely because we did not think that paragraph (g) gave the powers which we wanted community health councils to have—and I took the very best legal advice from behind me—that we put down this Amendment. We all know that if you have two lawyers you have four opinions, so we could not be too sure about that. But if the noble Lord feels that we are so right in spirit, he might have gone a little further and accepted the Amendment. We are disquieted that he should say that he would not wish to have an obligation on all community health councils because some of them would not wish to exercise the powers. It is precisely for that reason that we wish to have this written into the Bill. As the noble Lord has accepted the principle that it is the function of the community health councils themselves to pursue these matters, we think it is essential that they should know from the Government themselves that this is so. So I should like to plead with the noble Lord. I cannot see any reason why he should not accept our Amendment, since he accepts the spirit of it. If we have to wait any longer for Davis, we shall never get this Bill through. Can we beg the noble Lord just this once to give in?


I am sorry, but I have made my position as clear as I can. I can give the noble Baroness the assurance that what she wants can be covered in the regulations. Whatever her legal advice is, my legal advice is the opposite and I hope she will accept that.


As my legal advice seems to be sitting silently, I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

10.9 p.m.

BARONESS WHITE moved Amendment No. 91: Page 11, line 17, after ("Authorities;") insert ("districts in relation to a Council shall be coterminous with one or more districts in a non-metropolitan county, or ward or ward; in a metropolitan district or London Borough;").

The noble Baroness said: I recognize that this is a difficult point, because the Government's plan under this Bill is that there should be Health Service districts centred as far as possible upon district general hospitals; in other words, to meet solely the needs of the Health Service. However, in dealing with the community health councils we are not dealing simply with the Health Service but, as I said on an earlier Amendment, with an expression of public opinion, and with the connections between the Health Service and the other community services, where there is, as we all recognise, a considerable overlap of interest.

Had the Health Service been organised under elected authorities, the situation would have been different; but it is not, and therefore one is particularly concerned with other local authority functions on the social welfare side—the housing side, education and so on, which have all been touched upon in the course of our discussions. It was for these reasons that it seemed to us that for this function, that of the community health councils as opposed to the administrative function within the Health Service itself, we would be well advised, for this purpose only, to adopt the districts or the wards, as the case might be, which are the pattern for local government functions. We think it would be a very much tidier way of doing things in this particular field, and of course might also fit in better with the propositions, which have been put into cold storage for the time being, of the noble Viscount, Lord Amory, and his noble friends.

I realise that this is not an easy matter. I took counsel with the local authority associations, and I think that they themselves are in a rather indeterminate state about it. The Area Authorities, as we know, are coterminous with local authorities: it is only at the district level that one gets into this difficult situation. I still believe that it will be more satisfactory for this purpose to be able to fit in the work of the community health council with that of the local government organisation. As the noble Lord, Lord Aberdare, mentioned, in Wales, for instance, we shall be having, among other things, the community health councils, and so on, which will be within the context of our reformed local government. The English pattern may not be quite the same, but I think that some of the same reasons for this Amendment might apply there.

I am not proposing at this late hour and at this stage of the Bill to press this Amendment, but I would ask noble Lords who are interested, and particularly those who are concerned with the local authority associations' point of view on all this, to give it perhaps a little further thought to see whether we are not right in our instinct; namely, that for this purpose the local government boundaries are more appropriate than boundaries which are legitimate for the administrative functions of the Health Service itself but are not necessarily, in our view, the best for the functions which we understand are ascribed to the community health councils. I beg to move.

10.14 p.m.


Of course it would be ideal if the two districts, the health district and the local authority district, were to coincide. Unfortunately, they do not, and we have to face this problem. We certainly long ago looked very carefully at what the noble Baroness is now putting forward as a possibility, when we were thinking first about the constitution of community health councils; but we came to the very definite conclusion that it would be wrong, and that the community health councils would be much more effectively organised on the boundaries of the health districts. After all, the health district is the lowest unit of the Health Service which is capable of providing most of the health services, including the hospital service; and the important thing is that at that level the health services should be integrated, both community and hospital services. Therefore, to have a community health council at that level is very important because they will be able to watch over from the community point of view and see that there is proper provision in all types of health provision, both hospital and community. This sort of one-for-one relationship between community health council and the district management team will be of immense importance; because, as the noble Baroness, Lady Llewellyn Davies, was saying when talking about ideas from patients, the community health council should be responsive to ideas from the patient and should then talk about them with the authority. The authority in that first instance will be the district management team and then they could report back to the area. The first point of contact would be the district management team and the one-to-one relationship is right.

While the solution that the noble Baroness put forward would avoid having community health council boundaries cutting across local government districts, it would often result in several community health councils relating to one health district. This would bring grave difficulties. There are instances where you might have five or six local government districts relating to one health district. I do not think this would be a satisfactory way of operating if all had access to the hospital—five or six different community health councils. I think there would be grave difficulties. Of the two choices, we believe there would be difficulties in the way of the suggestion by the noble Baroness and that there are positive advantages in relating community health councils to health districts. I hope I have persuaded the noble Baroness, and I think my noble friend Lord Amory agrees with me on this occasion.


I think that on balance I agree. But the local government bodies had, to start with, the hope that it might be possible to work out a scheme where the boundaries would be coterminous with local government districts. At first sight that had attraction. We became conscious of the difficulties of doing it, and I think that our deliberations finished pretty well in agreement with the views that my noble friend has just expressed. We will give the matter further thought to see if there is any reason why the point of view of the noble Baroness may not be the right one. But, rather regretfully, we feel that at present the difficulties would be too great.


As I said at the outset, this is not an Amendment that I proposed to press. The converse of what the noble Lord has said can occasionally be true. I am thinking of the local authority of Powis, in which I shall be residing. The difficulty is that there is there no hospital in sight, so to speak, and therefore that local authority will have to deal with the whole ring of surrounding health authorities—which will also be very confusing. In view of what the noble Viscount, Lord Amory, has said, as well as what the noble Lord, Lord Aberdare, has said, I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

Clause 9 agreed to.


I beg to move the House do now resume.

Moved, That the House do now resume.—(Lord Aberdare.)

On Question, Motion agreed to, and House resumed accordingly.