§ 3.23 p.m.
§ THE MINISTER OF STATE, DEPARTMENT OF HEALTH AND SOCIAL SECURITY (LORD ABERDARE)
My Lords, I beg to move that the House do again resolve itself into Committee on this Bill.
§ Moved, That the House do again resolve itself into Committee.—(Lord Aberdare.)
§ On Question, Motion agreed to.
§ House in Committee accordingly.
§ [The EARL OF LISTOWEL in the Chair.]
LORD GARNSWORTHY moved Amendment No. 92.
After Clause 9 insert the following new clause:
§ Joint Consultation Procedures
§ ".It shall be the duty of each Area Health Authority to endeavour by taking all such steps as are in the circumstances reasonably practicable to promote the establishment and maintenance whether by negotiation or otherwise of such joint consultation procedures as will enable discussion and negotiation from time to time to take place between persons in a managerial position in any hospital or other establishment in the area of the Authority provided for or formng part of the national health service and workers employed in or for the purposes of any such hospital or other establishment, on or with regard to the terms and conditions of employment of workers so employed."
§ The noble Lord said: I think almost everyone will agree that ultimately the success of the reorganised National Health Service will depend on the good will and co-operation of all those engaged in that Service, and the more the workers feel that their views will be welcomed and given serious consideration the brighter will be the prospects of securing that good will and that essential cooperation. It will encourage the workers to feel that they are not merely cogs in a wheel but partners in a tremendously valuable enterprise.256
The section of the White Paper dealing with the staff of the Service, at page 36, said something that I feel is worth bearing in mind in considering this Amendment. I should like to quote briefly from paragraph 145:
Any large undertaking naturally depends for its success on the loyal and efficient support of its staff and the manner in which they identify themselves with its objectives. This is as true of the National Health Service as of any other organisation.
Then paragraph 146 says:
The service therefore needs particularly discerning and skilled personnel management at all levels from the centre outwards.…Good staff management demands good manpower information and work is being done on this both in the Department and elsewhere. The managers of the reorganised N.H.S. at all levels will be encouraged to give closer attention to this subject and will have better resources to handle it than their predecessors have had.
§ We are living at a time when, probably as never before, men and women want to be consulted, and ought to be consulted, about the environment in which they work. The contribution they are able to make to the efficient operation of the establishment in which they are employed can be enhanced to the degree that the importance of their work is seen to be appreciated. Their interest in that work can be increased by the extent to which they are conscious of consideration for them as persons—as individuals. People are entitled to terms and conditions of employment which show regard to the importance of their work and respect for their dignity as human beings. These are the people with whom I am concerned in this Amendment. It is all too easy for management to think that it knows best. The management that knows best is the one that recognises the dignity of the individual worker and the need to keep him aware that his importance, his everyday working experience, his entitlement to consideration are a matter of concern.
§ There are many matters which fall to be dealt with at national level and I am grateful for the indications that have been given that there will be written into the Bill provision for appropriate consultation with representative staff bodies. I am sure this will give considerable satisfaction and will help in the development of the Service. But such consultations cannot deal with the many differing local circumstances of each hospital or 257 establishment. Some of them will be quite unique, and in any case one anticipates that different establishments will develop in different ways. This means that at local establishment levels there will be problems—challenges; how to get the best response from those engaged as workers in the Service. It is to meet this situation that my noble friends and I have tabled this Amendment.
§ At local level we seek to bring those engaged in a managerial position in a hospital or other establishment in the area of an A.H.A., together with those workers employed therein, to discuss and negotiate on or with regard to their terms and conditions of employment. So the Amendment lays on each Area Health Authority the duty of securing, so far as is reasonably practicable, joint consultation procedures to this end. I believe the principle underlying the Amendment to be a sound one, and I believe its application would be most helpful. At no point does it seek to denigrate anyone's role but rather to bring dignity into relationships as between management and workers. It is far better to have a known and acknowledged channel of communication through which calm and constructive discussion can take place rather than the frustrations that are too often the alternative. I believe the Bill will be better for having a reference to joint consultative procedures written into it. I beg to move.
I should perhaps explain the procedure followed at present in the group of hospitals of which I am the chairman. We have a joint consultative committee which consists of the group secretary, or his representative when he is absent, the hospital secretary and two or three members of the hospital management committee. That joint body is called together when required, and from the staff point of view the members nominate or elect shop stewards, as they called, to represent the staff. Discussions take place on all manner of subjects affecting the staff.
I mentioned that two or three members of the hospital management committee were represented on the joint consultative committee. I do not know what will happen when the hospital management 258 committees disappear: who will take the place of their members on such joint committees. I believe that it is of value to keep these committees within the hospital set-up because there is much to be said for having a small group of people able to discuss these problems without having to go to a larger group, at which the problem under discussion may become enlarged and a difficult situation arise. I await the Minister's reply because I am not certain that I fully understand the Amendment, though I am in favour of it. I emphasise, however, that I am particularly in favour of small rather than large Area Health Authorities.
§ 3.32 p.m.
§ THE PARLIAMENTARY UNDERSECRETARY OF STATE, DEPARTMENT OF EDUCATION AND SCIENCE (LORD BELSTEAD)
I wish to make it clear at the outset that the Secretary of State wholeheartedly supports the practice of joint consultation with staff at all levels and looks forward to its improvement and further development in the reorganised Health Service. I really mean it when I say on behalf of my right honourable friend that I am glad that the noble Lord, Lord Garnsworthy, quoted from paragraphs 145 and 146 of the White Paper, because I assure him that in trying to achieve the objectives outlined in those passages there is nothing between the two sides of the House. Where I am afraid I must part company with the noble Lord is my inability to agree that it would be appropriate to legislate to bring about a development of this kind. The noble Lord rightly referred to the wish to-day of people to be consulted, perhaps in a way never evinced previously. From the point of view of the Government, is this not pre-eminently a development to be fostered, in discussion between management and staff within the normal collective bargaining arrangements which exist? The existing Whitley Councils were set up by voluntary agreement between management and staff. Their main constitution provides for securing the greatest possible measure of co-operation between management and staff and for providing machinery for considering terms and conditions of service.
The White Paper proposed that negotiation of terms and conditions of service 259 should continue to be conducted centrally. We expect the existing arrangements for collective bargaining to continue into the new Service, with such necessary changes as the two sides may agree to make. I understand that an amended agreement on joint consultation is currently under discussion in the General Whitley Council. The Government think that arrangements for local joint consultation and for any decentralisation of negotiations on terms and conditions of service—if, in the end, that is what is agreed—can best be determined by agreement in the national negotiating machinery.
I think I am right in saying that the General Whitley Council has an agreement, which is about 20 years old, saying that there shall be consultative machinery locally. I think I am also right in saying that joint consultative machinery locally has not perhaps always worked quite so well as it has done in my noble friend Lord Grenfell's group of hospitals. The noble Lord asked whether the consultative machinery would be as local as it had been before, and I would answer that question with two points. First, this is something which is being worked out in the General Whitley Council. This means that my right honourable friend's Department is a party to these talks; and I should like to draw the words of my noble friend to the attention of my right honourable friend. Secondly, an Amendment of this sort could be interpreted as being an interference with what is going on in the Whitley Council at the moment. In moving the Amendment the noble Lord, Lord Garnsworthy, pointed out that a willingness to discuss staff was the hallmark of good management and that there were obviously local differences between situations in different localities of the country. I understand that discussions are in progress between the management and staff sides of the General Whitley Council, and I think we should await the outcome of those. However, we can be optimistic because I am able to say this afternoon that I understand that there is already agreement in principle between the two sides about local joint consultation.
§ LORD GARNSWORTHY
I am grateful to the Minister for that reply, but I 260 suggest that he has raised obstacles that do not amount to very much. Noble Lords will have appreciated the intervention of the noble Lord, Lord Grenfell. I want to make it clear that my Amendment is intended to deal with the situation at local level in just the way the noble Lord mentioned, and I thought that his remarks gave powerful support to the principle underlying the Amendment. I gathered from the remarks of the noble Lord, Lord Belstead, about the consultations that are going on that it is anticipated they will produce a satisfactory result so that in his view we should await the outcome of them. I remind the Minister, however, that we are dealing with this Bill at this time.
Furthermore, I cannot see anything particularly controversial about my proposal. Certainly the noble Lord gave no indication that in his view there is anything undesirable in what the Amendment seeks to do in bringing about these joint consultative procedures at local level. I am aware that the White Paper states that pay and conditions of service are matters to be dealt with at national level. I thought I made it clear in my remarks that I believed that to be the right procedure. However, I endeavoured to draw attention to the fact that at the various local levels differences will be inevitable and that some establishments will be unique.
In so far as the noble Lord, Lord Belstead, considers that this is not a field in which we should legislate, I draw attention to the moderate approach of the Amendment, which says:It shall be the duty of each Area Health Authority to endeavour by taking all such steps as are in the circumstances reasonably practicable…I should have thought that that was a sensible and helpful way to approach the matter. I cannot see that that is compulsive legislation, as it were, which is going to create impossible difficulties. To have this provisison included in the Bill would help eventually to make it a better Act. Management can sometimes run away with the notion that it knows best and that it does not need to consult. Management can sometimes feel that it is much too busy to be concerned with the views or the experience of the humblest members of its staffs. In the long term, acceptance of the principle of this Amendment 261 and the writing of it into the Bill would help to secure a more effective National Health Service.
While I accept the idea behind what the Minister said, he has given no indication that he or his right honourable friend will give further thought to the matter. I should be happy if the Minister would give an undertaking that there will be another look at this matter and that if his right honourable friend is persuaded that the principle is right and sound, and that it would be of advantage to have it written into the Bill, the Government themselves will come back with an Amendment at a later stage. I feel that the Minister ought to give the Committee rather more assurance than has been given up to the present time that further and deeper consideration will be given to the point.
§ LORD BELSTEAD
There are two quick points in reply. The noble Lord said that I did not criticise the Amendment on any specific grounds. I submit to the Committee that perhaps it is a contradiction in terms to lay a duty for joint consultations on only one side. I simply put that to your Lordships. It strikes me as being a contradiction. I am a little surprised that the Amendment refers to "joint consultative procedures" and then goes on to talk about the very thing that the noble Lord, Lord Garnsworthy, has said he is not talking about, namely, negotiations on terms and conditions of employment. That is a very real stumbling block when we are talking about a situation where the General Whitley Council has this matter under review. The noble Lord has asked me whether we will take this Amendment away and have a look at it. I am only too ready to accede to the request made by the noble Lord if he would be so good as to bear in mind the two specific things I have just said and also the point, which I might repeat before I sit down, that the people concerned, the management and the staff sides of the General Whitley Council, have this matter currently under discussion. I know that a measure of agreement has already been reached, and what we ought to do is to await the outcome. But certainly I will take it away, and this does mean, as the noble Lord knows, that I shall get in touch with him before the next stage of the Bill.
§ LORD GARNSWORTHY
I am grateful to the noble Lord for what he has just said. On the one or two points that he raised, may I say that I doubt whether I shall ever produce an Amendment that is not faulty in some respect. The important thing here is the principle, and I believe I have made it quite clear that the Amendment is intended to deal with conditions of employment that do not lend themselves to being dealt with at national level. I can only hope that the outcome of the discussions to which he has referred will be made known before the Bill become an Act, but that would seem to me to be all the more reason for ensuring that there is something in the Bill. I beg leave to withdraw the Amendment.
§ Amendment, by leave, withdrawn.
§ 3.45 p.m.
LORD BEAUMONT OF WHITLEY moved Amendment No. 93:
After Clause 9 insert the following new clause:
§ Appointment of Ethical Committees
§ ".—(1) The governing body of every institution in which treatment under the National Health Service is provided (hereafter in this section called "an institution") shall appoint a committee to be known as "the Ethical Committee" of that institution.
§ (2) The Ethical Committee of an institution shall consider the ethical aspects of medical experiments proposed to be conducted on persons receiving treatment in that institution (hereafter in this section called "patients") and to decide in respect of each patient on whom it is proposed to conduct such an experiment whether or not to sanction the experiment.
§ (3) No medical experiment shall be conducted on any patient unless the experiment has been sanctioned in respect of that patient by the Ethical Committee of the institution and the patient has consented thereto.
§ (4) At least one-quarter of the members of an Ethical Committee shall be persons who are not medical or dental practitioners, nurses, midwives, registered pharmacists, ophthalmic or dispensing opticians and who do not hold any position in or employment under the National Health Service."
§ The noble Lord said: This Amendment in the name of myself and that of the noble Lord, Lord Strabolgi, has to deal with medical experiments and ethical committees in institutions under the National Health Service. The mention of the phrase, "medical experiments" is apt immediately to call up horrific visions of Doctor Hyde or Frankenstein, and thereafter equally furious reactions on the part 263 of those who are involved in the Health Service, who rightly resent any aspersions being made in this field. Obviously, it is not my intention to raise this matter in that way, because it is clear that two major threads are running through the whole of our debate on this Bill: one is that of the very high standard of our Health Service and the immensely high standards of the people who have to work within it; and the other one is to do with the safeguards which the patient, the customer, ought to have, not necessarily because in experience he or she needs them but because people who are ill, who are subject to worries and problems and who are at a low ebb should have every reassurance and safeguard that they can possibly be given.
§ This question of what experiments should be allowed—and "experiments" covers a very wide range, including a great many occasions when experiments are perfectly justified and perfectly harmless—is in fact, in the great majority of hospitals in the National Health Service, subject already to the decisions of an ethical committee. This is the practice, and it is an extremely good practice; but the fact that it is a practice does not mean that a reply to this Amendment is that such committees are not needed. Such committees have been set up voluntarily by hospitals and by medical personnel because it was obvious that an institution of this kind was a safeguard, not only to the patients but also to the doctors, and was needed. The main object of this Amendment is to say that where such a practice has been adopted by the medical profession and by hospitals, it is surely justified and a good thing that it should be put into legislation of this kind at this moment, so that there should be regularity of practice throughout the National Health Service and so that the customer, the patient, should know exactly where he stands and how his interests are safeguarded. That is the main object of this Amendment.
§ The only other point which arises under it is the requirement that one quarter of the members of every ethical committee should be lay people. I do not know whether the drafting of this subsection (4) is the best that could be achieved. It was the best that my advisers could devise and I shall be quite happy to 264 accept any corrections to it. But the idea is that one-quarter of every Ethical Committee should be lay people. That is not the practice at the moment, and this is the only real innovation in this Amendment. I hope it will be granted that in any situation like this there is a case for having representation of those people who are not professionally involved in the situation. If they are all professionally involved—and, rightly, an ethical committee comprises people who work in a hospital—possibly there will not be the kind of complete trust and reassurance which would be given if there were some kind of outside representation. There is in fact no question which comes up before an ethical committee for decision which intelligent and educated laymen cannot perfectly well understand. It seems to me that this is a mild but reassuring Amendment to write into the Bill. It is closely connected in some ways with the other Amendment I put forward about privacy. Both are Amendments devised to reinforce present practice and embody it in the law, rather than to make major changes. The noble Lord was, I am happy to say, able to meet me quite a way on my last Amendment, and I hope he will be able to meet me on this. I beg to move.
§ LORD STRABOLGI
I should like to say a few words in support of this Amendment standing in the name of the noble Lord, Lord Beaumont of Whitley, and myself. I must first declare an interest, as I am president of a voluntary body called AEGIS which seeks to give aid to the elderly in Government institutions. I have little to add to the very strong case that the noble Lord, Lord Beaumont, has put up. I think it is necessary to increase the formal protection given to patients. I do not deny the need to experiment if progress in medical research is to be maintained, but I would submit that in all cases this should be with the permission of the patients or someone acting for them. In the case of some patients, particularly children and the elderly and the infirm, the protection of an independent committee of this kind to sanction experiments is needed. The noble Lord, Lord Beaumont, made clear that this would be quite a different sort of committee from the ones that operate in some hospitals. This would be an important added safeguard.
265 There was a demand made in the other place for an inquiry into certain allegations of medical experiments. This demand was turned down at the end of 1971; the Government spokesman said that there was absolutely no evidence for that. I do not know whether these allegations can be substantiated. I very much hope they cannot be. All I know is that the doctor making them, who seems to be a responsible person, wrote a letter to the Press shortly after the Government had taken this attitude in the other place, citing the evidence he had given in a book he had written and published entitled Human Guineapigs. This alleged that there had been about 80 objectionable experiments carried out in British hospitals, involving over 2,000 patients. He alleged that in some cases the patients used were delirious, psychotic or comatose, and included many aged over 70, some dying from malignant diseases. He asserts that none of them could possibly have given legally valid consent. Whether or not this can be substantiated I do not know, but certainly the situation is deeply disturbing. In order to avoid this kind of situation arising, we need the additional safeguards which are proposed in this Amendment, and I hope it will commend itself to your Lordships.
§ 3.51 p.m.
§ LORD PLATT
It is quite clear from the terms in which this Amendment has been introduced that those who are proposing it are fully aware of the necessity for medical experiment. Every operation has been performed for a first time. But the difficulties are really these: the usual difficulty of drawing any kind of line you can define, and, above all, the difficulty of defining what is an experiment. To take the simplest example, if I am taking a blood sample and having it examined for the patient's benefit, and I decide at the same time to study certain aspects of it which may give me further information on the physiology of some body functions, that is in a way an experiment. But, of course, it does no possible harm to anybody. If I decide to use a new remedy for, shall we say, high blood pressure, which has been tried out by the pharmaceutical firms with their usual care in animal experiments and has been tried out on human volunteers, do I have to alarm the patient by telling him that this is a new remedy? 266 It may only mean a slight modification in what we have been doing for years. Or do I have to come before the Ethical Committee? Probably not. But supposing I am a scientifically minded doctor, and instead of just trying it out on individual patients I say: "Now, in my hospital, or in my department, I am going to take patients at random; some of them will have the new drug and others will have the old; then we shall really know the answer whether one is better than the other and will be able to make a decision". That, unquestionably, is an experiment, but it seems to me much more rational behaviour than just giving the remedy to some people to see whether they like it or not. I do not think I am exaggerating the difficulties of defining what an experiment is.
Then we come to experiments which have nothing to do with treatment at all but have to do with investigation; and scientific investigation has, of course, reached a stage, unquestionably, when some of it can be a little dangerous. The question is how much is experimental and how much can be legitimately said to be for the benefit of the patient, because it may find out something more about his illness which can be dealt with perhaps by surgery or some other means. So that is another form of experiment. I think that what is in the minds of the proposers of this Amendment—and I share their misgivings about some of the things that have happened—is the kind of experiment which is particularly complicated and requires a lot of co-operation on the part of the patient, has possible dangers, and is not really devised so much for the benefit of the individual patient but rather for the benefit of medical knowledge as a whole, so that perhaps some future patients might benefit from better understanding of the disease. There I think we sometimes come on to very controversial ground. I know that experiments have been done in hospitals which I would not have done, but which have turned out to be completely justified by experience, which have now made certain operations safe which in former years, not so very long ago, would have been extremely dangerous.
I have so far really touched only on the great difficulties. The subject has been considered at great length on many occasions by the Medical Research Council 267 cil and by the Royal Colleges, and both the Colleges and the M.R.C. have drawn up codes of practice and guidelines. As the noble Lord, Lord Beaumont, said, in most hospitals where there are active investigating departments there is now an ethical committee. I should not myself raise any objection to there being written into this Bill some recommendation that there should be an ethical committee, whose business it would be to meet from time to time and consider any major investigation which was brought to their notice. I very much doubt whether you can go further than that.
As to lay people being on such a committee, I should certainly have no objection. Whether that should be laid down or not I do not know. It would be possible, I imagine, to suggest that normally such a committee should have laymen upon it. No doubt the noble Lord who will reply will tell us what are the views of his Department on this subject, and whether instead of being done by legislation this might be done by further directives being sent out from the Department on the whole question of ethical committees and human experiment.
§ LORD ABERDARE
In order that the House may resume to hear the Statement that my noble friend the Leader of the House is going to make, I beg to move that the House do now resume.
§ On Question, Motion agreed to, and House resumed accordingly.