§ [References are to Bill 79 as first printed for the Commons]
Clause 2, page 2, line 7, leave out "(except in Greater London)".
§ LORD ABERDARE
My Lords, I beg to move that this House doth agree with the Commons in their Amendment No. 1. I think it might be for the convenience of the House if we were to discuss with this Amendment, Amendments Nos. 3, 4, 5, 6 and 64, which cover the same subject. The purpose of these Amendments is to bring the London Ambulance Service within the National Health Service in the same way as ambulance services in other parts of the country. We discussed this matter exhaustively during the Committee stage of the Bill and there is little more that can be said on the subject on either side. I failed at the Committee stage to convince your Lordships of the merit of the Government's case, but the other place has supported our view and I ask your Lordships to accept their Amendment.
The main aim of the Bill is to integrate the present fragmented health services into a comprehensive National Health Service and to provide that all those services—hospital, general practitioner and personal health services—should be locally managed by authorities responsible for a better service to the citizens of their region. Comprehensive health care for a community can be provided only by an authority able to mobilise all the available health resources to meet local needs and priorities. There can be no question but that the ambulance services are an integral part of the resources, since their essential task is to support the general practitioner and hospital services. It is right and logical, therefore, that the health authorities to 1712 be constituted under the Bill should be responsible for providing ambulance services. Changes in other parts of the Health Service, especially in hospital services, affect the ambulance service; and it is important that they should have a voice in the planning processes of the National Health Service. Equally the voice of the user should be heard in the planning of the ambulance services.
Bringing the services under the control of the new health authorities will ensure their most effective and economical use and their complete integration into the National Health Service. This applies particularly in the case of the 999 Emergency Service, where the care and safety of patients depends on close links between the ambulance services and accident and emergency departments. In fact, my Lords, I doubt whether anyone in this House would differ from these general propositions; yet a majority of your Lordships on the last occasion still thought that an exception should be made in the case of the London Ambulance Service. However, in my opinion, the general arguments for integration apply almost more forcibly to London than to other parts of the country.
The importance of the London Ambulance Service to the National Health Service is itself a strong argument for bringing it within the framework of the National Health Service so that it may be planned and developed with other authority services. Because of the concentration of hospital facilities in London, it is particularly important to ensure effective collaboration with neighbouring ambulance services, and this will be facilitated by bringing them within the National Health Service management structure. To leave it with an authority which will have no responsibility at all for other closely related health services seems to me entirely unjustified. It would tend to result in the ambulance service becoming increasingly isolated from the main stream of National Health Service development.
In financial terms, to leave the ambulance service with the G.L.C. makes no sense at all. I doubt whether it is really satisfactory at present that the G.L.C. precepts on the London boroughs, who are in fact the London health 1713 authorities, for the cost of the London Ambulance Service. But it seems to me quite unjustifiable that the Secretary of State for Health and Social Services should be responsible for meeting the cost of a service over which he would have no control. The G.L.C. would have the duty to provide the service without responsibility for meeting the cost and the Secretary of State would have the responsibility of meeting the cost of a service which it was not his duty to provide. That does not seem to me consistent with democratic accountability.
Under the Amendments I am now moving, it would be the duty of the Secretary of State to provide the Ambulance Service, and he would be answerable to Parliament. At local level, the community health councils would represent the interests of the public in this as in other health services, and the Health Service Commissioner would be able to investigate an alleged failure of ambulance services in London. I repeat the assurance that I gave to your Lordships in Committee: that the London Ambulance Service would be transferred as one Service. One of the four London R.H.A.s will be given responsibility for it. This R.H.A. will be required to set up a London Ambulance Committee representing all four London R.H.A.s. This Committee will have responsibility for planning and developing the Ambulance Service within the National Health Service framework, as it cannot be if it were left with the G.L.C. There will also be an Ambulance Service Liaison Committee on which each of the London Area authorities will be represented, so that the authorities which determine the demand on the Service will be associated with its management and operation, as they are not under present arrangements. For the first time they will have a direct voice in the operation of the Service.
The case for bringing the Ambulance Service within the responsibilities of National Health Service authorities does not imply that existing authorities have been inefficient in their management of those services. It rests on two main considerations: first of all, that the services to the citizen will be improved by the closer integration with the Health Service; and, secondly, that better use will be made of available resources if the health 1714 authorities can assess needs and priorities over the Service as a whole. These considerations apply to London and to the London Ambulance Service. We believe that the public will benefit from closer integration and better assessment of priorities in this as in other fields. My Lords, I strongly commend these Amendments to the House, and beg to move.
§ Moved, That this House doth agree with the Commons in the said Amendment.—(Lord Aberdare.)
§ 3.19 p.m.
§ LORD GARNSWORTHY
My Lords, the House will be very appreciative of the care taken by the noble Lord, Lord Aberdare, in presenting the best case he can make in support of this Amendment. But, having listened very carefully to him and despite the fact that I recognise that he has done his best, he, like other people, has not been able to produce a very good brick since he has so little, if any, straw with which to make it. There will be few indeed of your Lordships who would contend that this Amendment represents the free will of either House. Certainly none can claim—and, indeed, the noble Lord, Lord Aberdare, recognised this—that it represented the view of this House when the Bill was first before us for, as your Lordships know well, this House then accepted Amendments moved by the noble Earl, Lord Mansfield, whose Amendments were supported in all quarters of the House. His Amendments were designed to retain for London a service which the London Government Act of 1963—only ten years ago, my Lords—specifically placed in the control of the Greater London Council. As it was seen then and as it has been steadily seen since, that was deliberate recognition of the ability of the authority to discharge a regional function, and a function which dovetails with other duties where there is great advantage in securing the intercommunication and co-ordination which a unified control makes it possible to achieve. Indeed, the demonstrations of efficiency which have been seen so often have led us to take for granted this achievement on the part of the Greater London Council. I refer in particular to fire protection and rescue. We are well aware of such occasions, whether they be train crashes, bomb outrages or any other emergency.
1715 The noble Lord was good enough to say that no one had criticised the efficiency of the ambulance service under the Greater London Council. None dare because no criticism can lie. We in this House would do well to take note of that, and in so far as compliments have been paid, let us appreciate those compliments at their full value and not at the worth the Government appear to be attaching to them. The unified control of the ambulance and fire services in London is every bit as important—and, on occasions, more important—as matters that the noble Lord referred to. With regard to the matters he referred to, no criticism lies that the London Ambulance Service has failed the Hospital Service. The unified control of the ambulance and fire services in London has produced a standard of impressive efficiency in the protection and saving of life. Why put that efficiency at risk? In particular, why put it at risk in the way proposed by this Amendment we are asked to consider this afternoon?
What is proposed? First of all that the Greater London Council is to lose responsibility for the ambulance service. As the House well knows, London is to be divided between four regional authorities. The Bill, as amended in the other place, recognises that this proposal falls short of the desirable in regard to the ambulance service and therefore would establish a joint committee of the four regional authorities to control London's ambulance service. No matter how it is explained, that is what it boils down to. Does anyone imagine that this will lead to an increase of efficiency, as the noble Lord has claimed? How does he set about establishing that greater efficiency will flow from this transfer? If it establishes anything at all it is an acknowledgment of the fact that London's needs can best be met by a unified control. It serves also to confirm the importance of keeping the present service intact after reorganisation: intact not only in so far as the ambulance service itself is concerned, but intact within the structure created by the Greater London Council where the ambulance service is able to draw on other supporting services.
I shall not take long but, my Lords, let us remind ourselves of a few facts of the situation. I think it is important to do that, since some time has passed 1716 since the Bill was before us. The London Ambulance Service comprises 1,000 vehicles which requires support from a fully equipped and qualified motor vehicle engineering service. Under the Greater London Council that situation exists. In addition to expertise gained over the years in the selection and purchase of ambulances, there is also the matter of maintenance. Here the Greater London Council has a wide-ranging establishment and facilities which cater for another 2,000 vehicles of various kinds.
The noble Lord, Lord Aberdare, referred to economies. It is by bringing the ambulance service within the care of this motor engineering service that economy is to be achieved, as it is indeed being achieved at the present time. It is not only economy in regard to the running of the ambulance service, but economy to the Greater London Council as well. There is nothing in the Bill, and I venture to suggest that there is nothing in what the noble Lord has said, to match these arrangements in any one of the four metropolitan Regional Hospital Boards. Any attempt to create economies, if indeed that is the intention, must mean new capital expenditure as well as resulting in other use of the Greater London Council's workshops, thus creating increased costs on both sides.
There are many other services of the Greater London Council which benefit the ambulance service. I refered to them just now as supporting services: legal, supplies, vehicle design and communication facilities which, if the service is transferred, will need to be duplicated on the National Health Service side and will again result in more cost. Will the National Health Service have money to spare for such matters as this? I ask the House to recall that all this is proposed against a background of existing efficiency and that there are no figures to indicate any saving as a result of transfer. But I give a warning, as I think would the Greater London Council, that the contrary is likely to be the case—increased costs.
It has been suggested that the transfer is justified on the basis that those who control the hospitals should also control the ambulance service. The House is entitled to know what will be the gain, and I ask the noble Lord to go into the 1717 details, since London—and this needs to be continually borne in mind—is efficiently and economically managed already. Moreover, the Greater London Council has established a practice of discussion with the hospitals which is most effective in ensuring economic use of vehicles. It seems to me that the Government need to demonstrate in a way they have signally failed to do, that the upset they intend will improve either the efficiency or the economy of the service. The noble Lord may say, "I believe that it will improve it; you on the other side do not believe that. It is a matter for the House to make up its mind." There is far too much at stake here for this to be just a question of the noble Lord's belief or my opinion.
I think we ought to have detailed information before we agree to the acceptance of this Amendment. It may be argued that the four regions will extend beyond the G.L.C. area. This the noble Lord has hinted at. One thing is certain: the Amendment he is proposing will deprive the people of London of direct, democratic control, and that is an important fact when we are talking about democracy and democratic government. On the new bodies, the representatives of London look like being in a minority. In other words, the people of London are going to have less say than they have had in the past with regard to this important personal service.
I regret this treatment of local government and I am not impressed by any suggestion that the proposed co-ordinating committee may largely be composed of representatives of regions outside the G.L.C. area. If I regret it, then I am sure that both Parties on the Greater London Council not only regret it but, as is well known, resent it deeply. They are at one on this issue, as the House well knows. What is more, I believe the people of London will be in full support of the Council in the attitude that they have taken up. When an opinion poll was conducted the public gave London's Ambulance Service the highest commendation of all the services run by that authority. So much for the particular methods of control of London's ambulances.
My Lords, I want to touch, if I may, on the tactics that have been employed in seeking to thwart the declared will of 1718 this House. It was left until Report stage in the other place before the issue was put to the vote, with the Whips on. I am not alone in my feeling. There is a great body of opinion which feels that had this matter been put to the vote at Committee stage the Government would have been defeated on it. We ought to bear this in mind. It was left right until the last moment, when the Whips were on, to secure the acceptance of this Amendment; and by none too great a majority. I wonder why it was not put to the Committee. Were the Government afraid of the vote that would have been registered? It would have been tidier to have the matter decided at Committee stage. I not only disapprove of what is proposed by this Amendment; I dislike the way in which it is being done. The noble Lord the Minister has my sympathy, because he is always as frank as possible with this House and I have the feeling that he recognises that on this occasion he has indeed been given a very difficult task.
Furthermore, this issue, if I may say so, reflects an attitude that has been growing—it has grown to an alarming extent I believe—in the whole field of local government. In 1963-64 London local government was reorganised; and it was said at the time—and it has been repeated since—that it ought to have a greater role to play than it has in the past; that it ought to have greater responsibility and more power. The duties of the London boroughs and the Greater London Council were the subject of much thought and debate, yet within a decade we see the Greater London Council being stripped of services which it has performed particularly well. Not that the change gives more authority to other levels of Government; rather does it secure greater control by central Government. It seems to me that that comes out crystal clear.
The noble Lord raised the issue of finance and suggested that it would be improper that the Greater London Council should be responsible for running the Ambulance Service. The Secretary of State would have to pay the money, and he indicated that that would not be a democratic procedure; that it was not a responsible way of doing it. My Lords, is anybody going to suggest that in a matter like this the Greater London 1719 Council are not worthy of being trusted? Can it be shown at any point that they have ever taken advantage of a situation where they have had to spend money that belonged to other people rather than themselves? It is not so long since local authorities in regard to some services were getting up to 100 per cent. grants. We did not hear then any suggestion that it was undemocratic.
If I may go back to civil defence, let the noble Lord cast his mind back: it is not difficult, and there is no reason to mistrust local government in matters of this kind. We have seen in recent months, in the face of repeated professions that local government needs encouragement and responsibility, that there has been a sustained and consistent attack on it by way of depriving it of responsibility which it has discharged with credit. In the face of present reorganisation, which involves the creation of large authorities capable of carrying greater responsibilities—in England, at any rate—we witness a failure of trust in the responsibility for services which directly affect the people and are of a very personal nature. I regard this Amendment as one of a series of actions which deprive the people of power at local level, power to decide what they believe to be in their own best interests. This Amendment concerns London, in particular, but the rest of the country is not immune, and unless a stand is made now those of us who really believe in local government, believe that local government is responsible and should be trusted, believe that it has a tremendous part to play in the running of she National Health Service—and this Bill largely ignores the contribution it could make—will have cause indeed to regret the failure.
To sum up, my Lords, the present system in London works well. What is proposed is in the first place, a division of control and then a recognition that division of control will lead to inefficiency so that there is then created an ad hoc arrangement whereby unified control may be restored. Secondly, I believe that the time has come when we ought to make clear to the Government that we intend that local government shall indeed be local government. I have no intention in mind to divide the House because I 1720 take the view that the will of the House, however determined, on this matter, probably ought to prevail. I think there are issues that must be borne in mind, but let me make it clear beyond any doubt that, even if I do not ask my friends behind me to come into the Lobby with me against this Amendment, that does not mean that I approve of this Amendment in any way at all. I heartily dislike it and disapprove it.
§ 3.36 p.m.
§ LORD PORRITT
My Lords, I regret that I had not joined this noble House when this Bill was initially discussed in detail, and I imagine that we have now rather got to the stage of wishful thinking and pious hopes. But I have a very keen personal interest in this Bill, in that I have it on no less authority than that of the Secretary of State for Health and Social Services that the skeleton of this Bill was founded on the Report of the Medical Services Review Committee of which I had the honour to be Chairman some 10 years ago. This particular Committee worked for four years and consisted of some 35 senior medical men in the profession. It was the profession's attempt to assist the National Health Service, to make it work more smoothly and more efficiently, both for the doctor and for the patient.
The Report was, I suppose not surprisingly, filed away on the Ministry shelves until quite recently, when it received a sit-in, medically, with the suggested reorganisation of local authority government. The report of the Medical Services Review Committtee, which is relevant to what we are talking about to-day, had two basic suggestions. There were many suggestions, but the two basic ones were that the three parts of the profession—the general practitioner service, the hospital service and the public health and social service—should be reunited into one profession. This the Bill we are discussing would seem to have achieved.
The second major recommendation was that the management of the service should he delegated to the maximum extent to the periphery, that is to say, that it should be administered by those closest to the patient who was receiving the service. This I do not think has been achieved—at any rate, not to the extent that one would wish. Admittedly, new local bodies have been set up to deal 1721 with local problems, but they are to an even greater extent than ever before under central control. The new monolithic structure gives little scope for flexibility or for local initiative. One hopes and expects that the improvement in management which will certainly be there will effect worthwhile savings in the vast and steadily increasing expense of the National Health Service; but whether this will do good for the patient, whether it will improve the service to the patient is a moot point which I think only time will solve. Management and regulations, if put between a patient and the doctor, do no good to either. Inflexibility in dealing with human relationships is not a good measure.
Surely this Amendment which we are discussing at the moment, however well defended by the noble Lord, Lord Aberdare—and it certainly has been—is a classical example of inflexibility. Even if one does not take a particular case, the general principle still remains. What he suggests is undoubtedly neat and tidy. It is excellent integration, but does it justify turning down a service which has proved itself efficient and of great value to this great City? Your Lordships' House, if I remember rightly—all parts of it—appreciated the work and value of the London Ambulance Service when this matter came up at the Report stage, and I trust that, late though this is in consideration of this Bill, we can at least express some disquiet at the possibility of over-regimentation, not only in this particular instance but in the Bill in general.
§ 3.41 p.m.
§ LORD ABERDARE
My Lords, I am grateful to the noble Lord, Lord Garnsworthy, for expressing his sympathy with me, but I have no need whatever to accept it. I am quite convinced, despite what has been said by the noble Lord, Lord Porritt, that this is the only way in which we are going to co-ordinate those very services that the noble Lord, Lord Porritt, is so anxious to bring together. If I am asked to justify that there will be greater efficiency from bringing all the health services together, I would say that this underlies the whole Bill. This is the whole point of the Bill; there is no other point. It is stemming from the Report of the noble Lord, Lord Porritt, himself, to bring all the health services together so they can be planned together 1722 —not, if I may respectfully say so to Lord Porritt, for the patient but for the citizen. We are looking at health in the whole. We are going to try to keep more people out of hospital. If they go into hospital we are going to try to get them out sooner. We are going to try to provide for them in their own homes. This is what lies at the root of the Bill. This is what we hope to achieve by integrating the health services, and this is the reason why the ambulance service cannot possibly be left out.
When the noble Lord says that we are attacking local government, this is certainly not true. The whole of the local health services are being integrated into the National Health Service. This is what the Bill is about. This is what his own Party's proposals were about previously. The noble Lord raised certain special pleading on behalf of the London Ambulance Service. As I said, I had no reason to criticise it, but the whole scheme of things is changing now; the whole look, the whole management, of the National Health Service is being altered. He brought up the question of the links with the Fire Service. I know that the links with the Fire Service are very important in dealing with major disasters, but so are the links with the police and other emergency services, and this kind of liaison happens outside London perfectly satisfactorily where the Ambulance Service is run separately from the Fire Service; and indeed in London the two services arc operationally controlled completely separately.
The noble Lord drew attention to the maintenance and service facilities, which is another matter that has been brought up before now. I agree that the G.L.C. provide excellent maintenance and service facilities, and we very much hope that they would continue, at least for a time, to provide these services on an agency basis. This is specifically provided for in the Bill. I do not want to take up any more time in going over all these arguments again, especially as the noble Lord has said he does not wish to divide on this Amendment, but I merely put it to the House that this is a very important and integral part of the reorganisation of the National Health Service, and I hope your Lordships will agree to accept this Amendment from another place.
§ On Question, Motion agreed to.