HL Deb 29 July 1974 vol 353 cc2070-140

4.13 p.m.

LORD ABERDARE rose to ask Her Majesty's Government whether they agree that the provision of private beds in National Health Service hospitals has been accepted by all Governments since 1948; that they are a source of considerable extra revenue to the National Health Service; and that to phase them out will result in a heavier burden on the taxpayer and a less efficient service to the National Health Service patient. The noble Lord said: My Lords, I beg to ask the Question that stands in my name on the Order Paper. We are about to discuss the subject that bears on the National Health Service at a time when that Service is in very great difficulty and when there arc enormous problems facing it. The doctors are murmuring threats or, perhaps in some people's view, doing more than murmuring. Nurses are militant, the technical staff have been taking industrial action and the domestic staff have been involved in certain difficulties, too.

These categories of staff would normally not be seen to be using industrial action to obtain their ends. I am sure that your Lordships on all sides of the House consider that this is a terrible tragedy in a Service about which so many of us have expressed great hopes and of which we are extremely proud; indeed, a Service from which many of us have received healing and comfort.

I have no doubt we could have had a full-scale debate on the National Health Service on this occasion, but I rather doubt whether it is an appropriate time when matters are difficult, when negotiations are delicate. One does not always do much good by discussing them. Often the less said on these occasions the better. I have confined myself in this Unstarred

Question to one aspect alone of the National Health Service; that is, the private practice within the Service. This has the advantage of being the one subject on which we certainly know the Government's mind. It is also a subject that arouses strong emotions, stronger emotions, in fact, than some of the more major issues which affect the whole future of the National Health Service to a much greater degree.

My Question is further limited to private practice within the National Health Service, not private practice in general. This is because, as I have already said, the Government have outlined their policy. It is not suggested, as I understand it, that there should be any attempt to abolish private practice as a whole (although I know there are those people who advocate such a drastic move), but only the phasing out of private beds in National Health Service hospitals. This may be the thin end of the wedge, but I am assuming that the policy of the Government is confined at present to the phasing out of the so-called pay-beds in National Health Service hospitals.

I wish to begin by establishing three facts. The first is that private patients have paid taxes and have paid the National Health Service charges that are part of the N.H.S. insurance scheme which between them support the N.H.S. They do not get any relief on those payments. There are those who think they should but the fact is, as things are at present, they do not receive any relief; they pay their taxes and their charges in full. Over and above that they choose to pay the extra cost of a private bed for the privileges of privacy, of choosing their consultant and arranging their date of treatment. For those privileges they pay the full economic cost, which also includes a contribution to capital charges. The charge they pay is reviewed annually and, therefore, it ensures that the price that is paid keeps pace with inflation. At the moment, that price in acute hospitals is about £170 a week in London teaching hospitals, and over £120 a week in other N.H.S. hospitals. All these charges, in total, represent some £17 million to the N.H.S. I wish to establish straight away that private patients are not by any means "spongers". They are paying in full for

the facilities which they enjoy and, indeed, they are paying over the odds because they are also paying the taxes.

The second fact that I wish to place on record is the scale of private practice within the N.H.S. This works out at about 2 per cent. of acute beds which are made available for private patients and approximately 2 per cent. of all patients choose to make use of them. This is a very small proportion. It needs to be noted that these beds are always available for N.H.S. patients in an emergency. The third fact is that we are not talking about emergency admissions. If a person suffers a heart attack or is knocked down by a motor car and taken to hospital, there is, in that case, no discrimination whatever between the private and N.H.S. patient. We are solely concerned with non-emergency cases.

Bearing in mind these three facts, what are the advantages of the present system? It seems to me that, without any doubt, the main one is the integration of N.H.S. and private medical treatment within the walls of the same hospital. The consultant has his patients all under one roof and he is more readily available to all of them. In an emergency he is more likely to be on the spot, and this is of advantage not only to patients but also to the junior doctors whom he is engaged in teaching. The fact is that if all his patients are in one place he spends much less time outside the hospital. But, my Lords, there are many eminent consultants speaking in this debate this afternoon. and I am sure that they will bear much more convincing witness to the truth of these statements than I.

It seems to me that the easiest way to judge the advantages of the present mixed system is to consider the alternative which will come about if the Government have their way. All private beds will then be found outside National Health Service hospitals, in private clinics and nursing homes. I would remind your Lordships again that all emergency cases will continue to go to National Health Service hospitals; it is only in the non-emergency cases that there would then be an option for those who are willing to pay for their admission to go to a private clinic and to make their arrangements in a private clinic just as they would at present do in the case of a private bed in a hospital; and I have no doubt at all

that in this event, in the event of the separation of the Hospital Service and the private clinics, the private sector would grow very rapidly. There is no doubt that people are prepared to pay for private treatment, and there is no doubt that finance is available to build more private clinics and to pay attractive salaries to consultants and staff. The result would be a complete separation of the public and the private sectors—the same sort of separation as exists to-day in education between the State system of education and the private system of education.

Personally, my Lords, I have always thought that this was a pity. I have always thought it was wrong that, in education, there should be this complete divide between the private and public systems, and I would personally deplore the same thing coming about in health. It would create a dual system and two standards of treatment. The private sector will be flush with money: the National Health Service, as always, short. The private sector will consist of modern luxury clinics: the National Health Service will still be carrying a stock of old and inconvenient hospitals. The private sector will attract good staff and will provide every sort of comfort: the National Health Service will not be able to compete. Moreover, the private sector will attract the help of generous benefactors, and much of that generosity of people who have given expensive equipment or who have sponsored expensive research in the National Health Service may be hived off into the private sector. I cannot believe that this would be to the advantage of the National Health Service as a whole.

Moreover, if the Government do this it will cost the taxpayer more money, and already the National Health Service is short of money. At present, I understand that what is paid by private patients adds up to about £17 million per annum, which goes to the revenue of the National Health Service. This is no doubt a small but certainly a welcome contribution, and without it a further £17 million would be required. But some private patients, if the "pay-bed" system if phased out, may not be able to make use of private facilities. There may be no private facilities in their area, or they may not be able to afford them. Once again, this would be added to the cost of National Health

Service provision. It would also mean paying the consultants more. If there are to be consultants in the future who would be working whole-time in the National Health Service, quite clearly it would be necessary to make a considerable extra payment to those consultants who gave up their private practice and confined themselves to the National Health Service. Many of them might well opt to work entirely in the private sector. Some of them might even opt out altogether and emigrate. My Lords, I do not think that this separation is really going to be of any benefit at all, but will indeed be to the disadvantage of the Service as a whole.

What about the benefit to the National Health Service patient himself? Why is it that this phasing out of "pay-beds" is seen to be attractive? In the first place, it is said that it will increase the number of beds available in the National Health Service. I understand that at present there are just over 4,600 private beds in the National Health Service. But against this number there is also a large number of beds in independent hospitals which are at present used by the National Health Service under contract. I am not quite sure how many there are—perhaps the noble Lord, Lord Wells-Pestell, will be able to tell us—but the figure I have been told is that it is something in the region of 3,500 beds. If you separate the two. if you have all your National Health Service beds in the hospitals and all your private beds outside, then it would seem to me logical that the private beds now used under contract by the National Health Service should return to private practice. So you have to balance these two figures together, and possibly it would result in a figure of something over 1,000 extra beds being available, which is really a very small number of beds. In any case, as your Lordships are well aware, it is not only the number of available beds that affects the waiting lists.

Then it is said—and this is the most emotional and effective case that is put forward for phasing out "pay-beds"—that it would put an end to queue-jumping. But would it, my Lords? It does not seem to me that it would at all. Simply separating the two sectors of the Service would not, in my view, affect what is called queue-jumping, because the private

patient will continue to receive the privileges for which he pays, but he will receive it in a private clinic rather than in a "pay-bed" in the National Health Service—and what advantage is this to anybody? I would go further. I believe that in non-urgent cases—and these are the only cases that we are talking about—it is right to give some priority to those people who wish to spend their own money on their own health. I very much doubt whether we shall ever in this country, or indeed in any other country, have the resources in money and in skilled manpower to meet the demands of all people in non-urgent cases. I do not think it wrong that there should be an incentive to people to make extra provision for their own health, and by means of insurance this choice certainly exists now for the great majority of people. Unless we make use of all the extra available money that we can find for the National Health Service, I do not believe that our health services will anywhere near come up to matching the demand for them.

This is the feeling that I should most like to leave with your Lordships: that by dividing the private side of the Health Service from the public side we shall not be affecting the situation in any way at all. The private patient will still be able to get all that he needs; but by dividing the two you will be creating a situation which has not obtained hitherto, which obtains in education and which I believe to be thoroughly undesirable.

I deeply deplore the introduction of Party politics into the Health Service itself. These have never hitherto played a part in it and in fact it was Aneurin Bevan, the architect of the National Health Service, who realised the need to carry the doctors with him and to establish the present system. Every Government since then have accepted and supported that system. However, I deplore most of all the action of one union in pre-empting Parliament's right to decide the policy on pay beds. I consider that the Government have shown considerable weakness in not standing up to this challenge and in compromising on this issue in, of all hospitals, Charing Cross Hospital, where the provision of National Health beds is quite up to the standard of the best in private pay beds. I believe

that if the Government proceed with their plans to phase pay beds out of the service, they will not in the long run damage the position of the private patient but that they will damage the National Health Service itself.

4.32 p.m.


My Lords, may I begin by giving the noble Lord a word of comfort. I can assure him that a Government who have the vision to phase out the private pay bed have priorities that will be sufficiently civilised to see that, far from the National Health Service being run down and becoming more and more seedy and more and more Cinderella-like, it will go on from strength to strength. This is a sad, mean debate. When the noble Lord says that Party politics do not enter into the question of the Health Service, surely he was born before the years 1945, 1946 and 1948 and must be aware that his Party voted against every stage of the Bill and did everything in its power during those years to prevent the National Health Service as we conceived it coming into existence. Any amateur can reproduce the external facts of history, but it needs a great historian to recover the mood of the times.

We are debating in a placid atmosphere—and the other place is also debating in a relatively placid atmosphere—the present problems of the Health Service. This is in comparison with those stormy days immediately after the Second World War when a great people which had come through that war seemed to many of us to deserve civic victories worthy of the stand that they had made when the bombs were raining down on our cities. The Health Service was the envy of the world. Rich countries like America never attempted it. The rich wanted to keep their riches to themselves and we see how splendidly the private patients do in America to-day. It is cheaper to die! I think many people's American friends would be able to tell them what it is, even with all their insurance schemes, to have a serious or a prolonged illness in America.

My Lords, my first point, therefore, is: please do not worry about what will happen when we phase out the private beds, because that will not be done by a Tory Government, it will only be done by a Socialist Government and it will only be done by a Government who have the right priorities. My next point is that we cannot violate the spirit of our times. It is more than a quarter of a century now since the Health Service was introduced. It has gone through rather difficult times because the Conservatives when in power did not dare to abolish it—instead, it was death by a thousand cuts. It was starvation and assuming that the technical staff, the nurses, the domestic staff, the lot, would go on working for much less than a fair remuneration.

But what is the spirit of to-day? Have noble Lords not learnt the lesson of the Industrial Relations Act? The Labour Government, as we know, tried to bring in In Place of Strife, though some of us thought that that was just a passing madness. We knew that it could not work. We knew that if one railwayman, miner, docker, was fined, refused to pay and was sent to gaol, the whole industry would be out. It has taken us a long, painful time to realise that there are certain things which cannot be done at certain times, and just as both Parties have had to adjust themselves to the changing attitude and place in society of the trades union and working class movement, so we must adjust ourselves to the changing mood of the people who run our hospitals. I am speaking not just of doctors and consultants, supremely important though they are: I am talking about the nurses, the kitchen staff, the domestic staff, the stretcher-bearers and so on. When the noble Lord said that we cannot afford not to have private patients because they bring us in a revenue of £17 million, has he any idea how much we shall lose if we do not begin to get rid of this divisive arrangement? The sum of £17 million would be chicken feed compared with the money which will be lost if we continue to offend the people who do the hard, necessary work of running hospitals.

The great argument which was put forward was that if people want privacy they should be allowed to pay for it. One was always told that the doctoring would not be any better but that the privacy was something which people should be permitted to buy for themselves. Now there was no one who was more concerned about the problem of privacy than Aneurin Bevan. I sometimes went round the hospitals with him and we were concerned not just about the amenity wards, where there might be one or two patients, but about the restructuring of the general wards, because more and more we felt that by curtaining arrangements some people could have the partial privacy they wanted. Of course other people are afraid of privacy. In other words, no matter what one's income, if for psychological reasons one's need is a need for privacy, that need can be fully met inside the Health Service. Indeed, at the same time as we were considering the place of private practice in the Health Service we were also building up the system of amenity beds. I shall quote from a book, In Place of Fear, published in 1952, and the material which it contains represents the point of view of Aneurin Bevan while the scheme was going through. It is not a question of an inexperienced Minister thinking that he could run a Health Service in one way and then having to make concessions—not at all.

When we were introducing the Health Service in the strenuous but heroic immediate post-war days, it was absolutely essential to bring in the teaching hospitals; there could have been no Health Service without bringing in the great teaching hospitals. But at that moment there was the most fantastic scare campaign going on. I see that my noble friend Lord Hill is here and I am sure that he will bear testimony because he was a doughty fighter himself and knew how much was said about civil servants and politicians who would interfere in the sacred relationship between doctor and patient.

Of course this was all nonsense, and, when the doctors came along and asked for this kind of concession to be made, it was just fun, because no Government and no Minister ever had the slightest intention of interfering between the patient and the doctor. In other words, here he said, It is for the community to provide the apparatus of medicine for the doctor. It is for him to use it freely in accordance with the standards of his profession and the requirements of his oath There is no question of interfering in that sense. But in order to get it started, in this atmosphere of scares and uncertainty, a concession was made of a number of private fee-paying beds.

These must not be confused with "amenity beds", and if your Lordships will bear with me I should like to quote Aneurin Bevan's words on this very issue. He said: Pay beds are a profitable source of income to the specialists, and there is therefore a disposition to prefer patients who can afford them at the expense of others on the hospital waiting lists. The number of pay beds should be reduced until in course of time they are abolished, unless the abuse of them can be better controlled"— and it has not been controlled. He went on: The number of ' amenity beds ' should be increased. Note that, my Lords: These are beds for which the patient pays a small sum for privacy along, all the other services being free. Of course, it would mean some loss of revenue, but we thought about all these things. The next sentence reads: These changes would mean a loss of revenue to the National Health Service, but they would cut out a commercial practice which undermines the principle of equality of treatment that is fundamental to the whole conception of the scheme. I say again, my Lords, that running a great hospital is a fantastic joint operation. You need the doorkeeper and the laundry, as well as the doctor and the consultant. Everyone has to be involved. In those days when people were talking about participation they were insisting upon being in it, and they did not like this divisive attitude of private and public patients inside the same hospital. I make another prophesy. Far from shedding tears about what would happen to the National Health Service, the noble Lord might spare some compassion for the person who wants to opt out of the National Health Service, because if it costs £170 a week in a London teaching hospital and £120 a week in a provincial hospital to-day, people will need something rather different from the London Clinic. I shall not get myself into a libel action by making any comments about that, and I shall not even claim privilege. But nursing homes and small hospitals cannot be compared with the apparatus of our great teaching hospitals, and the idea of a private sector that would willingly try to acquire this kind of apparatus is just not on.

Therefore, I am certain that we are right to hold to our position that poverty should not be a disadvantage and wealth should not be an advantage, but that all of us, according to our needs, should be able to go into a hospital where we not only receive first-class medical treatment but are treated with dignity. I wish that more was said not just about the shortcomings of the Health Service and the poorer hospitals, but about the wonderful service and the improvements in many of our great hospitals; for example, better food. I was foolish enough to fall off my garden wall last summer and had to have an emergency operation. I found myself handed a menu from which I could choose what I wanted. I did not get smoked salmon and caviare, but who wants that? I did not want them then.

The care and the service in our great hospitals is fantastic, although we have to bring the lesser ones up to their standard. But, I repeat, do not let anyone use the argument about privacy. There is every possible provision for privacy made under the terms of the National Health Service. Do not let anyone pretend that the Government of 1945 to 1950 and Aneurin Bevan, the Minister who was responsible for introducing it, had any doubts about the undesirable effect on a hospital as a whole—on the other patients and the staff—of having a private sector. In the same chapter, dealing with the defects of the Service, he wrote: Another defect of the Service, which was seen from the beginning, is the existence of pay beds in hospitals. All these things were thought about over a quarter of a century ago and in a mood of greatness, because it took great courage at that time to introduce a Service unique in the world with the kindness and compassion of it, and the recognition of the fact that the mother was being brought in as well as the husband who was sometimes covered by industrial insurances. How sad and how mean that, after all those years, Members opposite should think it worthy of themselves, of Parliament and of this House to bring forward this petty plea this afternoon that a small percentage of people should be allowed privilege inside a National Health Service.

I would much rather have two Services and I am quite certain which of the two would win. I know how few people would be able to afford a genuinely private health service, and we would begin to see the choice that doctors and consultants would make. I do not have such a poor opinion of them as that. They are like the rest of us. They are a mixed bag. But I believe that one would give an incentive to the young doctor, the young consultant and nurse—the dignity, in other words. Why do those on the Benches opposite go on talking about this country as a family and then deny the principle of a family spirit? If there is one time when we ought to behave as a family—and it is not just in times of war—then surely it ought to be when there is sickness.

We created something a long time ago of which we are still proud. We are sad that it should have been starved of funds. We are sad that so many who work for the Health Service should be underpaid. But instead of trying to dodge those issues, I hope that in the near future we will have a Government that will face up to them and show what a great National Health Service is and what it can become. I hope that there will be very few people who will want to pay their £170 a week—and believe me, my Lords, it will be a great deal more—in order that they can stand aside from the rest of their fellow countrymen.

4.48 p.m.


My Lords, before the noble Baroness sits down, may I ask her a question? Would she not agree that at the time when her husband introduced this wonderful National Health Service there were many inequalities that went with it? For instance, the consultants as distinct from the general practitioners, did very well, and it has taken over 30 years for the general practitioners to obtain justice. Therefore, if that was the position at the time, and all honour to the late Aneurin Bevan, why now should we not discuss the idea of private beds, almost in the same kind of context as at that time? Let us not look at this just from the point of view that it is completely unfair—there are still many unfair things about the Service—but in the whole context of privacy and of consultants and junior hospital doctors.


My Lords, I am not quite certain whether or not the noble Baroness is advocating the continuation of private beds in the National Health Service. I gather that she is not. But if she is, then we must agree to differ. This is a deeply divisive thing which will have an increasingly serious effect on the morale of the entire staff. We have to face it at some time, and I hope that we will stick to the original intention of phasing it out. As I say, my only regret is that a quarter of a century later this should still be one of our unsolved problems.

4.50 p.m.


My Lords, this is the first time that I have risen to address your Lordships' House. I ask for your forbearance, and I must apologise to you all for making my maiden speech on such a controversial subject; but I have been persuaded by a number of noble Lords to do so, and I shall try to atone for breaking with tradition by putting to you both sides of this difficult and complicated problem, about which I feel deep concern. During 32 years of general practice in London, my patients have been admitted to the private beds of almost all its large hospitals. I have visited them there frequently, often every day, and I think that I know something about the advantages and disadvantages of these private beds in National Health Service hospitals.

Reviewing all the evidence in the 476 pages of the excellent Fourth Report of the Expenditure Committee on National Health Service Facilities for Private Patients (1972), and from analysis of much that has been written since then and during the past month since the Charing Cross Hospital affair blew up, it is clear that there have been some difficulties at times in connection with private beds in the National Health Service. Some of these have arisen from the likes and dislikes of those who treat both National Health Service and private patients under the same roof; others from the occasional apparently unjustifiable (but perhaps merely unthinking) use of National Health Service junior doctors, nurses and other personnel, equipment and premises for the treatment of private patients, although the National Health Service does charge these patients a modest sum for most of these services. It is equally clear that over the past 26 years these private beds have been of considerable help to a great many patients who get everything or nearly everything they would get (and sometimes more) in a modern, moderately-priced BUPA non-profit making private hospital. They have been helpful also to consultants who can work with the teams they have trained; and to the National Health Service itself, not only financially but through the convenience of having part-time hospital consultants always near at hand in their hospitals—"geographically full-time" as it is called. We must remember that within living memory, but before the National Health Service began, many generous benefactors gave us millions of pounds for the buildings in which these beds are placed—the Lindo Wing of St. Mary's Hospital, the Woolavington Wing of the Middlesex Hospital, Nuffield House at Guy's and. the largest of all, the Private Wing of University College Hospital, and also many others both in and out of London—for the express purpose of encouraging private medical care within our teaching hospitals for patients of moderate means.

One of the happiest periods of my medical life was five years spent in the salaried medical service of the Royal Air Force during the war, so I have nothing against a full-time salaried service for the right patients in the right place. The Royal College of General Practitioners, of which I was the honorary secretary for 14 years and President for three more. has, I like to think, helped our National Health Service not inconsiderably during the past 22 years. I am strongly in favour of the National Health Service, which has been one of the finest conceptions of modern times, and I want to go on helping it in every way I can.

This problem of private beds in National Health Service hospitals raises the whole question of whether or not private practice is going to survive at all in Britain. When the National Health Service began many of us thought in a hopeful, trusting, somewhat starry-eyed way, that before long it would be so good that all the private sector, both inside and outside hospitals, would soon die a quiet and natural death. But that has not come to pass, although it has happened in certain places; and many doctors (general practitioners and consultants) still do private work. Indeed there are people who tell us that the National Health Service is perhaps, in some respects, "tottering to disaster," while private practice is slowly but steadily increasing in special fields by helping, among others, three important groups of patients: those who insure themselves, their families or employees independently against illness and accidents; those from overseas who come specially to Britain for treatment which they cannot obtain in their own countries; and those many foreign visitors, who are taken ill here when on holiday or on business, most of whom are insured in their own countries against the cost of private treatment in just such a contingency.

I myself do not believe that our National Health Service is so totter), as some people claim. When more money can be raised for it somehow, or it reduces the services it offers to patients to those which it can afford to run efficiently, and with more good will all round, I am sure that it will survive and flourish. But with its financial and other difficulties I think that there is little chance of its ever giving everyone in this country all the medical care and attention they need. when and where and how they want it, as there is of our public transport taking everyone from door to door just when and where and how they want that. So I feel that the private sector of British medicine will be certain to survive too; as indeed it does to some extent even in Russia, which I visited for five weeks not so very long ago.

My Lords, I have never been impressed by the argument that having both these sectors and by keeping private beds in National Health hospitals gives rise to two standards of medical care—one for the rich and one for the poor—which everyone wants to avoid. There are two standards already—the best and the worst in each sector. I had a patient recently, a professor of engineering, who developed severe heart failure late one Saturday night. We admitted him to a public ward of St. George's Hospital where we were told that the only way to save his life would be to give him a new heart valve at once. A team of surgeons, physicians, nurses and orderlies worked on him thoughout the early hours and by breakfast-time on Sunday he was out of danger with a new valve in his heart. He recovered well and none of this cost him a single penny above what he had paid in the health portion of his National Insurance stamp and in his taxes. Surely this was the best of our National Health Service; it would be hard to find anything better anywhere else in the world. A few weeks later I sent to another National Health Service hospital, a patient with severe varicose veins which were painful and interfering with his work, only to be told that the waiting list for that operation was three years. Here are two standards within the public sector—the best and the worst. The private sector, also, has two standards—good and bad—and both can be found in the Harley Street area and elsewhere. Surely our job for the future must be to try to raise the lower standards of both, rather than to set up one sector against the other.

Queue-jumping, as my noble friend Lord Aberdare has already said, is another point often brought forward when these matters are being discussed. Improper jumping of a queue through a private consultation or undue influence of any kind is, of course, quite wrong, whether it is into an ordinary N.H.S. bed, into a so-called amenity bed, or even into a private bed when there is a waiting list for that. An amenity bed is one which an N.H.S. patient can have in a single room or in a small ward, by paying, for it, allowing privacy which is not required on medical grounds. The simplest way of avoiding queue-jumping is, of course, to have no queues; but that has not been possible so far in many hospitals. We are told now that it is almost non-existent in the N.H.S. because of the vigilance of hospital admission officers; and I hope that that is right.

There is sometimes difficulty in distinguishing queue-jumping from perfectly fair and proper priority which must be given to those who are seriously ill and also, at times, to prominent men and women with important work which others cannot really do—Cabinet Ministers and other Members of Parliament, senior civil servants, judges, bishops, nurses, officials of the T.U.C., and even doctors. The difficulty, of course, is where to draw the line in deciding who deserves such priority, medical or occupational, and who does not. This problem will he with, us until all waiting lists for N.H.S. beds and for private beds disappear. For illnesses needing urgent or fairly urgent treatment, the waiting lists for private beds now are longer in some London hospitals than they are for N.H.S. beds, although I know that their bed occupancy in some parts of the country has sometimes been too low.

Another question before us is whether or not the use of private beds robs the N.H.S. of some of the services of valuable personnel. While to a minor extent this is true, we must remember that for every patient treated privately the N.H.S. is saved the effort and expense of that treatment, and that if all consultants were forced against their will to work full time for the N.H.S., instead of the 9 /11ths of their time which many of them do now, some would go entirely into private practice and others would probably emigrate, when all their services would be lost to the N.H.S. for ever. Most countries are short of doctors and, as a straw in the wind, it is worth noticing in connection with emigration that only last week more than 1,600 young doctors who are at present working in Britain—one of my doctor sons among them, and many of them from overseas—sat an American medical examination called the E.C.F.M.G. which is held in London twice a year. To pass this examination will help all these young doctors towards being allowed to practise medicine in the United States or in Canada should they ever wish to do so.

There is one last question, my Lords, which I should like to ask. Are private hospitals outside the N.H.S. going to be allowed to exist in Great Britain in future? At the Trades Union Congress in September, 1973. a resolution was passed, and I shall quote from the minutes: Congress expresses its total opposition to … the building of private hospitals…. In the event of planning permission being granted for a private hospital development, concerted industrial action be sought through the T.U.C. General Council to ' black ' the development". I know that a composite resolution to abolish all private practice, private insurance schemes, private clinics, private nursing homes and nursing organisations and private beds in hospitals, was not passed at a subsequent Labour Party conference. But on the agenda for its conference this autumn I understand that there are motions to that effect. The National Health Service can hardly pay now for what it has on its plate; if it is to take on the work of all that lot too, one may be forgiven for wondering what will happen.

The Trades Union Congress agreed its policy of "blacking" the building of private hospitals less than a year ago. Less than a month ago we saw the militant industrial action of the National Union of Public Employees at the Charing Cross Hospital and, since then, the threat of members of the Association of Scientific, Technical and Managerial Staffs to "black" doctors who opt out of the National Health Service into private practice, if private beds in the National Health Service are abolished, so as to prevent these doctors from having laboratory and other diagnostic tests done elsewhere on their patients. These sinister threats must surely be considered seriously by my profession. If private beds are to be phased out of the N.H.S. as our present Government intend, and if trade unions by militant industrial action are to prevent the building and running of all private hospitals, that, my Lords, would be twisting the arm of a great and learned profession on purely doctrinaire grounds in a way which is intolerable in a free country. Most doctors cherish their freedom of choice as to where and how they work, within the traditions of their profession of course and within the law, just as much as other people value freedom of speech and freedom of the Press. If that clinical freedom were to be taken from them by militant trade union action, they would be likely to react firmly, unitedly, and at once, just as the British Medical Association reacted immediately to the Charing Cross Hospital affair. And the action our doctors would take would probably do no good whatsoever to our National Health Service.

In conclusion, my Lords, may I say that I think that the brightest future for British medicine will lie in friendly and helpful co-operation and harmony between the public and the private sectors, with adequate safeguards against all abuses on both sides. Somehow we must achieve this. Where better can some of this co-operation take place than within the walls of our great and famous hospitals? If this symbiosis is impossible, however, then the two sectors will have to develop quite separately, which I firmly believe will prove in the end to be to the detriment of both.

5.8 p.m.


My Lords, this is the first opportunity I have had of congratulating a noble Lord on his maiden speech. It does not seem very long ago since I myself was sitting down suffused with much gratitude when another noble Lord did the same treatment for me. But the privilege becomes more than a privilege and is a great pleasure when the author of the speech is an old and trusty friend and colleague. I could wish that the noble Lord. Lord Amulree, had retained his place in the batting order this afternoon, because his long experience of procedure of this noble House would doubtless have allowed him to express much more felicitously than I can the feeling which I am sure suffuses all parts of this House as a result of that interesting, informative and challengingly provocative speech from the noble Lord, Lord Hunt of Fawley. It would be difficult to think of anybody more knowledgeable on the subject of general practice than Lord Hunt of Fawley, the father of the Royal College of General Practitioners. As general practice is the essential and vital link between the medical profession and the people at large it implies that his knowledge covers a far larger scope than today's debate permits; and I have no doubt your Lordships will look forward to many future occasions when this noble House can benefit from his wide experience of life and of living and his very warm humanity.

My Lords, I am sure you will agree that the whole House has reason to be grateful to the noble Lord, Lord Aberdare, for his timely Question about a matter of topical interest to us all, and I am equally sure that he will agree that the specific Question he asked is but a small part, albeit a very important part, of a much wider canvas. It seems inevitable that discussion will spread from the particular to the general and I trust that your Lordships will forgive me if I deal rather with the latter than the former—the general aspects that urgently face us today in respect of our medical services. I take this opportunity to do so, not having had the honour of being a Member of your Lordships' House when the medical services and their reorganisation were discussed early last year.

I have to admit that I make this contribution with considerable sadness, having had experience of twenty years' practice in pre-war voluntary hospitals; of six years in the finest national service that this country, or possibly any other country, has ever seen (with due apologies to the noble Lord, Lord Hunt), the Royal Army Medical Corps in time of war; of more than 15 years with the National Health Service (its first 15 years); of an overall forty years of private consultant practice and, for good measure, the opportunity over those years of seeing a considerable number and variety of the health services of the world.

My Lords, with this background I see the private patient/private bed fracas of to-day as just the tip of an iceberg—an iceberg well on its way to freezing out of existence what was originally a magnificent ideal—Aneurin Bevan's National Health Service. And how good it has been this afternoon to hear the noble Baroness, Lady Lee, supporting and reminding us of those early days. This ideal—despite, in the end, its somewhat precipitate launching and its many impracticalities—had all the hallmarks of a great humanitarian adventure and an outstanding social experiment. It is indeed sad that over the years almost every worth while aspect of that scheme (and there are many, my Lords) has, in steady sequence, run into the sunken, sinister, ever-expanding depths of that same iceberg of which we are discussing the outward and visible sign to-day.

It is sad that from the very first the Service was misnamed, for it has been our "Disease Service" and for 25 years it has used as its very poor cousins indeed the real growing points of medical practice: research, methods of prevention and public health education. Health—the care of the people—is essentially an ethical problem. It is not a political plaything. In recent years it has been shown that certain industrial and commercial enterprises are amenable to nationalisation—not always, of course, very effectively or very efficiently—and it is possible to envisage a reasonably satisfactory nationalisation of the facilities for, and the environment of. the practice of medicine. However, to nationalise the profession itself—its vocational personnel—was, and, I submit, always will be, a virtual non-starter. Why was no attempt ever made to nationalise any other profession? The Church—no. The law—most certainly, no. Engineering, architecture, accountancy and so on have never been approached and have never been considered. The only genuine nationalised profession—and they are surely a special case—are the Armed Forces.

My Lords, the essence of medical practice is the doctor-patient relationship of which we have heard so much—a mutual contract between two willing and consenting individuals involvingtrust, understanding and shared loyalty. Anything—and I would emphasise "anything"—that interferes with that relationship can only. to some degree (a lesser degree or a greater degree) diminish its value both to the individual and to the mass of individuals whom we call the community. And when that "something" is the massive bureaucracy of a Government Department, then the original humanitarian and, of course, the entirely worthy ideal of health for all without financial restriction becomes a travesty and appears in its true light as a political manoeuvre of great electoral value—of value to any and every Party and to any and every Government. It becomes a matter of competitive bribery.

No thinking person would query the worthy objective of maintaining and improving the nation's health. It should be only too obvious to all of you that without good health all the other attributes of life—wealth, power, prestige. Position, the enjoyment of the environment and of opportunities—are relatively valueless. It is the implementation of that objective that is so very difficult, and successive Governments seem to have become increasingly blind to the fact that present methods are allowing the system to crumble around them and equally are resistant to any sort of practical advice from the only quarter that can really produce it—the medical profession. It is, indeed, a sad thought that we had plenty of warning of the dire possibilities now staring us in the face if only we had had the eyes to see and the ears to hear; and this dates back to the days before the inception of our own National Health Service.

May I refer to the experience of other countries in this field and particularly, for reasons which ail noble Lords will understand, to the experience of New Zealand which set up a prototype of Western state health services. New Zealand—a small country with a small population—over the years has proved a valuable seedbed for socio-economic experimentation. It may interest the House that New Zealand was the first country ever to give votes to women—and that was a long time ago. Also, it was the first country to have a Minister of Health, as such, in Government. He was a Maori and a very successful Minister of Health. Perhaps, therefore, it was not surprising that New Zealand initiated the ideal of a national health service in the late 1930s. Wisely, as things turned out, they did not implement the scheme in one fell swoop (as we did later) because by the time that particular Government fell from power—and due to the intervention of the Second World War this was 13 years later—they had proved that the scheme in toto was not economically a viable proposition. In fact, to this day—35 years later—the New Zealand health service is still incomplete; but such parts of it as are available are working well, with a co-operative profession, and are financially sound. Surely, my Lords, we are big enough to learn a lesson from a little country.

The post-war years, the years of our own National Health Service, have amply shown (and this is a most important fact) that no country in the world has yet been prepared to spend enough of its gross national product on establishing a State health service which can, with any honesty, be called either "free" or "comprehensive". And both internationally and Europeanwise, Britain is a long way down the league table.

The last thing, I want to suggest (and I hope that I am not doing so) is that the profession is against the National Health Service. You have already heard from the noble Lord. Lord Hunt of Fawley, that this is not true, and I can certainly back up that opinion. In fact, the Service has been kept alive over the years by the medical, nursing and ancillary professions—as the noble Baroness, Lady Lee, pointed out. "the complete team"—having dedicated one-third of their working time, free and for nothing. What they object to—increasingly so and now, my Lords, very positively so—is the blatant lack of appreciation of this fact and the casual exploitation of this dedication on the part of successive Administrations which, while they boast of the Service being the "best in the world", "free for all" and "comprehensive", do less and less in an inflationary world to provide it with the wherewithal to survive efficiently—or, perhaps more importantly, with any real understanding of its many problems.

In both these respects the recent so-called reorganisation has added fuel to the fires of disillusionment, depression and doubt. The morale of the profession is at its lowest ebb ever. Less and less money—and let us not forget the drastic cut in the N.H.S. budget of £1,200 million by the last Administration before Christmas—has led to new hospitals being shelved, and in this connection it is worthy of note that only 40 of Britain's 2,300 hospitals are new since the war. Wards and departments are being closed through lack of staff; posts are remaining unfilled; the health centre schemes are being truncated; the resources for research into health education have been woefully curtailed and the doctors—and not only young doctors—are leaving the country in increasing numbers. And we have the dismal spectacle of wholesale revolt throughout the Service—throughout a wonderful Service.

Personally I do not favour so-called "sanctions", but I have the greatest sympathy with those who are being forced in to-day's world to feel that nothing else is left to them. At the same time the "reorganisation" itself is proving an expensive luxury and its emphasis on "management produces to me a sinister smell of indoctrination. To give it its due. it has achieved a somewhat uneasy unification of the three main streams of the profession: general practice. hospital service and public health service. This tripartite arrangement of the original N.H.S. was certainly one of the most serious wrongly-directed signposts in the early days. Another was the use of the capitation system—an impersonal, cold, inhuman method which, while probably easily computerised, put a Government Department clearly and squarely and permanently between the patient and his doctor, thereby wrecking the basis of a vital relationship essential to the practice of the best medicine.

The third seriously misdirected signpost has sadly been erected quite recently, actually in the reorganisation itself: the tragic divorce, despite being under the same departmental aegis, of medicine and social services. Man is an entity: his overall wellbeing cannot be efficiently dealt with in compartments and the reorganisation has built up a monolithic bureaucratic administration, far more extensive and therefore far more expensive than ever before—an administration that lays emphasis on the managerial and organisational doctor rather than on the clinical and humanitarian doctor; that takes medicine away from the periphery where it belongs, as it is there that the consumers—an awful word; the patients—live and have their being; that reduces flexibility, removes responsiblity and stifles initiative and good competition and puts at risk a free choice. Meanwhile masses and masses of red tape, becoming more and more entangled at each of the various tiers of administration, daily delay vital decisions, clog up the channels of supply and demand and lead to frustration, which to-day has been sadly translated into cold anger.

Many of these points were made and, surprisingly enough, constructive and practical suggestions were produced for the improvement of the N.H.S. by a Committee—the Medical Services Review Committee, often I am afraid, eponymously called the Porritt Committee as I was its chairman—consisting of representatives of the 12 major medical interests in this country. This Committee worked steadily for four years, fifteen years ago, to try to define what the profession could do and could suggest for the improvement of the Service after its first ten years of existence. This Report, as is not unusual, was put on the shelf. It was brought down, dusted and apparently used as a basis for the first discussion on the reorganisation of the Service. One has to use both one's imagination and one's faith to see the relationship and the resemblance between the Report and the reorganisation. But many of the recommendations made by the Committee originally could still he implemented, to the great advantage of all concerned—but the implementation would cost a great deal more.

The nation bought the Health Service for £132 million. Now it is currently running at £3,000 million per annum and that figure is more than likely to be considerably inflated next year. Has the Service ever been recosted in the intervening years? If so, when, and by whom, and were the results ever publicised anywhere or debated in Parliament? We are at present the owners of a rather dejected Service—a second-class Service I am afraid—a fact which has done great harm to the value and prestige of British medicine that for many years stood so high. If we are not to slip further into the third grade—of which decline I am sure your Lordships will agree there are ominous signs to-day—a rescue action is called for urgently.

To my mind even to-day there is nothing basically wrong with the Service—certainly with its primary ideals and its concepts. What is wrong is that those who administer it will insist on its being described as comprehensive; will continue to believe that it is a monopoly. This frankly is just untrue. The facts of life are that the Government just cannot afford a monopolistic Service—and the sooner this is appreciated by Government (any Government!) and a statement to that effect is made honestly to the public, the sooner will they begin to get value for their money in what can only be a limited sphere of first priorities. Beyond that limit it will be essential that services are paid for by the individual—through insurance schemes, contract subsidies, or, in particular, by the ridiculously maligned method of private practice. If the Government Service cannot produce overall cover for its people, then it is vital to encourage and support other methods of service which, running parallel to the State Service, would complement it, would stimulate it and would be of great benefit to both systems concerned and to all those in them. This would seem so eminently simple and logical that one wonders why it is not done to-morrow.

Sadly, one is up against the entrenched and ingrained doctrinaire policies of the Ministry. That is nothing against that Ministry; it is just what has happened over many years: a chronic resistance to enlightened development, unfortunately common to all political Parties but now being heavily underlined by the present Administration. When will politicians and/or Parties realise that health is not politics—it is people? When will they take off their rose-tinted spectacles and see that their optimism and exaggerated praise for the N.H.S. is baseless and misleading to the people whom they serve and represent? When can we have an honest, factual reappraisal of what is, at base, an excellent system, but is now at that base rotting away from over-stretching and undercutting? At the moment the "Elephant" is a white elephant—pachydermatous and untrustworthy. The "Castle" is a castle in the air, without foundations and uninhabitable. The former demands euthanasia, the latter a firm rebuilding on a base of British tradition, both medical and national.

It is from this milieu that I return briefly and finally to the Question. I would hope that from what I have said I have justified my initial remark that the private practice question is just the tip of the iceberg. The disgraceful affair recently at Charing Cross Hospital was surely the most disgusting example of rank hate, envy and jealousy—the most destructive of motivations, the nadir of egalitarianism. And, my Lords, egalitarianism, which is always a levelling down, apart from being a physical impossibility (for we all have different genes, whether we like it or not; we all have differences in environment; we all react differently and at different rates to the stimuli that surrounds us) has never worked as a policy throughout history. That this miserable example of it should receive at least the tacit support of a Minister of the Crown—one hopes an emotional rather than a rational reaction—is a sad and sinister happening. The fact that by militant activities a small trade union can not only enforce its will on the doctor/patient relationship, but at the same time can threaten to usurp Government power and dictate Government policy, demonstrates how near the National Health Service is approaching to clinical and financial chaos, and how dangerously close it has come to anarchy.

My Lords, with reference to the various pros and cons of private practice, which have already been mentioned, and will be brought out in the speeches of other noble Lords, suffice it to say that from everyone's point of view including, one hopes, that of an impartial D.H.S.S., it will be found the balance of evidence weighs heavily in favour of retaining private practice. It is the outward physical sign of the medical freedom of choice for the individual, both doctor and patient. It provides an incentive to higher standards of medical care; it positively helps both the State Service and the State, clinically and financially, and it boosts the prestige of British medicine and of Britain overseas.

My Lords, I would return simply to my original thesis. If the National Health Service, through no fault of its own and essentially for financial reasons, cannot provide the overall medical coverage required by the people of this country, it should be happy and gratefully ready to encourage and support a method which can do—and in fact is doing—much to repair these deficiencies; that is, private practice, subsidised, insured or otherwise. Let us hope that before much longer some Government will be prepared to ignore emotional and political undertones and, realising that the health of the community is a matter of vital and primary concern to the nation, will be prepared, courageously and genuinely impartially, to organise as a matter of dire urgency a radical rethink of the principles, priorities, policies and concepts of our National Health Service. We are in dire need of a National Health Service that is national. We are in dire need of a Health Service that deals with health as well as disease. We are in dire need of a Health Service that is a service to the people and not a servitude for the profession.

5.32 p.m.


My Lords, perhaps it seems a little impertinent of me to join in the congratulations to my noble friend Lord Hunt of Fawley, because we were enobled on the same day. But with great pleasure I do so, as the noble Lord is one of the many experts from whom we shall be hearing to-day. I speak as a patient and I should declare a rather obvious interest. As a family we have been insured with a non-profit-making organisation for the past 25 years, but I have never actually been a patient in a National Health Service hospital.

What worries many people is that the strikes over pay and conditions, with which I have every sympathy, have in some quarters taken on a very different tone. Here we should all beware, or yet another freedom of choice will have gone. We live in a democracy in an imperfect world, and there may well be abuses in the National Health Service, but noble Lords speaking to-day will be able to tell us what improvements should be made. I agree with my noble friend Lord Hunt of Fawley, that it cannot possibly be right that leaders in Government, industry and many other spheres should have to wait for treatment. People come here from all over the world, because they know what we can offer. We have every reason to be proud of what has been achieved.

My Lords, decisions which might mean the separation of National Health Service from private patients, must not be taken under duress, or we will surely all be the losers. To have to fight for the right to choose how we run our own lives seemed inconceivable a short time ago, but the prevalent attitude on the part of some, that equality in all things is the only aim, poses a threat to us as a nation which is very evident. Yet all the present political speeches talk of uniting the country. Leave us to choose for ourselves where our priorities lie; for example, to make a conscious decision between hiring a colour television or paying for health insurance. They cost the same. Surely the difficulties of the National Health Service should be viewed rationally, not emotionally. A free society is to be cherished, not swept away. We should seek to extend freedom of choice, not the reverse.

5.35 p.m.


My Lords, I have always regarded the noble Lord, Lord Aberdare, as a very fair-minded person. I am surprised to learn that he has initiated a debate at this time when the Secretary of State for Social Services is engaged in the most delicate negotiations with various categories attached to the National Health Service. This is entirely the wrong moment to make speeches, particularly like the one made by the noble Lord, Lord Porritt, which I deplore, which will be read by the medical profession, by professions supplementary to medicine, and, indeed, by all those whose heart is in the National Health Service, who are determined to make it succeed, because they know it is a humane service which has one object—to serve the people when they are in their gravest need of help.

We should not have a debate at this time, just when the Secretary of State is trying to negotiate terms which will be acceptable; at a time when, instead of denigrating the Service, we in our responsible positions should be doing our very best to tell the country that we have a Service second to none in the world, and that we are determined, despite its defects, to do all we can to improve it.

Before I spoke, there were on the list the names of three other noble Lords, all medical men. The noble Lord, Lord Amulree, had to go, but after I have spoken there are three more medical men to follow. I would particularly like to draw their attention to the article in the British Medical Journal, the doctors' journal, of July 13, which read: The conflict last night at Charing Cross Hospital about private patients would never have arisen had not those concerned had their patience stretched to breaking point. The porters, orderlies and other ancillary workers who make up the bulk of members of the Hospital Branch of the National Union of Public Employees have been paid far too little for far too long, and doctors may ask themselves what, if anything, they have done about it. While we are considering what the doctors have done about it, I also want the House to consider what has been done for the nurses, and their miserable rate of pay? I find that the most distressing scenes in our streets to-day are the protest marches of the nurses, radiographers and other professions supplementary to medicine who have been called to their life's work by a sense of vocation. This I think is very important to remember.

The great difference between these and other workers and the willingness to suffer every kind of hardship is the fact that these workers have been called to their jobs by a sense of vocation. My Lords, I experience a deep sense of shame in the knowledge that the financial exploitation of these young people has finally led them to revolt. Their training in professions which instil compassion and gentleness has always led them to regard the strike weapon with aversion. Successive Governments have known this. The last Government knew this but they repeatedly turned a deaf ear to their appeals for improvement in their rates of pay. The well-organised medical profession have used their well-organised power to improve their own position while disregarding the conditions of the army of young women who are responsible for the welfare and the care of their patients.

My Lords, the arduous work of nursing with its increasing need for technical knowledge combined with miserable pay are all conducive to the high fall-out in the first year of nursing, which is the most deplorable waste of some of our finest young women. No one can argue that the private bed question is solely to blame for this confrontation. Wards in many hospitals throughout the country over the years have been closed due to shortage of nurses. This is not new; it is the culmination of neglect of the wonderful men and women who have served the National Health Service over the years, and finally they will not tolerate it any longer. These closed wards should have provided sufficient warning that the National Health Service could be in jeopardy if the pleas of key workers go unheeded.

Many of you have heard of the Royal College of Nursing. In the world of medicine I think doctors will agree that we have always regarded the Royal College of Nursing as an organisation which has been very moderate in its demands. In fact I would almost say it was a rather conservative organisation (with a small "c") and, although I am delighted to see it, it astonishes us that the Royal College of Nursing is no longer prepared to accept the position. The Royal College of Nursing is in revolt. In a paper to the Secretary of State it says: The representative body, speaking on behalf of the 100.000 members of the Royal College of Nursing, is determined to make the Government aware that the profession has reached the point where it is no longer prepared to be ' played along'. The nurse who wrote that summed up the position very well. Successive Governments have played them along for too many years. The paper went on: All is not well with nursing; indeed a great deal is wrong with it. Radical treatment is essential and this must be undertaken with a real sense of urgency. The profession will not again put off with placebos. My Lords, of course they are right, and the last Government put them off with repeated promises and excuses. I am surprised that the noble Lord, Lord Aberdare, should come here as though he is completely innocent of playing any part in not recognising that these people should have consideration and should have their demands examined immediately. I am delighted to learn that the Secretary of State has personally applied herself to the position, but I should like the House to learn that the Royal College of Nursing also draws attention to bed utilisation—and I understand that this debate was initiated primarily to focus attention on the question of private beds.

As I have already said, the Royal College of Nursing is fairly muted and uses moderate language. It says: It is an insupportable situation that after 30 years of the National Health Service extra beds may still be put up in one ward while an adjoining ward may have several empty beds. This is what we are talking about. They go on: Another deplorable practice is the two patients per bed situation whereby the patient occupying the bed by night has to sit up during the day while the day patient uses the bed. Do any noble Lords who at the moment are supporting private beds know that that happened? I wonder whether any of them have been in a ward where they have seen a bed shared by two patients, one in it during the day and one in it during the night, while in an adjacent ward there are empty beds.

My Lords, this is what we are talking about. The nurses say: Problems of this kind which have profound implications for standards of patient care can only be solved with the co-operation of the medical staff who must be prepared to accept some flexibility in the system of bed allocation". Here we find the nurses, who are surely better informed than any of us, who are living in these hospitals, who are watching these conditions and know precisely what the administration is, coming to say that the medical profession must put their house in order if we are to improve matters. The medical profession must say, "We are not going to allow empty beds in one ward while in an adjacent ward beds are put up in the middle and in another ward one bed is shared by two people.

My Lords, here is the case and I ask any of you here to say whether the Royal College of Nursing should be told that this will be remedied. Of course, they have complained time and time again over the years and nothing has happened. Frankly, I find it difficult to understand why there has been such consternation concerning the use of private beds in hospitals. The policy proposals of the Government included the phasing-out of private practice and private beds in hospitals, and they are pursuing that policy. There has been no secret about it. The Government have not suddenly said, "We are going to do this". This has been the policy. Every Labour candidate in the country during his speeches has told their audience that this is the policy of the Government, and now the Government are pursuing the policy. I recall a similar outcry from the medical profession—and all the outcry, my Lords, is coming from the medical profession—in 1945 when Mr. Attlee made it clear that he proposed to introduce the National Health Service. Perhaps few people know that one of the first things Mr. Attlee did in his youth was to go up and down the country describing a National Health Service. The Conservative Party voted against the Bill. They not only voted against it on Second Reading when the principle was being discussed, they voted against it in Committee and again on Third Reading.

So when I hear speeches like that of the noble Lord, Lord Porritt, I simply recall the speeches that were made in 1945 when in another place we heard impassioned speeches from Conservative Members denouncing the whole concept of a National Health Service and then walking into the Lobby and voting against it. Fortunately, we had a large majority and therefore the Labour Party was able to put it on the Statute Book. Of course, we heard the threats, similar to those we have heard recently from the doctors, about withdrawing their services. They threatened to withdraw them if the Bill was passed—and of course they did not. For the first time in their lives they had a measure of financial security, and those threats were subsequently proved to be empty.

It is not surprising that consultants wish to treat private practice patients in a National Health Service hospital. Technological advances in medicine have been so rapid that the necessary laboratory facilities, X-ray equipment and intensive care units, are to be found only in the fairly large modern hospital. It is quite understandable that the consultants should say how much more convenient for them it is to be in the same building. The consultant knows that all these facilities that he needs for first-class work are there in the modern hospital.

The consultant who says that he will not work if these beds in the National Health hospital are taken from him has an alternative, so let him take it. I understand that the Wellington Hospital, which was opened this year, has set out to show that these facilities can be provided for the private sector of medicine. Finally, it seems to me that all those who are refusing to recognise that the change must come would be well advised to devote their energies to providing well-equipped private hospitals. where the private patient can be responsible for the upkeep, without relying on a considerable subsidy in kind from the public sector.

5.52 p.m.


My Lords, I speak to you as a layman, but as one who has been for twelve years closely connected with hospitals. During that time, which has ended through reorganisation, I have learned of the utter dedication of the consultants and the fact that they are at all times determined to defend their rights in those spheres of medicine in which they are expert. The hospital beds allotted to private patients are small in number but they are very important, not only to the consultant but also to the patient who takes advantage of them. There are those among us who badly need privacy when they are ill. On the other hand, there are many who prefer the companionship of the general ward and are happier in those circumstances. Both of those categories will recover much more quickly if they continue to be given their choice. Again, there are patients who come from overseas and bring a welcome revenue to our National Health Service and, God knows!, we need it. They come to this country as they can have the surgeon of their choice. They have faith in him and believe, rightly, that our doctors are the best in the world. It is hard to believe that all this should be thrown away for the reason that if the choice is not open to all of us it should not be open to anyone. What tragedy envy can bring in its wake.

I have spoken about the patient, and I now turn to the consultant. As is well known, at the beginning of his career the doctor decides whether he will go into general practice or work his way up through the Hospital Service, with very little pay to start with, in the hope that he will reach consultant standard in the speciality of his choice. Naturally, a great deal of a consultant's practice is in the National Health Service, but at present he is allowed the facilities of the hospital for his private patients. A limited number of private beds are provided for this purpose, and the patient pays the full economic value of the beds.

May I give your Lordships a little illustration. Some ten years ago I was taken into hospital very ill with a stoppage in my inside. I was taken to the King Edward VII Hospital for Officers, affectionately known as Sister Agnes. Halfway through my treatment there, when I had to have a colostomy, one bit of equipment which was needed was somewhere else and I was taken off to the University College Hospital where it was available. If it had not been for the fact that I went there, I would probably not be here today. I am glad to say that everything in my inside was put in its proper place again. It would be a great tragedy if these facilities were denied to the consultant, and to the patient who has put money into insurance schemes for this purpose.

Apart from what I have said, there is the fact that any decision to phase out the private beds will mean many consultants leaving the Service and either taking lucrative offers abroad or confining themselves to private practice. neither of which, in my opinion, they wish to do. Nor is it in the interests of the Service, which is so hard-pressed at this time. Some may say that they will never do that, but I can assure your Lordships' House that they will do just that, with all the resultant chaos which will ensue. We are all deeply apprehensive about the future of our National Health Service. and I have grave fears that if this added doctrinal burden is thrust upon it an irretrievable blow will be struck against that Service, which I have tried to serve, of which I have been very proud, and for which I have been very grateful. I should not like to end this short speech without thanking my noble friend Lord Hunt of Fawley for his maiden speech, which was, I agree, on a controversial subject, but was the truth, the whole truth and nothing but the truth. I thank him.

5.58 p.m.


My Lords, I should also like to add my tribute to the noble Lord, Lord Hunt of Fawley, who, according to our conventions I cannot today call my noble friend, for his maiden speech. His particular variety of instant wisdom I have often made use of in the past and hope to make use of in the future. He was indeed, as has been mentioned today, the very founder and father of what is now the Royal College of General Practitioners, which has done such a great deal to improve the standards of general practice in this country.

My Lords, because I happen to want a copy of what I am saying, and we have no Hansard, I shall, I am afraid, stick to my written notes rather more closely than is my custom. I hope your Lordships will forgive me for doing so. I shall make little reference to the events which have led up to the present discussion on the provision of private beds in National Health Service hospitals, except to say that I have great sympathy with those who work in the ancillary services, and I am glad to know that the Secretary of State is trying to go some way to meet their claim. I have, however, little sympathy for those in my own profession who, as soon as a dispute arises, seem to pick a quarrel and start negotiation by threats. "Consultants are working to rule"—how sadly degrading. We in medicine are an honourable profession, and if we expect to be treated with respect we should start in a spirit of collaboration, and not make an enemy of the Department of Health and its Ministers. This is precisely what the B.M.A. did at the inauguration of the Health Service with, in my view, disastrous results for the morale of the profession, and with the generation of the greatest amount of when the building of the new Service most needed our collaboration. Fortunately, Nye Bevan was equal to his task—and who would now want to go back to pre-Health Service days?

For many years I held positions of responsibility which brought me into touch with a succession of Ministers of Health. It never occurred to me that our relations should be one of enmity and opposition. When people know that you are anxious to collaborate they respect your point of view, and you have a much better chance of being heard and, sooner or later, getting your own way.

But now to the question under discussion. I think that I am probably unique in this House in having earned my living by consulting practice in pre-N.H.S. days, and having later become a whole-time professor of medicine with no private pratice whatever. So perhaps I can see both sides. What I hope to do is to look at the matter solely from the point of view of the reputation of British medicine at home and abroad, which, I may say, stands very high at the present time. I am afraid I do not recognise our Health Service in the dismal portrait painted by the noble Lord, Lord Porritt. Unless we earn and maintain that reputation we shall fail to recruit the right people into medicine and, what is more, we shall lose some of the best in our present Service.

Teaching, research, and post-graduate education are all important to this reputation, but it also must depend to a high degree on the quality of service which we give to our patients. I want to convince your Lordships that although there are exceptions, the continuing education and standards of practice of the consultant are enhanced if he has both private and National Health Service practice. From his hospital experience he derives a knowledge of a wide variety of disease. He has every facility at his service irrespective of cost, and is aided by a team of younger men and women who are a continual challenge to him to keep his knowledge up to date. Thus the chief learns from his team, but the team in turn benefits from the wisdom and experience of the chief, whose attitudes to patients may be considerably moulded by his experience of private practice, to the benefit also of his hospital patients.

In private practice the consultant is much more on his own. Here he faces a different challenge, with often a more demanding and articulate patient. He has to make his own first contact of the patient and come to his own conclusion. When I gave up private practice and became a whole-time professor, I greatly missed this clement. I had, it seemed to me, far too many assistants, all avid for knowledge and experience. Nearly every patient that I saw had already been seen by a house physician and a registrar, his history had been taken, investigations were already in progress, and I missed too my contacts with the general practitioner and never seemed to have what I call a real consultation, which is meeting a general practitioner in the patient's own home.

In hospital the patient gains by the presence of the team and the experience of the chief. The private patient is less well off in many ways, but he has the advantages, for which he pays, of a closer contact with the consultant and the amenity of privacy and, in many cases, a better opportunity to choose the time of his admission should it not be urgent.

Some comment has been made about the Secretary of State choosing to go into a private ward. I point no accusing finger. Why should she not? I think she was very wise. As she said (according to the newspapers), she was a Cabinet Minister, and she wanted to go on with her work and have people bring papers, and so on, some of which would be highly confidential. But I am sure that she is wise enough to realise that she is not the only person in Britain who wants such amenities.

I am sure your Lordships do not need convincing that a whole-time Hospital Service on the one hand and a purely private service on the other would be the worst that could happen to British medicine. The private sector would attract those consultants most activated by gain, and the Hospital Service would attract the less adventurous. The only question then is whether they should remain under one roof. Of course they should. Before the Health Service you received no pay for your hospital work, and you had to make the whole of your living in private practice. For this reason, you were dependent on the good will of the general practitioner, and it was a great temptation to make private practice your first interest. Nye Bevan could see that he must change the balance and pay the consultants so that their first loyalty should be to the Hospital Service. With that in mind, the advantages of the consultant doing most of his work within the hospital precincts are surely obvious.

But we must be realistic and examine the potential for abuses. I do not say that they do not exist, but it is my firm belief that most consultants do more, and not less, than the hours for which they are notionally paid. There are a few black sheep in every profession who will exploit any possible opportunity to their personal advantage. But, as Lord Moran (who I am afraid is not here to-day) once said to me, "Don't go around chasing the black sheep. It isn't worth while."

What is the private patient buying? If his illness is acute he is probably sent direct to the N.H.S. wards as the private wards have to keep beds for booked-in patients. If his illness is not urgent, he is buying amenities and the right to determine, within limits, the date of his entry. Is that a medical need? In many cases it is entirely a social need. Nevertheless, in many cases waiting lists could be greatly reduced by a proper collaboration between the doctors and the authorities. There is no doubt in my mind that many patients stay in hospital longer than is strictly necessary. Perhaps the new community councils will press for these reforms.

We have in Britain to-day probably the best Health Service in the world, in spite of any remarks which may have been made to the contrary this afternoon. Like most British genius, it is based on compromise. Let us not destroy what we have got and put something much less desirable in its place.

6.9 p.m.


My Lords, I, too, must express my apreciation of the maiden speech of the noble Lord, Lord Hunt of Fawley, which was most instructive and inspiring. The ground has been thoroughly covered this afternoon, but there are one or two points which have been omitted. No one has yet succeeded in proving that private beds in general hospitals do any harm to them. Until that is proved, I cannot see any excuse whatever for altering the system.

Another point is that all British subjects have contributed by taxation and rates towards the National Health Service, which entitles them to a free bed in hospital costing £100 to £120 a week. If the patient opts for slightly greater comfort, slightly greater amenities, more privacy, a wider choice of diet, there is nothing reprehensible about that; any more than. there is if he elects to have his midday meal in a snack bar rather than in a dining room. I have spent a considerable time in both wars in the general wards of Service hospitals, and I have them to thank for my present relatively remarkable health. During the last year it has been my lot to go into pay beds in four hospitals within six months, in London and in the country—Health Service hospitals and private ones. My experience is that one was quite excellent, two were jolly good and the fourth one was beneath contempt. All that is a matter of management and this is not the debate in which to discuss management. But I am absolutely certain that the Service hospitals which I was in during the war owed a great deal to the fact that they were administered by officers who had been trained in the care of men. So many of the other hospitals are now administered by people with a Civil Service attitude, who are much more punctilious over the rules than the chap in the military hospital or elsewhere, who has been brought up to consider the personnel.

I could go on about this for a long time, because between the wars I had the privilege of serving on the General Committee of Guy's Hospital, and I saw a great deal of that great leader, Emily MacManus, who was then matron. Many of your Lordships will no doubt be familiar with the broadcasting she did after she retired. Going around the hospital with her, there was obviously mutual respect but no familiarity. Every nurse was delighted to see her, there were smiles everywhere, and a kind word both ways. That was leadership and there was never any trouble at all under those circumstances, and what we really want in the hospitals are more Emily MacManuses.

6.15 p.m.


My Lords. I, too, should like to join in paying a tribute to the noble Lord, Lord Hunt of Fawley, on his maiden speech. I do so all the more readily because he has come to swell the rather attenuated ranks of general practitioners who sit in this House. I also do so gladly because, like him. I had the privilege of serving during the war in the Medical Branch of the Royal Air Force, for a longer period than he did, and I was able to join in that wonderful feeling of camaraderie of loyal devoted service to one of the grandest medical activities that this country can lay claim to.

My Lords, to-day's debate takes up right back to 1948 when the long-drawn out controversy took place between the Minister and the medical profession. Now, after a lapse of 26 years, the same battle of pay beds is being fought all over again. In 1948, the Minister felt that compelling the doctors to yield would not work and very wisely gave way. To-day the situation is far more complicated. The nurses, the maintenance staffs, the technicians, have all threatened direct action and in some cases have resorted to it. Their attitude has even spread to the doctors and some of them have recently threatened direct action within the National Health Service. Fortunately, wiser counsels have prevailed for if doctors as a body tacitly agreed to work to rule or, even worse, embarked on a go-slow campaign, the whole National Health Service could be thrown into confusion. Now that pressure is being exerted to abolish pay beds in hospitals, what is likely to happen? Pay beds will simply be created elsewhere, in nursing homes and private hospitals outside the National Health system.

Let us first try to agree on some of the basic issues. Can anyone deny that the National Health Service, which has often been described as the best in the world, can maintain its reputation only by the full co-operation of all who are employed in the Service? And on which branch are the greatest demands made, if not at the highest levels of all, the skill of the surgeon and the judgment of the physician. These are the result not only of years of prolonged training and discipline, but of highly developed skills and experience. On them, in the last resort, the whole of the National Health Service must stand or fall. Without their wholehearted and willing co-operation the Service is bound to fail. Aneurin Bevan discovered this hard truth many years ago, and after months of conflict wisely accepted most of their terms and allowed pay beds, as well as amenity beds, to exist in National Health Service hospitals. The actual number of practising specialists and consultants has no relevance to the issues. However few they may be, they are the keystone of the whole National Health Service arch and without them the whole structure would collapse.

I joined the Socialist Medical Association over 40 years ago and have been a life member ever since. But I have always regretted the fact that ever since the days of Somerville Hastings, no consultant surgeon or physician of any eminence has joined the Association, much less taken an active part in its work, and Somerville Hastings remained a lone, isolated figure even in his own Middlesex Hospital. He may have been able to recruit a few enthusiastic young doctors—perhaps I was one of them in those days—or medical students among his supporters, but no one of outstanding distinction in the profession, and so it has been ever since 1948. When its doctor members became fewer, the Socialist Medical Association had to recruit into its ranks technicians and ancillary workers to swell its numbers. The same has been true of the Medical Practitioners Union, a breakaway organisation of general practitioners from the B.M.A. which became affiliated to the T.U.C, and which has failed to attract the support of even one specialist or consultant of any eminence. The reason for this is not hard to understand.

We have got to be realists in this matter and adjust ourselves to things as they arc and not as we would wish them to be. A doctor of any standing in his profession must be an individualist, if only because in order to be a good doctor, he must treat his patient as an individual. We can legislate for levels of wages, for conditions and hours of work, but when it comes to illness, each case is not a text book entity, or a bargaining unit, but a human being, and must be treated as an individual in his own right.

I have always supported the National Health Service, always regarded it as inevitable, and still believe in it as our great hope for the future. But the danger lies in our attitude of acceptance of salary scales, conditions of work, of relative security. When a doctor comes to the acceptance of a patient's condition, that may often be an indication of the need for a change of doctor. Each patient has to constitute a challenge to the doctor's knowledge and skill in his determination to restore his patient to health. Of course this challenge may not always be accepted.

As they grow older many doctors can be lulled into acceptance of their conditions of work, of increasing salary scales, of their relative sense of security. But I hope that by these doctors our National Health Service will not be judged. Instead, it must stand or fall by those relative few, who are prepared to accept the challenge of maintaining their highest standards of excellence, of bringing an inquiring mind to serve in the interest of their patients, of constantly reaching out for new ideas, new methods and new lines of approach in their fight against sickness and disease. It is these doctors, perhaps few in number, who must always set the standards by which our National Health Service can be judged. not those whose future is provided for by the benevolent State, who are content to be free from the basic cares of their daily economic anxieties.

We do well to remember that the pre-1948 era was not one of unrelieved darkness. Although I believe that the N.H.S. had to come, and that it is just as necessary to-day as ever it was in 1948, there were many desirable features of pre-1948 medical practice that ought to be recalled. In those days many doctors were utterly dedicated in their work of healing, and when a patient could afford to pay, he often paid gladly for personal help and human sympathy that could not be assessed in terms of hard cash. Equally, where a patient could not afford to pay his doctor, the doctor would often waive his fee altogether and attend the patient without sending in a bill, for the sheer satisfaction of seeing his patient restored to health.

The trouble was that with the complications and ramifications of modern medicine investigations became so involved. So many disciplines had to be called in to effect the diagnosis, so many new complicated procedures had to be adopted for treatment, drugs became more sophisticated and consequently more expensive, that the patients who were able to afford to pay gradually became fewer. Many were even faced with bankruptcy when serious illness overtook them, as so often happens to-day in America. So in nearly all highly developed capitalist countries pressure is now veering towards the creation of a State health service. But just as there will always remain a minority of doctors who are highly individualist, all searching for new ideas, groping around for new methods to advance their skills in the interests of their patients, so there must inevitably remain the small minority of patients who are also individualists, who are willing and able to pay for individual treatment and individual care. There is nothing inherently wrong in this. Such patients are often able to subsidise the physician and the surgeon in his search for new ideas. Through them, the mass of patients will stand to gain.

It is the drabness of uniformity, the dead hand of relative security that can sometimes act as a barrier to a patient's recovery. That is why we must face the facts that there always will be queue jumping. As a nation we must learn to live with it. A Cabinet Minister who is ill will always be able to jump the queue. It is in the nation's interest that this should remain so. A large employer of labour, even of labour in nationalised industries, should always have the right to immediate treatment, even if it means jumping the queue. It is right that it should be so. A doctor who falls ill should be allowed to jump the queue. It is in the interests of his patients that he should not have to wait his turn at the end of the queue before receiving treatment.

I have been a member of B.U.P.A. for more years than I care to remember simply because I want the right to have the hospital, doctor or surgeon of my choice. I do not need to remain a member of B.U.P.A. at all, because as a doctor I and my family can always have these privileges anyhow. But I still keep on with B.U.P.A., despite its appalling increased premiums to meet the increased hospital charges, because it stands for a principle in which I believe. There will always be diversity of hospital treatments, just as there will always be a diversity of hospitals, nursing homes, hotels, theatres, cinemas, restaurants, motor cars, meals, clothes, or what you will. No one will ever succeed, even under a dictator. ship, in imposing complete uniformity on all and sundry, not even in a completely Socialist State. I may add that it is a far better Socialist State that recognises this, and allows some scope for human feelings and human eccentricities. The architect of the National Health Service, Aneurin Bevan, had the wisdom to recognise this, and derived, I believe, a deepening joy from cultivating his own personal differences and eccentricities.

If you ban pay-beds in hospitals you will simply force the building of private hospitals and private nursing homes outside the N.H.S., and the N.H.S. will be the poorer. Our own National Health Service should seek to combine the best elements of private practice and private solicitude under the same roof as public medicine and public care, so that each can draw new stimulus and understanding from the other.

There are times when we all feel the need to escape from one another, times that occur in sickness as well as in health. Let us not seal up every avenue of escape and condemn ourselves to a form of perpetual institutionalism. Let us extend to as many others as possible the consideration and the occasional yearning for privacy that we would seek to claim for ourselves.

In medicine it is hard to serve two masters. To remain supreme a specialist has to be dedicated to his art. That is why specialists are so often bad committee men and even worse politicians. It is worth while that this should be so, if they are to remain better doctors. They should be left to serve their art with the fullest sympathy and understanding of the community, and remain to some extent screened from the pressures of Ministries and civil servants. I say this after many years of experience as a civil servant working in the Department of Health.

At the same time, it is encumbent upon the medical profession as a whole to put its own house in order. The few black sheep that exist (and they have already been referred to by the noble Lord, Lord Platt, although I do not quite agree with him that they can be dismissed altogether), who seize the headlines, as they do in every other profession, should be weeded out and put under some sort of restraint. This should be done by the doctors themselves long before public clamour demands it. Ethical principles to-day are far too loosely observed. When I read in the newspapers, as I did the other day, that half of the hundred beds licensed for surgical purposes to a certain company are used for abortions, and that a large proportion of these patients are foreigners, I feel it is high time that the professional bodies took the matter in hand and put an end to these abuses.

The flagrant abuse of medical skills simply to acquire wealth as rapidly as possible must be halted; otherwise, the profession as a whole will fall into disrepute and both the National Health Service and private medical practice must inevitably suffer. No amount of extra millions pumped into the National Health Service from the national economy will atone for a lowering of ethical standards, and unless the medical profession itself takes the initiative in rooting out some of the glaring abuses which still exist, there will be a danger of deterioration in both the public and private sectors of medical practice from which, in the course of time, they may find it increasingly difficult to recover.

6.32 p.m.


My Lords, it is a great pleasure for me to congratulate my old colleague and friend Lord Hunt of Fawley on his splendid maiden speech. I must first declare an interest in that I am chairman of one of the co-operative associations that provide insurance for medical care. I also wish to declare my deep support of the National Health Service. It is something of which we should all be proud. I am glad that the noble Lord, Lord Aberdare, is asking this Question of Her Majesty's Government, and I note that the Question does not introduce the whole matter of the merits or otherwise of private practice but is confined to the inter-relationship of private practice to N.H.S. hospitals. It is clearly desirable that comments should be confined to this matter and should not digress into the wider one of private practice in general: nor to the reasons for the revolt of the paramedical services, which surely cannot be due to private practice despite what the noble Baroness, Lady Summerskill, implies.

We know that the original organisation of the National Health Service in 1948 dealt with our problem, and it is significant and shows the wisdom and good judgment of Aneurin Bevan that he fully recognised and accepted that it was desirable to include the provision of beds for the treatment of private patients within the N.H.S. hospitals. As the Question of the noble Lord, Lord Aberdare, points out, this provision has been accepted by all Governments, both Tory and Labour, since 1948. Moreover—and I think the significance of this cannot be over-emphasised—numerous Ministers of all Parties and many Back-Benchers have availed themselves, and continue to avail themselves, of the facilities of this provision—and very right, too. Mr. Aneurin Bevan himself, in his last sad illness, was not treated in a general ward, and neither was Mr. Hugh Gaitskell.

Perhaps most significant of all—seeing that she is so determined and so vociferous about abolishing these facilities—is the current holder of the post of Secretary of State in the D.H.S.S. However much the right honourable lady may seek to play down her acceptance and use of these facilities, it is a fact that she chose to be treated as a private patient in an N.H.S. hospital; and, moreover, not casually or without due forethought but, from her own account, only after carefully weighing the advantages and deciding that it was meet for her to enter into a private room rather than into a general ward. This decision does her credit and shows the wisdom and good sense which guided her—an attitude which is markedly absent from her total condemnation of pay-beds in N.H.S. hospitals. Indeed, it would seem that the wisdom of her first choice, so understandable, is in great contrast to the intolerance and prejudice which mark her present attitude. I find it difficult to understand how such a change in attitude can be pursued. At the very least, it is unconvincing, and it even suggests effrontery in denying to others what she was ready to take advantage of.

The arguments for the retention of pay-beds in N.H.S. hospitals are many, and have been eloquently presented by many people and in many ways, so I feel it is better for me not to attempt a full presentation of the case. The White Paper published by the D.H.S.S. in April, 1973, presents a full, lucid and convincing case. I wish only to select for emphasis certain aspects of the problem which specially impress me as demanding earnest and serious consideration. The first aspect is the financial one. Payments by private patients have been variously assessed as bringing some £17 million or more to the N.H.S. If they are done away with, the money that they pay will be lost—a significant matter in view of the present difficult financial situation of the N.H.S. It is not enough for the right honourable lady the Secretary of State airily to wave this aside by declaring that there will be that much more for the N.H.S. The money will just not be there; it will be lost.

The second aspect is the harm to our medical and surgical prestige abroad. At present, many patients come to this country for treatment that they cannot get at home and because they feel that they will obtain treatment of a high standard in Great Britain. If these people cease to come we lose in two ways. We lose the money that they and their relatives and friends bring into the country. As well as payment for hospital accommodation and treatment, these patients and their friends spend money in many other ways. On a global scale this may not be large, and perhaps it is not large in relationship to the National Health Service, but it can form an invisible export which should not be brushed aside as unimportant. We should also lose much national prestige, which again should not be lightly cast aside. I also point out that patients from this country who cannot obtain treatment as a private patient in Great Britain will also seek treatment abroad. It is easy to lose ground in this matter; it is more difficult to retrieve the loss. We talk about doctors going abroad and emigrating, but I am sure that many patients who wished to be treated privately would also go abroad.

The third consideration, and one that should not be forgotten, is the advantages which accrue directly to the running of the N.H.S. by consultants and others having their private patients within the hospital at which they do most of their work; that is, work for their N.H.S. patients. They do not have the distraction of leaving their N.H.S. hospital work to visit a private hospital or nursing home perhaps some distance away and at an awkward time. If all their patients, private and non-private, are in the same hospital complex it is clearly an advantage that everyone shares—hospital organisation and patients alike. Also in this connection I place the great advantages which arise in the case of those more serious and more complex forms of treatment and of diagnostic investigation; for example, certain high-grade radiological techniques which are difficult to provide outside a large hospital organisation.

Private patients, even though they make a separate payment for all their hospital investigation and treatment, have already paid their contributions under the N.H.S. It seems scarcely fair that they should not be permitted to share these high-grade facilities for which they have already paid and must pay again. This also imposes a great extra disadvantage on the consultant if he is selecting and advising patients about, for example, open-heart surgery, or, indeed, any major medical or surgical field of diagnosis or of treatment. To carry out the exercise, be it diagnosis or a major operation, all within one hospital complex is one thing; but if the consultant has to adjourn to another hospital or nursing home to direct his attention to a private patient who is also under his care, it is a very different matter.

It has already been mentioned that the juniors whom he is teaching benefit greatly from hearing him treat private patients, and seeing the techniques of treatment of those patients. If the patient has come from abroad, it is even invidious that the consultant's attention and efforts should he separated in this way, and it scarcely adds to the efficiency of the treatment which such a patient receives when he has made up his mind to travel to Great Britain to receive the very high standard of treatment which he has been led to believe he will obtain here. It seems to me scarcely a gracious, nor Christian, nor praiseworthy social action to refuse to a visitor from abroad the best that this country can provide both in service and facilities. Let us disabuse ourselves of the idea that they are all oil sheikhs. That is far from being the case. They are quite humble, average people—I know them well.

We hear a great deal about waiting lists and queue jumping. There are long waiting lists for some conditions and no doubt at times there is some queue jumping. This, again, has been carefully considered and the 1973 White Paper concluded that though the existence of private practice may sometimes have a marginal effect on their length, the problem of waiting lists is essentially due to other causes. The White Paper presented figures to give substance to this comment. For example, it states that, with more than half-a-million National Health Service patients waiting at one time, the average number of private patients on any one day in N.H.S. hospitals is about 2,600—that is, less than 0.5 per cent. of all patients waiting for non-private treatment. I will not deluge your Lordships with figures, but they indicate that changes in the waiting lists are unrelated to changes in the number of pay beds. For example, from 1969 to 1971, when there was a small increase in the number of pay beds from 4,700 to 4,800, for the first time for many years waiting lists showed a reduction of 6 per cent. It is also stated that there are acute general hospitals with long waiting lists and few or no pay beds, and some with shorter waiting lists and a large number of pay beds. The evidence from waiting lists is certainly not an argument for ending the existence of pay bed facilities in N.H.S. hospitals.

My Lords, I do not think that I should try to drive into the ground the argument about pay beds in N.H.S. hospitals. But I think it fair to state firmly from my own experience, dating from the very beginning in 1948 of private practice in N.H.S. hospitals, that it is my solemn opinion that there are certain great and real advantages to N.H.S. hospitals which would be lost if the pay beds were phased out, and that the hospitals would lose by it. My final comment about the suggestion that there is one standard of treatment for N.H.S. hospital patients and another for private patients, is that this is so contemptible that I cannot bring myself to discuss it.

6.44 p.m.


My Lords, there has been a wide variety and a wealth of experience displayed in this debate, but I am sure all your Lordships will agree that our deliberations have been vastly enriched by the contribution of my noble friend Lord Hunt of Fawley. The noble Baroness, Lady Summerskill—who left the Chamber at almost the exact moment when I was about to speak—was critical of my noble friend Lord Aberdare for having introduced the debate at all. She quoted in her comments on the speech of the noble Lord, Lord Porrilt, two sentences from the British Medical Journal. She stopped at the second sentence, but I think your Lordships will forgive me if I read the next sentence, which says, Having said all that, however, the union's action in seeking to force private patients out of N.B.S. hospitals and its tacit support by the Secretary of State for Social Services were quite unjustifiable and represented a serious threat to the future of the Health Service. That, surely, is a justification for the debate to-day and I do not think that any of us who have heard the debate will feel that it was not very necessary, timely and right.

My Lords, I cannot speak with the authority of the noble Lords who have spoken, particularly the consultants and general practitioners. My own very modest experience, apart from being an occasional patient, is that of having been chairman of a teaching hospital for 11 years. I was appointed by Mr. Enoch Powell, my appointment was renewed by Mr. Kenneth Robinson, by Mr. Cross-man, and by Sir Keith Joseph, all of them great Ministers of Health, and Sir Keith Joseph did not in any way diminish his greatness by causing my appointment to cease. It is, of course, a modest experience but I think I can say that this idea that private patients offend is quite wrong.

I am not aware that there was any seething discontent in public wards against the existence of private beds, nor do I believe that the staff, in the years that I knew them, were disgruntled and unhappy about the fact that private patients were in the same hospital. The human race is just not as mean-minded or as envious as that, and I do not believe in it as the basis for the present action. I will come back later on to what I think are the reasons. If there were complaints, they were almost invariably from private patients who were usually complaining of the fact that a standard charge was imposed for rather unequal accommodation.

My Lords, while I do not wish to repeat the many arguments which have been expressed to-day, there are three to which I should like to refer. The first is the obvious advantage for consultants and patients in hospital in having the consultant under the same roof. I recall that when a member of my family who was a private patient was being treated by her consultant, he was called away to deal with a National Health Service patient—and quite rightly, because priority was given to the more urgent cases. Secondly, I should like to point out that very generous gifts for research sometimes come from grateful private patients, both British and foreign. In my experience alone, in the hospital I know best, three specialities have benefited to the tune of £l million in the last two years through gifts from grateful patients.

The other point, to which I have already referred briefly, is the fact that private patients provide a stimulus of interesting and varied clinical material, and—and this is the most healthy of all things—clinical material which is rather more critical of its doctors than are other patients. That is a very good thing. My wife was once a private patient at a teaching hospital. The consultant was in her room describing her symptoms to his students, when my wife had occasion to correct him on one or two of the things he said—to the unmitigated joy of his students and to the considerable and healthy discomfiture of the consultant.

My Lords, I ask whether the rather sad figures who are rebelling against the private sector realise the medical apartheid which will spring up in our system, and the fact that we shall go back to the days when there were two standards and two systems. Indeed, how far will this go? Will the National Health Service be allowed to employ consultants who have outside sessions, or will the condition of 100 per cent. service to the National Health Service be enforced? If so, the long-term effect on teaching—which has hardly been mentioned to-day—and on research will be very considerable.

My Lords, I should like from my personal experience to say a word about consultants, if noble Lords who are consultants will not listen too carefully to what I have to say. I have a tremendous admiration for them, after years of being associated with them. They are, as has been said in one speech, a "mixed bag". No doubt there are some "black sheep" among them. They can, as I know, be very tiresome and very temperamental at times; but I have always borne in mind that they bear very great responsibilities, and the kind of decision that a consultant has to make is of a kind which it falls to the lot of very few human beings to have to make. If their remuneration is considerable, it is in my view only commensurate with the kind of decisions that they have to make and the responsibilities which they have to bear which I for my part have never had to bear. I certainly think that they deserve better than the description which, unless my ears totally deceived me, I heard used on television by Mr. Clive Jenkins as "money-grubbing pirates". For myself I prefer the "money-grubbing pirates" among the consultants to a power-grubbing potentate of a trade union boss. As has been said, the whole of this campaign springs from the emotive phrase of queue-jumping ". Of course it is a privilege: so is a taxi, so is a private car, so is first-class train travel and so is an amenity bed in a hospital which, we are told, is not against socialist principles.

The noble Lord, Lord Wells-Pestell, will have the last word in this debate. If I may anticipate his argument, he has one valid argument which was also used by the noble Baroness, Lady Summerskill. This proposal was in the Labour Party Manifesto at the last Election. That is quite correct, and everybody should have been warned and nobody at all should have been surprised. I am sufficiently interested in this subject that I decided to do a little research into the past history of this proposal, and I read through the Labour Party Manifestos of the past. I got as far as 1910 in which the only interesting sentence was in large block letters; namely, "The Lords must go". But, my Lords, time marches on and your Lordships are still here. The first reference to "queue-jumping", vague and unspecific, was in 1955, in the Party Manifesto of that year. In 1959 it was stated that they would abolish all charges in the National Health Service starting with prescription charges. In 1964, they said that prescription charges will be abolished and they would take steps to combat queue-jumping—again that emotive phrase—for hospital beds. In 1966, there is a triumphant note: Prescription charges were abolished—but no mention of private practice. In 1970, there is no mention of queue-jumping or of prescription charges. Why the surprise? Because of course they have just brought back prescription charges. In 1974, relying once again on a short public memory, they promised in this order: to abolish prescription charges and to phase out private practice from the hospital service. And that was the justification for the Owen Committee and, of course the subject of our debate to-day.

So I should like the noble Lord, Lord Wells-Pestell, to explain the priorities of his Party. If the money is available in the National Health Service—and it is not, and we know it is not—why this particular choice of priority? The reason is obvious: this phasing out of private practice at this stage is a sop to Cerberus; the National Union of Public Employees has spoken and must be obeyed. I ask myself, and your Lordships should ask yourselves, whether all future priorities of the National Health Service will be dictated by union pressure. What happens if the Confederation of Health Service Employees, known as COHSE, in its turn, chooses to take the initiative and demands the phasing out of prescription charges? Will the Government yield? Will they surrender the necessary cash before they deal with the many more urgent matters in the National Health Service? My Lords, this is a move towards equality, if you wish, without too much stress on either liberty or fraternity. In the long run it is bound, as anybody who knows it must agree, to damage the standards in the National Health Service, because equality is very seldom to be equated with quality.

6.55 p.m.


My Lords, I have particular reason to intervene in this debate to-day. In the first place, I should like to add my congratulations to those of other noble Lords to my old friend Lord Hunt of Fawley, on his excellent maiden speech, and to express my hope that we shall hear him frequently in debates on medical matters in which he has had outstanding experience. It gives me all the greater pleasure as we went through Barts as students together—in fact on the same medical, surgical and obstetrical firms. How little did we think then that, 45 years later, both of us would be Members of your Lordships' House and would be taking part in a debate of such outstanding importance to our profession as that we are engaged in to-day!

At this stage of the debate, it is almost inevitable that points that one would like to make will already have been touched on by previous speakers. There are two points, though, that I should like to underline briefly, both based on my experiences at the Royal Postgraduate Medical School at Hammersmith Hospital, where I was on the staff for over 30 years.

The first is in connection with the support that private benefactions have given to medical schools and hospitals, even since the introduction of the National Health Service. I have been very much aware of this as Chairman of my school's building and research fund appeals in my later years there. Among these benefactions—though not at Hammersmith—there has been the provision of private wings at some of our great teaching hospitals, now threatened with being phased out. I am not going into the question as to whether this would involve a breach of faith with those who donated the funds that have made possible this additional bed accommodation. I would only say, though, that anything that discourages such philanthropic giving, that reduces the financial load on the Health Service—which is escalating beyond all bounds—is completely contrary to its best interests. That is precisely the effect that the present proposals to phase out pay beds would have, a point which I think the noble Lord, Lord Aberdare, and the noble Lord, Lord Hunt of Fawley, touched on.

The other point I should like to mention is the effect that the phasing out of pay beds would have in particular on that medical school and hospital I have referred to. As many of your Lordships will be aware, the Royal Postgraduate Medical School at Hammersmith Hospital has an international reputation, and is concerned with the teaching of doctors and the training of teachers, specialists and research workers in many fields—not only in diseases encountered in this country, but also in some that are only seen overseas. When doctors trained there return overseas and are faced with diseases that require highly sophisticated techniques and equipment for their treatment, they frequently refer their patients to Hammersmith. It would be unthinkable that the hospital should have to refuse to admit these patients who constitute by far the majority of fee-paying patients there. Their fees contribute materially to the Health Service and to research. With few exceptions the staff is employed full-time by the University of London and any fees collected on their behalf are used in the medical school for further research and teaching.

During the last year the sum made available in this way was no less than £70,000. Nor is it only a matter of the benefit that the school derives from fees. As other noble Lords have mentioned, occasionally a patient is extremely grateful and wishes to make a donation towards research—as, for example, the Collier building at Hammersmith, which is entirely involved in cardio-vascular research and patient care and was the early forerunner of present intensive care units in other hospitals. For these reasons the withdrawal of facilities for fee-paying patients from hospitals such as Hammersmith, with its extensive responsibilities overseas, would be disastrous for its activities. It would be particularly indefensible as the hospital has no private wing, and all patients receive exactly the same food and amenities.

In conclusion, a point the noble Lord, Lord Hunt, mentioned: a clinical colleague of mine told me that patients of his who had visited Soviet Russia and Czechoslovakia for treatment were asked to pay hospital fees in those countries; so this practice can hardly be regarded as restricted to a capitalist society. I hope that the Government will think again about their proposals to phase out pay beds, and that this debate today will materially contribute to that end.

7.0 p.m.


My Lords, I speak at the end of a long and most absorbing debate, following speeches by many of the highest professionals in the medical world. It seems unsuitable that someone like myself from the Back-Benches should be the last speaker in this debate before the Minister winds up. But I can say that for at least 22 years I have worked in and for the Health Service. I do not know whether I have contributed anything to it, not being a professional, but I have certainly tried my best to make the lot of both patients and staff a better one and more comfortable.

I am making this little speech now because I begged, implored and supported my noble friend Lord Aberdare to put down this Question. I think he was dubious of doing so at first, but I am very glad he did it. I feel that I perhaps urged him on to take this step. I hope the noble Baroness, Lady Lee of Asheridge, will forgive me, but I was told by two consultant friends of mine that her husband, the late, famous Aneurin Bevan (whom I should like to call a personal friend), said to these two consultants at the inception of the National Health Service, "I have got to keep you bastards in the Service". I think it is obvious that the consultants are the lynch-pin of the National Health Service; they take the ultimate responsibility for the treatment of the patient and the training of the registrars and other hospital medical officers who look to them for guidance. If we cannot have them there we shall lose a great deal of the National Health Service. I am very much afraid that a great many of them, as has been said several times, will probably give up the National Health Service and that we shall find another health service growing up alongside. That would be a terrible loss to the National Health Service and I beg and implore the Government to think again before they take this step.

I sympathise with the nurses, theatre and laboratory technicians, and others, who receive no additional remuneration when they are serving private patients. But on the other hand I feel that it is vital for the consultants to have the private patients and, if necessary, put them into National Health Service beds. If this privilege is removed from the consultants, I feel the same as Mr. Bevan, who was clearly convinced that the Health Service will lose a large number of them. It will suffer irreparable damage from the loss of their skills, and the next step, as I have said, would be the possibility of starting up another private health service. This would be an evil step for the National Health Service. A private health service would draw on the same residue of skills and thus drain the National Health Service of its consultants, nursing staff, technicians and other ancillary staff. They would obviously be paying more realistic salaries than the National Health Service.

There are a great number of people all over the world—and this has been said several times, but I happen to know several from the Middle and Far East—who come here especially for our Health Service. They have heard of it and are prepared to pay the high fees for treatment. Particularly with people from the Middle East there come a huge retinue of family and servants, all of whom have to be put up in hotels throughout the country or in the capital, and that means that we should lose the extra "export" benefit which we get at this moment.

I do not know whether your Lordships have read the article that appeared in the Daily Telegraph of last Friday from a consultant physician from Charing Cross Hospital. I should like to quote one small paragraph. He writes, referring to the medical members of the National Union of Public Employees, that they were: … asking for a pay rise one week after their union was demanding the closure of the private ward at Charing Cross Hospital. He says: This ward brings into the hospital coffers around £1 million a year to help pay for the running costs of under £10 million for the whole hospital, including the technicians' pay. Forty beds are subsidising the running of 800 beds. This money is quite separate from any fees paid to consultants, fees which mainly go, I imagine, knowing the consultants, in taxes which help to run the National Health Service. I have also had the experience not only of seeing and working in hospitals in this country, but of visiting hospitals in countries all over the world. I know how much they admire our standards; and I have a feeling that if we do not keep the standards at the level they are now, we shall not get these people coming to us to cure their illnesses and operations. I have already pointed out that the people who come from abroad can make a valuable contribution. I have made some inquiries from BUPA, P.P.P. and other similar bodies. I find that they insure large numbers of organisations under group schemes. I am informed that a large percentage of those insured with BUPA are insured through these sources. P.P.P. told me that about 25 per cent. of their members are companies covering their employees in this manner. A number of individuals also take out insurance against illness—one or two noble Lords have said that they themselves are insured, as are their families.

We have not yet arrived at the moment when we are not allowed to spend our own money; if we prefer to spend this money on our health—and at my age I need it because I am always being ill, falling and going into hospital—it is better to do that than spend it on cigarettes, betting, bingo, et cetera. I should like to repeat that we have not yet arrived at the moment when we are not allowed to spend our own money as we like.

I am convinced from what I have seen that there is no difference in the treatment given to a private patient from that given to a National Health patient—and I can assure you, I have seen a great many hospitals. In a ward a patient gets his operation, his specialist attention, nursing, drugs, X-ray, theatre charges, anaesthetics, et cetera, for just his National Health insurance contributions. In a private room patients pay for everything, although the patient is already paying National Health stamps and is also probably paying much higher taxes than the patient who simply goes in as a National Health patient. I do not think it upsets the nurses—and this is certainly not so in the hospitals I have known. They do not seem to mind looking after private patients. It seems to me most peculiar that a domestic worker at Charing Cross should have made such a fuss. I cannot see the difference between cleaning out a ward and cleaning out a private patient's bedroom; it seems to me exactly the same.

The trouble with the National Health Service is that it is suffering a political crisis. Any of those who read Medical World, in particular the July edition, will find that this is true. It is not true to say that the Conservative Party would increase private practice—I am quite certain it would not—and the present Government oppose it. Both Parties really are anxious that we should have the best Health Service in the world, and having travelled extensively all over Europe and America and the Near and Far East I can say that our Health Service is the admiration of all those countries.

I was speaking last week to a friend of mine, a leading surgeon. He is probably one of the world's experts on gall bladders. He is faced with the situation now where he has patients who should he operated on straight away. But as the radiographers have struck he has to make the decisions whether to operate on these people without X-rays, in which case they might die, or not to operate at all. in which case also they might die.

In conclusion, I would emphasise that the real danger to the Health Service is lack of money, which a succession of Governments have withheld from the hospitals and their staffs. All the Governments I have known have come into office with great ideas of how much they are going to spend on the Health Service and in particular on the mentally handicapped, the psychiatric and the geriatric patients. Alas! other things intervene and the Health Service comes very low in the list of priorities. I repeat, my Lords, that the abolition of pay beds will do nothing to remedy the real reason for the near collapse of the Health Service. It is merely that we do not have enough money to run our hospitals.


My Lords, before the noble Lady sits down—I did not want to interrupt her—I am quite sure that she did not want to give the impression that Aneurin Bevan regarded pay beds as a desirable permanent feature of the Health Service. He said, and wrote, very clearly that he regarded this as a defect, as a passing phase that had to be got rid of.


My Lords, may I say to the noble Baroness that he said this at the beginning. He got the consultants in, so that he was all right. Hg can then later think differently, and think he could have improved it.


My Lords, it was perhaps inevitable because of the experience and knowledge of Health Service matters of those who have taken part, that this debate would range over a wide field. I am particularly grateful to my noble friend Lady Lee of Asheridge and to my noble friend Lady Summerskill, since what they have said makes me feel a little superfluous because, I am happy to say, they have answered quite a number of matters. I am grateful to the noble Lord, Lord Platt, for his balanced view of what is facing us today. I would say to the noble Lady, Lady Ruthven of Freeland, that she is doing the late "Nye" Bevan a great injustice. I knew him, although not as well as many people in this House. He was not the kind of man whose integrity would allow him to agree to something and then to go back on it subsequently. If there is one thing for which we hold him in deep affection it is the courage he always had of his convictions and the integrity that was behind it. It was a great loss, not only to the Socialist movement of this country but to the country as a whole, when he died many years before we had thought he would do.

I want also to make clear that I myself was connected with the Socialist Medical Association almost forty years ago, and believe I was on the first committee of that organisation when it was considering the possibility of ultimately establishing a National Health Service in this country. So I speak with some conviction on this matter. My brief, which is mainly my own, is written out of that conviction. This is not a debate about private practice, although several times the whole question of private practice has been brought in. Private practice is not threatened. What we are concerned with to-night is the question of pay beds. This is a matter which has been exercising the minds of many of us on this side of the House and in the movement which I represented for many years. I would, before continuing, extend my congratulations (it always seems a little impertinent to do so) to the noble Lord, Lord Hunt of Fawley, for his contribution. While he and I would not agree on a number of matters, he discharged his responsibility to the House magnificently by making a balanced contribution, which I know is not easy for one in his position in a debate of this kind.

The Question of the noble Lord, Lord Aberdare, relates only to pay beds in the National Health Service and the desirability of retaining them. It is this matter I want to deal with in the main, although I hope I shall be able to answer some of the questions which have been raised to-night; noble Lords and noble Ladies will, I hope, forgive me if time does not permit me to do so in full. We on this side of the House are grateful to the noble Lord, Lord Aberdare, for raising this matter at this particular time. There may be a method in his raising it. It could easily be a kind of pre-Election matter which may be of some importance during the Election. But whatever his reason for raising it, it gives me the opportunity of stating clearly our position on the subject of the Question.

Let me say at the outset that we are not going to agree on this subject. There has always been a deep divide between Members on this side of the House and noble Lords on that side with regard to this particular matter. If a moral situation is a political one, then this is a political question. But we do not see it as a political question—only in respect of the fact that the two major political Parties take different sides with regard to it.

When the National Health Service was established in 1948 the majority of specialists accepted part-time or full-time appointments in it. The National Health Service Act 1946 empowered the Minister of Health to set aside special accommodation for private patients and to allow doctors on the staffs of hospitals to treat private patients in those hospitals. In this way some private facilities existed before the appointed day, and those arrangements were carried over into the new Service. Part-time consultants had the right to provide medical care for private patients whether in the special accommodation set aside in the National Health Service hospitals or outside the National Health Service altogether.

The charges to be paid to the hospital authority by private patients in National Health Service hospitals, and maximum fees to be charged by consultants to those patients, were laid down by regulations. These arrangements were modified by the Health Services and Public Health Act 1968. Under this Act hospitals authorised to take private patients no longer had to set aside special accommodation for them but could admit them to any suitable accommodation in the hospital so long as the total number undergoing treatment did not exceed the number of beds authorised. At the same time, the power to control the maximum fees charged by consultants to private patients in National Health Service hospitals was abolished. As part of the changes, the number of pay beds in the National Health Service hospitals was reviewed and reduced in England from 5,672 to 4,310. In other words, it was reduced by about 24 per cent. The number of pay beds currently authorised in England is 4,559 and 68 beds in Wales. These facilities for private patients in National Health Service hospitals have continued since the inception of the National Health Service, but I must emphasise that the Secretary of State is under no statutory obligation to provide them. Her powers are purely permissive.

My Lords, while I am on this matter may I say to the noble Lord, Lord Brock, that if he had given me notice that he was going to (I use the word advisedly) attack my right honourable friend the Secretary of State for accepting private patient facilities I should have been in a position to give him the exact information and the facts relating to it. The facts were these. At a time—


My Lords, the noble Lord is mistaken. I did not attack the Secretary of State. I congratulated her on her wisdom.


My Lords, then let us talk about her wisdom. My right honourable friend, who was a Minister at the time, had been abroad and had returned to this country in considerable pain as the result of sinus trouble. She had out-patient treatment in a well-known teaching hospital in this country. The situation became more acute. She was due to leave this country on another visit within a matter of days and she was advised by the consultant—whom, as I have said, she consulted as an out-patient in that hospital—that she needed an operation. She went in for that operation, and if my memory serves me correctly she was advised that it could only be done by going in as a private patient. It was also pointed out to her that as she was a Cabinet Minister and that she would be dealing with State documents, it was desirable that she should go in. However, it was not her first choice. I have known my right honourable friend for a good many years and my recollection is that since its inception she has always used the National Health Service. On this occasion there were particularly good reasons for my right honourable friend doing what she did. She has never made a secret of it.

As I tried to say earlier on, the question which is now before your Lordships' House highlights a fundamental difference of opinion between the Government and the Party of the noble Lords opposite. To those of us who sit on this side of the House, pay beds represent a serious and unacceptable defect in the National Health Service and it is a situation which we are not prepared to tolerate any longer than is necessary. In fact, for many of us it has gone on for too long. The noble Earl, Lord Fortescue, said that pay beds do no harm to hospitals and the question in the minds of certain noble Lords is whether or not queue-jumping is important. Many of us think that it is important.

Many of us feel that the real test, the real need, should be what a person needs to have done at a particular time and not what he can afford to pay for and get done ahead of everybody else. The time must come, and come quickly, when the real test must be medical need and not the ability financially to buy privilege over the needs of people who may be in greater need of out-patient treatment. If I may put it another way, in the future we must not permit money to speak louder than need and that is precisely what is happening at the present moment.


My Lords, I am trying to follow very closely what the noble Lord is saying, but is he not now attacking the whole principle of private practice? So far as queue jumping is concerned, what is the difference if a person can get private practice treatment in a clinic rather than in a hospital? It is the same thing.


My Lords, we are not attacking private practice. What we are saying is that if a section of the community wants these facilities, then those who want them must provide them. They cannot and should not be provided within the framework of the National Health Service. There are a number of private hospitals. There may have to be many more private hospitals. We are not objecting to that. If people want to pay for specialist help, for specialist treatment and for specialist facilities in the kind of environment which they consider is important, we have no objection at all. Let them pay for it, but let them obtain that treatment outside the National Health Service.


My Lords, the noble Lord has referred to a difference of opinion between his Party and those on the opposite side of the House. Of the seven doctors who have spoken to-day, four of them sit on the Cross Benches. We are not "the opposite side of the House". Of the two who sit on the Government Benches, one spoke in favour of pay beds.


My Lords, I was talking, broadly speaking, of the views held on both sides of the House. My noble friend Baroness Lee referred to a statement which was made by Aneurin Bevan, and I think that it is worth while my reading exactly what he said in his own words. The essence of a satisfactory Health Service is that the rich and the poor are treated alike, that poverty is not a disability and wealth is not an advantage". In my view, and in the view of the Government, queue jumping cannot he tolerated much longer and pay beds have to be eliminated from the National Health Service.

The noble Lord, Lord Aberdare, drew attention to the amount of money brought in as a result of pay beds, and he mentioned the figure of £17 million. I think that is the figure which is anticilated in the next year, 1974–75. The latest figure which I have been able to obtain is £121 million. Of this amount, we have no idea how much it costs the National Health Service to recover what is due to it. Not all private patients pay their bills, and a good deal of costly time is spent in pursuing defaulters. So far as we can tell, in 1972 and 1973 bad debts and claims abandoned amounted to over £74,000.


Out of how much, my Lords?


My Lords, we got in something like £12½ million.


My Lords, it is not a big percentage.


My Lords, it is not a question of whether it is a big percentage. It is a question of whether somebody who wants privileged treatment will be honest and pay for it. It is as simple as that. I was a member of the Court of Governors of the Middlesex Hospital for some years. I sat on the Finance Committee, and every time we met we had a list of people who had bilked the hospital, the surgeon and the physician—


My Lords, I do not want to give the noble Lord the impression that I am in any way thinking that bad debts should be tolerated. But what I do not want the noble Lord to do is to give the impression that a large proportion of private patients do not pay their bills.


My Lords, I do not think it really matters whether it is a large proportion or a small proportion. There is surely a principle involved here.


Certainly, my Lords.


I think noble Lords ought to know this, and I venture to suggest that there is not a noble Lord on the opposite side of the House who really knew that. What I am saying is that we do not know how much it costs the National Health Service to recover this money by legal means and by other means.

In his Question, the noble Lord, Lord Aberdare, stated that to phase out pay beds would result in a heavier burden on the taxpayer and suggested that it would result in a less efficient service to the National Health Service patient. The loss of revenue from private patients would not be very significant to the taxpayer—and I am sure that the noble Lord, Lord Aberdare, would agree with me on that—and would be more than offset by the fact that we would acquire over 4,000 extra beds for the National Health Service. This is equivalent to four 1,000-bed hospitals. which at to-day's prices would cost about £80 million to build and equip. So here we have a small group of privileged people using what amounts to something like £80 million worth of capital expenditure. Although I am sure some noble Lords opposite will tell me that this is taken into account when assessing the cost of a bed in the private wing, it is almost impossible accurately to assess the economic level when one considers capital expenditure of that kind.


My Lords, I should like to make one small point here. Under the "swap" arrangements between the private sector and the National Health Service, I think the noble Lord will agree that there are approximately 3,800 beds which are lent to the National Health Service. So it is very nearly an equivalent state.


My Lords, it is not equivalent, because they are loaned to the National Health Service which uses those beds for ordinary National Health Service patients and not for paying patients. Again, the principle is entirely different. The beds are used by people in need and they are not there simply because they can afford to pay for them. They are there as pert of their rights as citizens of this country, and these 4,000 beds to which I referred a moment ago would enable us to provide earlier in-patient treatment for those waiting for a hospital bed.


My Lords, I am sorry to interrupt the noble Lord again, but how can he talk about 4,000 private beds and suggest that those 4,000 patients would either vanish and not need treatment, or alternatively that there are available at this moment alternative private facilities to take them? They are still sick people and many of them would come in and take non-paying beds.


My Lords, I do not deny this. What I am saying is that if noble Lords opposite want to maintain the pay bed system, they must take it to the logical conclusion and provide private hospitals into which these people can go. We are not opposed to that, but noble Lords cannot have it both ways. They cannot have a free National Health Service for the people of this country and then continue—as we have continued to do for far too long—to provide a sector where, because people can pay, they can go in over the heads of other people. By all means provide separate facilities. We are not against that at all, and the sooner it is done the better.


My Lords, we are having great fun and I am enjoying this debate, but the noble Lord has not answered the point made by my noble friend Lord Sandys, which is a point I made in my speech. I specifically asked how many privately owned beds are occupied by National Health Service patients under contract. Is it true that there are 3,500 private beds which are under contract to the National Health Service and occupied by National Health Service patients? If there are, and if the public and private sectors are to be separated, these beds will be taken back into the private sector and there will not be 4,000 extra beds. There will be only 1,000.


My Lords, the noble Lord is quite right. In fact, if I can trust my memory the figure is 3,501 to be precise. But the fact remains that this is part of the facilities provided by a free National Health Service. Many of the beds are not used regularly. We pay only for the weeks in which the beds are in use, and many of these beds are not used week after week, month after month, and it would not pose a serious threat if the pay beds were to disappear into some other field. We must face the fact that there are over 500,000 ordinary people—people without money, people who cannot afford privilege and special treatment—at this moment waiting for a hospital bed. Do noble Lords realise that there are over 500,000 people waiting to go into hospital?

In a community that is supposed to be a caring community—because this is what everybody in your Lordships' House talks about from time to time, and feels passionately about—how can we go on maintaining a system that allows people preferential treatment because they can pay for it? Although the Government are firmly committed to phasing out private practice from National Health Service hospitals, it is their intention to proceed in an orderly way and after the fullest discussion with those directly involved. Obviously, we are not suddenly going to close down. Of course we want to take into account the needs of people who are in pay beds and this may well be a long-term operation. But because it may be long-term, that does not mean it is something that we shall allow to continue by default.

Something must be done to remedy this situation and as noble Lords know, a Joint Working Party with the medical profession has been set up under the chairman ship of the Minister of State for Health, Dr. David Owen, to consider the terms upon which the medical and dental staff are employed in the National Health Service, systems of remuneration and arrangements for private practice. It has been agreed that the Working Party will speed their work and they aim to report in November of this year. The Joint Working Party will be considering generally the terms of service upon which senior hospital medical and dental staff are employed, and the Government will consider and will base detailed proposals for the phasing-out of pay beds on the report of the Working Party. Meanwhile, although the Secretary of State has discretionary power to reduce or withdraw the authorisation of pay beds, she made it quite clear in another place recently that she has no intention of making any arbitrary reduction in the present allocation of pay beds while awaiting the report of the Working Party.

Furthermore, I must remind your Lordships that the Government have no intention, as has been suggested by a number of noble Lords to-night, of trying to abolish private medical practice. This is really a red herring that a number of noble Lords have introduced. It is not the intention of the Government. We conceive this working alongside the National Health Service. Private patients, whatever their nationality, who wish to obtain medical treatment in this country will be able to continue to do so, but they will have to seek their treatment in private hospitals and clinics. This seems to me very reasonable.

The Government are concerned at all times to safeguard the interests of patients in particular, and we hope, as a result of the discussions now in progress, that agreement will be reached with the medical profession which will result in more consultants accepting whole-time contracts within the National Health Service. We realise that the whole question of payment has to be considered. But to take a tilt at the National Health Service, as I think the noble Lord, Lord Porritt, did in a most extraordinary speech—I was staggered how ill-informed he was, notwithstanding his knowledge and his experience of the National Health Service—and to say to this House that what the Government are trying to do is to nationalise the medical profession, really is such nonsense. Nothing that the Government have said, nothing that the Government have done has ever been designed, and nor has it in effect happened, to affect the doctor-patient relationship. When people like the noble Lord, Lord Porritt, pour contempt and scorn on the National Health Service, noble Lords who think as he apparently does should ask themselves what the position financially would be of a good many consultants, and in particular a vast army of G.P.s, but for the National Health Service. I was going to say that the great architect, Nye Bevan, who introduced this concept into this country, did one of the best things that has ever been done for the medical profession of this country, and at least those working in the grass roots, the general practitioners, by and large acknowledge it.

My Lords, I must remind your Lordships that the purpose of the National Health Service is provision for the people of this country of a basically free service for the prevention, diagnosis and treatment of illness. This is the basic and fundamental purpose of it—free services for the prevention, diagnosis and treatment of illness for the people of this country. Some noble Lords have taken exception to members of the Health Service, to nurses, suddenly becoming militant, as they did some time ago in Charing Cross Hospital. A number of consultants talked about the harm it was doing to patients. But, a few days later, some consultants had no compunction in talking about withdrawing their services from the National Health Service. What about this concern for the patients?

If the people in a particular industry cannot make some comment as to what they know, feel and see, then there is no hope for anything, because in the last analysis the people who are best able to advise are the people who are engaged in it. I accept that they are also members of the medical profession. But I do not believe that the vast majority of the consultants are opposed to the National Health Service. We have been told that the clinics available to-day leave much to be desired. When one thinks that it costs something like £20 million to build a thousand-bed hospital, I am beginning to wonder how many of these queue-jumpers will be able to afford private treatment.

Where facilities are insufficient to meet the demands, whether because of shortages of qualified staff or because the advances of medical science have provided new therapeutic techniques which can be developed only slowly, it is surely right that facilities should be made available solely on the basis of medical priority. Surely this must always be the yardstick. As I have said, we believe that there is no longer any place for private National Health facilities, or for according priority on the basis of ability to pay. I am almost tempted to say it would be immoral to continue to do so. The power to buy scarce National Health resources in advance of the National Health Service patients who need them inevitably involves a lesser service to those patients. Therefore, private medicine must be confined to its own sphere so that the National Health Service can be developed free of this encumbrance and devoted entirely to the treatment and health of those who most need its services.

My Lords, there is no point of communication on this matter between those of us on this side and noble Lords on the other side. We feel it to be of supreme importance to the community that we should maintain a free National Health Service. Despite what the noble Lord, Lord Porritt, said, I believe it to be a reasonably comprehensive one. I have spent a substantial part of my life in hospitals as an in-patient, always as a National Health patient. I have been most grateful, and shall remain grateful for the rest of my life, for the skill that I have met. I have been totally paralysed in my time, and the fact that I can stand here unaided perhaps is some tribute to the care and attention that I have received. But the fact remains that this should be the right of everybody. While we have some of the resources of our National Health Service serving people who can pay to have those services, an equal number of people are denied them.


My Lords, before the noble Lord sits down, may I ask a question? I must apologise for the fact that I have been busy all day so was not able to be in the Chamber for the whole of the debate. So far as the Government see the scheme of things for the future, where do the people of many colours and creeds, and all of paying capacity and who use insurance companies like BUPA or P.P.P., come into it? I must apologise if this has been answered before. As we have no Hansard I have no method of finding out.


My Lords, if I may say to the noble Baroness, Lady Macleod of Borve, I do not think that this has been answered. But quite clearly, I should have thought that a good many of these concerns are in a position to provide a private hospital, as some do. I think BUPA is one, though I may be wrong.


Yes, they do.


I thank the noble Lord. They will have to go on providing more. I believe one noble Lord took exception to the fact that people who use private facilities are contributing to taxes and paying the National Health insurance and so on. This seems to me to be a right and proper thing to do. We are supposed to be the kind of community where we are concerned about the wellbeing of people less fortunately placed than ourselves. We all should go on making this contribution. If we want to act this out, we must do so at our own expense.