HL Deb 03 December 1975 vol 366 cc599-620

2.42 p.m.

Lord ABERDARE rose to draw attention to the state of the National Health Service; and to move for Papers. The noble Lord said: My Lords, we are debating the state of the National Health Service when it is facing a crisis more dangerous—and I mean more dangerous for patients—than ever before in its history. Nevertheless, I hope that this debate will not be over-gloomy and will take account of the good as well as the bad things, for whatever the seriousness of the situation, on the face of it the National Health Service is still made up for the most part of unselfish, dedicated and highly trained people and I cannot believe that, with good will, we shall not be able to find a solution to our present difficulties. It is no good disguising the fact, however, that a good deal of gloom exists in the Service and, if we take too pessimistic a view or are too critical, this will merely add to the general depression and will do nothing to help us overcome it. I should like to try to analyse the reasons for the present difficulties and I hope to be as constructive as possible in this situation.

The first reason is the present economic state of the country. The sort of inflation we have experienced recently is particularly damaging to a Service which employs so many people. Costs have risen astronomically and vastly increased revenue expenditure has necessarily put a brake on capital development. I certainly do not blame the Government for the worldwide economic recession, but I must say that I hold them responsible for allowing inflation to get out of control on a vastly greater scale than in any other country before going back on their own words and introducing wage restraint.

The second reason for the present difficulties is that the medical profession has lost confidence in the Government. I do not want to be unfair. I simply want to be factual. I fully acknowledge that the Government can claim considerable credit for some of their actions in the health field. Not only the doctors but especially, and deservedly, the nurses have had considerable increases in salary. The Government have finally introduced a free family planning service which all will applaud if it does anything to reduce the number of abortions. They have also continued with a considerable health centre building programme. But they have, to put it mildly, lost the confidence of the majority of doctors, partly as a result of their mishandling of negotiations for the new contracts and partly as a result of their pig-headed insistence on the abolition of pay beds in hospitals.

So far as the present emergency situation with regard to the doctors is concerned, I should like to make it clear at once that those of us who sit on these Benches will not support any action that contravenes the Government's pay policy. I cannot forbear from commenting that the history of the last two years would have been very different if the Labour Party had shown the same regard for the national interest at the time of the miners' strike in 1974. However, there it is. In the national interest, we support the Government in their policy for restraint in pay awards. Nor do we approve in principle of industrial action by any section of the workers in the National Health Service. However, having said that, it is impossible for us not to sympathise with the feeling of the doctors in their dispute with the Government.

First, let us take the junior hospital doctors. They agreed on a new contract with the Government in September 1974. They subsequently agreed to the postponement of the implementation of the contract from 1st July to 1st October 1975, at a time when the Prime Minister, the Secretary of State and every member of the Government were all assuring the country that there would be no wages freeze and no statutory control of salaries. Now they find they are caught by the Government's "U-turn", and, understandably, they are furious. Moreover, as it was initially proposed, the new contract meant that some junior doctors would have been worse off than at present. Admittedly, this was an anomaly which could have been corrected by the Government's proposal to implement the new contract only on change of job. However, this would still have meant that a junior doctor moving into a new post might well have found that he was to receive a salary which was several hundreds, if not thousands, of pounds less than that of the previous holder of the post.

What is to be done in these circumstances? One point seems to me to he of paramount importance, in view of the fact that the junior doctors themselves accept that their settlement must be within the pay policy; that is, to establish how much in total has been paid annually to junior hospital doctors in extra duty allowance on their present contract and, therefore, how much is available within the pay policy to he redistributed on their new contract in accord with the pay policy. The Government say that this is a sum of £12 million. The Junior Hospital Doctors' Association claims to have figures to show that it is much greater. Surely it is of the first importance that this figure should be independently agreed. I ask the noble Lord who is to reply for the Government whether he will kindly tell us what is the exact position now. It is very complicated and difficult to follow—complicated not least by the fact that the junior hospital doctors themselves, as well as being represented through the BMA on the Hospital Junior Staffs Committee, also have an independent association of their own, the Junior Hospital Doctors' Association.

As I understand it, the Office of Manpower Economics is to enter into technical discussions with the BMA, and I believe also that the Junior Hospital Doctors' Association has been invited to put its evidence to the Department of Health and Social Security. If this is correct, then I should welcome both these moves. Given an independent assessment of the figures, then certainly so far as we are concerned we would accept these figures as the global sum available for redistribution in accordance with the pay restraint policy.

Quite apart from the dispute with the junior hospital doctors, the Government are also in dispute with the medical profession as a whole—consultants, general practitioners and junior doctors —over the question of pay beds in National Health Service hospitals. We debated the matter of pay beds on 29th July last and I do not intend to go once again into all the pros and cons. But I simply draw your Lordships' attention to the fact that on 25th November last all the major medical bodies in this country signed a memorandum rejecting the Government's proposals to extend control of the independent medical sector and to separate independent medical practice from the National Health Service. The signatures to that memorandum included those of all the Royal Colleges, the Faculties of Anaesthetists, Community Medicine and Dental Surgery, the BMA Council (including representatives of various bodies that subscribe to the Council), the British Dental Association, the Hospital Consultants' and Specialists' Association, and the Junior Hospital Doctors' Association. I shall quote only one paragraph from the memorandum which sums up the whole of the argument. This is it: The Consultative Document proposals are unsound and undesirable, and profoundly damaging to the community, the National Health Service and to the professions, and constitute a threat to fundamental freedoms ".

It is this threat to freedom that is uppermost in the doctors' minds. Without the right to practise privately the doctors become whole-time State employees; and it is important to remember a fact that is often forgotten in criticising doctors who are paid for private practice in National Health Service hospitals—that they give up something in the region of £2,000 a year of their National Health Service salaries for that privilege. It is not good enough to say that private practice is not being abolished but simply separated. The fact is that in many parts of the country no private facilities exist and the only private beds available to doctors are in fact in National Health Service hospitals. The Government go further still and tell us that any attempt to provide extra private facilities will be subject to licensing, not only on grounds of quality but also on grounds that the projected building would compete with the National Health Service.

No one questions the right of the Secretary of State to license private institutions on grounds of quality, hut to refuse permission for a private hospital or nursing home for any other reason—other than the normal planning reasons—is quite unacceptable and to my mind is a monstrous interference with individual freedom. At a time when the National Health Service faces great financial difficulties and a considerable crisis of confidence, why on earth choose this moment to pursue so divisive and controversial a proposal? Having agreed to set up a Royal Commission, why not leave it to that Commission to make an unbiased assessment of the problem? To do this would go a very long way indeed to regain the confidence of the medical profession. I beg the Government to take an initiative. I believe that this initiative must come from the Prime Minister himself. There is still any amount of good will to be built on throughout the National Health Service, provided that these problems are faced realistically, and I am quite sure that a gesture on the part of the Prime Minister to take the steam out of this issue and allow for further discussion to take place would be welcomed wholeheartedly by the doctors.

Therefore I am very glad to know that the meeting that took place this morning involving the Prime Minister, the Secretary of State and the doctors was acknowledged by both sides to have been valuable and that a further meeting is to be arranged shortly. I can only hope that these talks will proceed swiftly so that there can be a quick end to the present crisis. I also hope that the talks will result in an agreement that is satisfactory to both the doctors and the Government.

I do not want to say any more about the current disputes in the National Health Service. However, I should like to draw attention to a less controversial but perhaps in the long run a more important matter; that is, the progress of reorganisation following the 1973 Act. The first point I should make is that the general financial situation has made things far more difficult than they otherwise would have been. A major reorganisation of this character is difficult enough at any time, but if it has to be carried through at a time of financial stringency it creates great difficulties. I wish to speak on only two aspects of the reorganisation that have attracted a good deal of criticism: first, the question of the number of tiers of management; and, secondly, the alleged growth in administration.

First of all, with regard to tiers, it is said that there are too many tiers; that to have a district, and an area and a region, before reaching the Department at the top of the tree, is overburdening and top heavy. I do not believe that any of us would doubt the need for the lowest tier—the district. This has always been the basis of planning within the Hospital Service, founded on the district general hospital, and serving a population of about a quarter of a million people. I cannot believe that it would be sensible to work on a larger lower tier than that. Therefore we are left with the two other tiers: the Area and the Region. Personally I have a great belief in the Region. Were it not for a regional authority, the Department would necessarily have to increase its staff in order to administer 90 Area Health Authorities, and this would inevitably mean a greater degree of centralisation and an increased number of civil servants. Instead of Regional Boards we should undoubtedly have regional offices of the Department.

There is no doubt at all that there will always be hard decisions to take in respect of priorities in spending, and personally I think that it is greatly preferable that, where possible, these should be taken by Regional Boards, rather than by the Department. This seems to be in line with the present tendency towards devolution of decision-making. Moreover, the building programme has always been conducted at regional level, and there are several specialised facilities which are best provided on a regional basis. Certainly in my view the organisation before 1973 of Regions and districts functioned fairly well, and I believe that we should be foolish to consider doing away with the Regional Board.

I must confess with hindsight that I have more doubts about the Area tier. It has brought into existence a whole new tier of authority, with all its attendant panoply of officials, committees, paper work and offices. In some cases, where for example there are only two districts in the area, there is barely enough work for officials at Area level, without their unnecessarily interfering with the responsibilities of the district; and so far as I can see the ideal seems to be the one district area, and it is towards this ideal that I believe we should work.

At the same time, the justification for the Area is as good today as it was originally. It allows for the closest possible collaboration between health and social services in future planning and in current administration. The present shortage of money for the Health Service, and the future prospect that there never will be enough money to meet all demands, means that it is essential to make the best possible use of resources. This inevitably leads one to the conclusion that we shall have to expand our provision for community care rather than the more expensive provision of hospital beds; if that is so, then the need for the closest collaboration between the Health Service and the social services remains a very powerful argument for the Area Health Authority.

Where I believe the system is not working as well as it should is in the delegation of authority downwards. Within agreed budgets, the Area Health Authority must delegate authority to its districts so that the minimum of decisions have to be referred back. The same goes for the Region and. indeed, for the Department in its dealings with the Regions. Of course, the Department must remain responsible for national policy, but it should not be involved in management decisions. Yet I fear that the number of civil servants employed today on the health side of the Department has greatly increased, and I wonder whether the noble Lord could tell us how the present number compares with the number a year ago, in December 1973.

But, most of all, I hope the present system will be allowed to settle down without any immediate further change. I am quite sure that it would now be wrong to alter the system, or to make any further major changes, and certainly such research as I have been able to do in the last few days in preparing for this debate has indicated that this is a widely-held view within the Service. After all, a Royal Commission is to be set up, and I am sure it would be wisest to leave it to that body to assess the situation in the light of experience. I hope that the noble Lord will he able to assure us that there is no intention of further change in the organisation until the Royal Commission has reported.

Finally, my Lords, I should like to say a word about administration in the National Health Service. There has been much criticism, and it is said that the reorganised Service is over-administered. I believe that in saying this we use the word "administration" too lightly, and in so doing we greatly malign that member of the district management team who is called the district administrator, and his colleagues, both in individual hospitals and at Area and Region. At a time when morale is so important, this is far from helpful. In fact, I believe we owe a great debt of gratitude to the administrators in the National Health Service. Despite the very rushed time-table of reorganisation, despite the fact that they were caught by the statutory pay policy while their colleagues in local government had escaped and despite all the difficulties of a reshuffle of jobs the work of hospitals, health centres, clinics and offices went on throughout the reorganisation period as if nothing had happened. This, indeed, was a great feat, and it was not accomplished without a very great deal of hard work. We must not forget that at the same time the National Health Service was taking on a considerable extra burden in assimilating the local health departments of the local authorities.

When we talk loosely of administrative delay, much of it arises from increased provision for consultation. It was one of the key points insisted upon by doctors, nurses, trade unions, politicians and others that there should be proper consultation throughout the reorganised Service, and appropriate bodies have been established at all levels. No wonder, then, that a decision sometimes takes a long time to be made. Even a fairly simple decision by the district administrator may require that he should consult with his colleagues on the district management team, probably with other district officers who are not on the team, with the professional advisory committees, with the staff commitees that represent the trade unions and with, perhaps, the community health council representing the general public. Moreover, should the decision be one which requires authority from the Area Health Authority, then in addition he has to consult the Area team of officers, the Area Health Authority and, may be, even the joint consultative committee with the local authority. If we want consultation, it necessarily involves delay; it is no good doctors complaining that they are being involved in too much committee work if they really wish to be consulted on the management of the Service.

There is another form of administration also loosely included in the general concept; that is, administration within a profession. This has undoubtedly grown and, I think, needs careful monitoring. The formation of an Area tier has given rise to a number of new appointments at that level, as well as at the district and regional levels, in professions such as catering, engineering, building and domestic services, as well as the health professions. Often this comes about as a result of pressure from the staff concerned for a career structure, but it is a development that needs careful control if the Service is not to be over-administered. Moreover, the adminstrator also now has the unenviable new task of coping with extremists who seek to disrupt the Service for political ends. This perhaps is more especially true in London, where the National Health Service has undoubtedly been infiltrated by extreme Left-Wing elements. There really are Reds under hospital beds in London, and this again makes an administrator's life more difficult. Coupled with the difficulty of trying to cope with what are now thought of as more orthodox forms of industrial action which unfortunately have crept into the hospitals, I think we should acknowledge that we owe a great deal to the administrators in the National Health Service.

Despite all the difficulties, the National Health Service has at least maintained its level of service, even if the benefits of reorganisation have not had time to emerge. Some aspects of it have shown signs of promise; for example, the district management team, which is proving effective in co-ordinated decision-making, the integration of general practitioners, teaching hospitals and social services in joint planning, and the merging of community and hospital nursing services. But one of the most imaginative ideas for the new National Health Service, the health care planning team, has not yet been brought into being, and there is a need for guidelines from the Department in order to enable these teams to be set up. I wonder whether the noble Lord could tell us why there is this delay and whether we could not go ahead with the formation of health care planning teams, which have so much to offer in joint planning. But above all, my Lords, what the National Health Service needs most today is a period of stability to allow it to function without interference from outside and to develop its services with one single aim—the good health of the whole community. I beg to move for Papers.

3.9 p.m.


My Lords, in view of the fact that the noble Lord, Lord Aberdare, informed your Lordships that my right honourable friend the Prime Minister and my right honourable friend the Secretary of State for Social Services this morning met leaders of the medical profession, that both sides feel that the discussions have served some useful purpose and that they will be meeting again, I want to be rather circumspect about what I say this afternoon. Furthermore, bearing in mind that the noble Lord, Lord Aberdare, and I are going to give an encore later in the proceedings, as we both will be speaking again, and that there arc 30 other speakers, I want to use this opportunity to deal with one or two matters rather than to survey the whole of the field. May I say to the noble Lord, Lord Aberdare, that I personally am grateful to him for what has been a very restrained speech on his part. We know, and he knows, that there are certain basic philosophical differences between us which are not going to be healed by any amount of debate or any amount of talking. But so long as we know what our philosophical differences are about and try to understand them and, where possible, to see the other person's point of view, it should not be impossible to make some kind of progress.

I must confess that I have taken grave exception to the insinuation—not by the noble Lord, Lord Aberdare; I exonerate him of that; but in what I have heard sometimes in this House and in what I have read—that the present troubles in the National Health Service have occurred since March 1974. Let us get one thing perfectly clear. I believe that noble Lords on the other side of the Chamber attach considerable importance to The Times newspaper. If that is so, let me remind them that on the 21st October last it contained an article headed: "Clear thinking in the National Health Service" which stated: The Government is not really to blame for the long-term problems that have so greatly undermined morale in the National Health Service.

In March 1974, when my right honourable friend took over at the Department of Health and Social Security, there were three things seriously undermining morale. The first thing that everybody said to her and to my honourable friend the Minister of State when they walked into Alexander Fleming House was that morale had never been lower in the National Health Service. That may be true; it may not be true. They were given three reasons for this by the deputations lining up to see them: deputations from the BMA, from the nursing profession, from the radiographers and from the ancillary workers, as well as many others interested in the welfare of the National Health Service. The first reason that all these people gave for the collapse in morale under the previous Government was that the rewards for everyone working in the National Health Service had fallen seriously out of line as a result of our predecessors' statutory pay policy.

The second reason was the reorganisation (which the noble Lord, Lord Aberdare, touched on) of the National Health Service by the then Secretary of State, Sir Keith Joseph, who was responsible for some expenditure cuts which caused a certain amount of disruption and uncertainty, to say nothing of the expense. I want to remind your Lordships that we are talking at the moment of the financing of the National Health Service and we must not forget that the transition to this elaborate new structure brought in by Sir Keith Joseph cost the National Health Service a once-and-for-all payment of £9.5 million in 1974–75, and is now adding something like £4.5 million a year to the Service's administrative bill. Some of that money goes on trying belatedly to democratise the Service through the addition of the community health councils. Some of it goes on its professed aim of improving management. I only know that in the innumerable talks that the Secretary of State has had with representatives of the medical profession one of the things they have repeatedly raised is that under this new four-tier structure a few doctors are up to their eyes in committee work while the rest feel more remote from management than ever before.

I am only quoting what the doctors themselves say and this is confirmed by the University of Hull's illuminating study of the reorganisation on the Humberside. I would seriously say to every supporter in this House of reorganisation: please look at the University of Hull's study of reorganisation on the Humberside! Of course, all changes cause disruption—and this was a point that the noble Lord, Lord Aberdare, made—but it is remarkable how ineptly the previous Administration handled this; and to some extent we are paying the price today.

The third cause of the low morale which was inherited was lack of money. By March 1974, the previous Chancellor of the Exchequer, now a Member of your Lordships' House, had just cut the health and personal social services by no less than £110 million, involving an almost complete moratorium on major schemes; and I think it is fair to say, for we have to face these facts, that the Conservative Government were obviously planning further swingeing cuts. It is interesting to note, in view of the recent cries about the under-financing of the National Health Service, that the medical profession took very calmly these cuts by a Conservative Administration; even though they would have reduced the spending on the National Health Service in 1974–75 to £3,756 million—in real terms at the 1974 survey prices—compared with the £3,860 million approved by this Government. It is always a source of wonder to us that the medical profession can accept certain things when there is a Conservative Government but cannot accept similar things when there is a Labour Government. We have actually spent another £750 million to cover pay and price increases during the period we have been in Office.

Finally, there was widespread dissatisfaction among both consultants and junior doctors with their contracts. We were confronted with demands that they should be renegotiated and we were prepared to try to do that by agreement even though—and I must say this—the previous Administration had refused to look at their discontents and anxieties. But we immediately said that we would do so—and look where it has landed us!

My Lords, faced with this complex situation, we had to try to work out a balanced strategy. First, it was essential to correct the gross inequities in pay caused by our predecessors' statutory pay policy. The sense of grievance that this had caused had inflamed all who worked in the Service, from consultants down to the kitchen staff, but we had to do it in an orderly way so that the disengagement from the statutory pay policy did not become a stampede. That is why we felt it necessary to resist the demands, backed by industrial action, to make an interim payment to nurses and radio- graphers—and we did not get a great deal of support from the people who should have supported the Government, because they knew the situation. At this point, I want to say that we owe a great and continuing debt to the noble Earl, Lord Halsbury, and his Committee for the way in which they have served the people of this country; because the National Health Service is a very important part of the daily lives of every one of us.

At that time my right honourable friend gave resistance to an interim policy, which cave time for the Halsbury Committee successfully to complete its reviews and nurses, radiographers and the rest received their biggest ever increase in pay in the first independent and searching review of their pay ever undertaken in the history of the National Health Service. Later the ancillary workers caught up, and in April of this year consultants, general practitioners, junior doctors and the corresponding groups of dentists were given a substantial award—from 30 per cent. to 38 per cent.—by their Review Body. True to the Government's promise, the Government accepted the award subject only to the cut-off which had operated in respect of top salaries. Last year the percentage of gross national product devoted to the National Health Service rose to 5.4 per cent., the highest figure in the history of the National Health Service.

Now I want to come to the junior doctors. It is in moments like these, when the National Health Service is threatened with a serious and a widespread industrial dispute, that we can test the honesty, courage and consistency of people. If the Government were to try to reach a settlement of this dispute by allocating additional money above the pay policy limit, that policy would be in ruins in a matter of weeks. Everybody in your Lordships' House knows this to be true. Newspaper after newspaper has admitted this. Even the Daily Mail, in a leading article the other day, castigated the industrial action by some of the junior hospital doctors by saying it was: both unjustifiable and irresponsible". It went on to say: Under the £6 pay limit there can be no special cases. I wonder whether we realise that we are living at a time when history is being made, and that when that history comes to be written it will record that never before have millions of people agreed voluntarily to a pay policy—to a pay pause. It is one of the most significant things which have happened in our time. It was the Labour Government which in 1970 first introduced the principle of extra duty allowance—it was not recognised before then—for the juniors who did such long hours, and a Labour Government which in 1974 implemented the reduction in the hours at which those allowances became payable above 80 hours a week. Of course the position is still unsatisfactory. Of course junior hospital doctors are working far too long. But whose fault is it? Have the British Medical Association ever made a sincere and determined effort to do something about it? How has this grown up? This has always been the situation. This House today has in it something like five, six or seven top members of the medical profession. Have the consultants ever come together to decide how long their junior hospital doctors should work? Some of the junior doctors do not work for so long because they have good consultants who take more than a fair share of their responsibility —and I am not getting at anybody here—but there are many consultants who do not, and who place a far heavier burden upon the junior hospital doctors. There is nobody more sympathetic than we are on this side of the House to people who work all the hours that God Almighty gave them. We have been against it in the trade union movement for decades, and we have a great deal of sympathy with them.

Last May, the juniors found in my Ministerial colleagues a ready listener when they asked for a new type of personal contract which would clearly set out a junior's commitment in each case and include, in place of the extra duty allowance, payment for all units of medical time contracted for above their standard hours. The principles of that new contract, which have now been negotiated, mark a vital breakthrough for the juniors in their conditions of work. But it has all along been agreed with the juniors' negotiators that the pricing of the new contract would be done by the Review Body, which is their own independent body and is nothing to do with the Government, and that each side would be free to give all the evidence about the costing of it that they thought fit.

By the time that a new contract came before the Review Body in July, the Government had announced their new pay policy and inevitably, therefore, had in their evidence to maintain that any settlement involving new money on top of the 30 per cent. increase which the junior doctors had last April would have to be constrained. All this was known to the junior doctors' representatives when they met to consider this new deal on 2nd October. In full possession of the facts, the juniors' representatives voted, I admit reluctantly, by a massive vote of 41 votes to nine in favour of the deal. Your Lordships know that they later repudiated their agreement. This is well known.


My Lords, would my noble friend permit me to interrupt? I wonder whether he has in his possession the joint communiqué issued after this morning's meeting between the Prime Minister, other members of the Government and the doctors. It says—I think I have the exact words in my mind—that the meeting was jointly thought to be valuable and that the Government will approach the doctors. If the noble Lord has that document in his possession I wonder what is the point of going back over old history when the Government have undertaken to approach the doctors.


My Lords, f should like to say to my noble friend that I shall conduct myself at this Dispatch Box as I want to. I am always prepared to take advice and I took advice before I came here. I should now like to deal with the pay bed matter. We are anxious to introduce this policy, as your Lordships know, in a planned and reasonable way which will help the patient to have access to private treatment outside the National Health Service if that is what he or she prefers, and in a way which will recognise consultants' anxieties. That is why we proposed a system of licensing, not as a sinister first step to the abolition of private practice but because we want to have the means to encourage the fairest possible distribution of private practice throughout the country to give the maximum freedom of choice. Moreover, we are already aware of a number of proposals for large-scale developments in the private field which could do enormous damage to the National Health Service and so to the overwhelming majority of the medical profession itself. I mention just one example: the proposal for a 500-bed centre of excellence, as it is called, in the Bristol area. It would draw its patients from a wide catchment area, being placed at a strategic point on the motorway, but it would obviously recruit most of its nursing and ancillary staff locally, with consequences for the local National Health Service hospitals which must surely cause all of us anxiety.

These are the sort of problems that we want to discuss with the medical profession, without preconditions of any kind. We want to try to reach agreement on the best way, from everybody's point of view, of dealing with the situation which we know must arise when the pay beds are phased out. If the profession can convince us that the way we propose is wrong and damaging, we shall be pleased to consider other ways. However, I must repeat, as my Ministerial colleagues have done many times, that our policy is not to abolish private practice. As we have told the British Medical Association, we intend tore-embody the existing right of private practice in the legislation which we propose to introduce. I do not think I can say very much more on that.

Some noble Lords may say, "Why is this not being referred to the proposed Royal Commission?" I think it is generally recognised both by the quality Press and a large number of other people that you cannot expect a Royal Commission to take what is, after all, fundamentally a political decision. Political decisions must be taken by Parliament and not by a Royal Commission. I had intended to answer certain questions which were put to me by the noble Lord, Lord Aberdare, but I have spoken longer than I intended at this stage and I hope that perhaps he will allow me to reply to him when I attempt to deal with various other questions which no doubt will be put to me during the rest of this debate.


My Lords, before the noble Lord sits down, I wonder whether he could answer one question on this matter of policy. He says, quite rightly, that the matter of private practice must be in the long run a matter for Parliament and not for a Royal Commission. The Royal Commission has been set up to investigate, among other things, the finances of the Health Service; included in this are prescription charges. Am I to understand that the passage in the Labour Party's Manifesto saying that it stands for the abolition of prescription charges no longer holds good?


My Lords, if the Royal Commission is to be invited to express an opinion on all financial matters, including that of prescription charges, without altering anything in the Manifesto of the Labour Party, the Labour Party will give consideration to the recommendations of the Royal Commission.

3.33 p.m.


My Lords, I should like to take part in this debate and say just a few brief words. The first thing I should like to say is that the National Health Service was established for one purpose and one purpose alone; that is, to take effective care of sick people. It has worked reasonably well for over 20 years, although it has never been very well financed. Then several worries began to come along, which are partly tied up with the finances.

One thing which has worried many of us for quite a long time has been the question of what is to be the fate of the "little" hospitals. One is told that they will be merged with bigger ones or destroyed, or something of that sort. I should like to put forward a very strong plea that as many of them as possible should be retained for the care of patients who are not well enough to be cared for at home yet not really sick enough to go into a big general hospital. They should also be retained for the care of the elderly and for general practitioner work. One is told that some of these little hospitals are not really economic to run. I am afraid I must agree, but I think it should be said that the care of the sick should not be governed entirely by economics. Obviously, one has to be careful, but economics should not be the whole basis. The same thing, in my view, applies to the use of agency nurses. For them I hold no particular brief, but if by cutting down the amount of money which is paid for them it means that you have to close down beds which are at present occupied, then I would say that the agency nurses should be retained for as long as possible. Perhaps the noble Lord will be able to tell us what effect the reduction in pay for agency nurses has had on the number of beds.

There have been several further disturbances of the Service which have had some effect on the feeling of the members of my profession. The first one was the Salmon Report on nurses, which rather changed their main work—that is, the care of the sick—so that they could, if they wished, be promoted and take up an administrative post. At the same time, they rather wished to be trained to be what I might almost call "little doctors" instead of being nurses taking care of the sick. That was called "making a career structure for nurses". Then in 1968, the Seebohm Committee reported on social workers, both medical and others, and put them all into a separate department. This meant that a group of people who were taking care of the sick was again fragmented. That was called "making, a career structure for the social workers". I went to a meeting—though I cannot quite remember now what it was—shortly after that, and I asked: "What about a career structure of the patients?" That perhaps rather frivolous remark was greeted with complete silence.

I think we all agree, or at least many of us do, that the administration following the 1971 reorganisation—which after all was very largely a managerial one—led to a very top heavy and somewhat expensive administration. I do not think that the expense has perhaps been as great as some people thought it might be, but it certainly has been expensive. I read the other day that although ten years ago doctors comfortably outnumbered the administrative and clerical staff, by last year that position was reversed. One wonders whether these four tiers are really needed. I should have thought that the case for the abolition of the Area Boards was quite strong, so long as there is a powerful Department of Health at the top. It is indeed true that the doctors have to spend a great deal more of their time on committee work. As the noble Lord, Lord Aberdare, pointed out, this may be a natural result of wanting to have more communication with the administrative side, but I should have thought that whatever could be done to cut down the amount of administration which doctors have to do should be done.

The present trouble with the consultants—and I do not want to go into this matter at great length—is the pay bed dispute and the reference in the gracious Speech to legislation intended to separate private practice from National Health Service practice. I have no particular views about pay beds, but if they are to be phased out I wonder whether this is the right time to do it. The pay beds bring in a certain amount of money to the Health Service. I have seen one figure of £40 million a year, and another figure of £20 million a year. I do not know which is right. I only know that over the course of four years my own hospital brought in nearly £2 million to the Health Service from pay beds, which did not include consultants' fees.

As I have said earlier to your Lordships, I have never made a great deal of use of the pay beds in my own hospital. This was not for ideological reasons, but purely for practical and geographical ones. But, as I have said before, I once had a senior member of the Party opposite who was admitted at the urgent request of Transport House. Of course, that was in the days before the NUPE was being so active; otherwise, I am sure that they would have been down on me like a ton of bricks.

I remember talking to the Minister, Nye Bevan, for whom I had great respect and considerable affection, too, about pay beds in the Health Service hospitals. We both agreed that one good thing they had done was to get rid of a large number of expensive and not very good nursing homes. We discussed the subject at a dinner party one evening, and decided that it was a great advantage to have got rid of those nursing homes. So when I now see it suggested that new hospitals should be built for private patients, even under licence, I feel that that would be a somewhat retrograde step which we should try to resist.

One of the advantages of private beds being in the same building as the general wards is that the doctors in charge of both private patients and National Health Service patients have far more time to deal with their patients of both types. They do not have to travel from X to Y by car in crowded streets, and so on. They can merely walk across from the private ward into the general ward, and that is surely something which should he encouraged. I quite agree that if it is found that pay beds are not fully occupied they should be used in the normal way for National Health Service patients. There should be no question of keeping them sacred, as it were, for private patients.

Then, I have heard it said, too, that if the private beds are shut down and used for National Health Service patients it would be the equivalent of building four or five new hospitals. But it would be nothing of the sort, because the bulk of the people who go into private beds are British. The number of sheikhs who come with their gold dangling all over the place is not very large, and therefore I can never see the strength of that argument. Furthermore, I think that a sheikh who is kindly and properly treated in a private ward may do something of value to the Health Service. The sheikhs have plenty of money and, when they have had successful treatment here, there is no reason why they might not be encouraged to give kidney machines or something of that kind.

I should like to make one further small point about pay beds. If the London ones were abolished, there might be a very serious effect on the staff of the London teaching hospitals, which are probably the best in the country, in Europe, or even in the world, because if any of the attractions of London are to be taken away there will not be the same good service. When my profession has discussed pay beds, it is curious that there has been little mention of the value of amenity beds. The noble Lord, Lord Wells-Pestell, will correct me if I am wrong, but I believe that there are in the country approximately 4,000 of these beds which give the privacy which one requires. One has to pay a certain amount for them—I cannot even remember how much, but they are relatively cheap—but the great difference between them and the pay beds is that the doctor in charge is not paid anything. Therefore, I wonder why there is not more use made of the argument that if you take away the pay beds you will leave the same number of amenity beds, or possibly even increase them, which will solve the problems of people who want to be by themselves and to be quiet.

The pay beds dispute has been excluded from the terms of reference of the Royal Commission, and I believe the reason given for that is that pay beds arc in the Manifesto of the Party opposite and the subject covers financial matters which are complicated. I can see no reason for that argument. Some things which are put in a Party Manifesto are like the Tables of the Law which Moses brought down from Mount Sinai; they cannot be altered. I cannot believe that that is true, and it seems that the Government are pre-empting the findings of the Royal Commission. But what one has to be absolutely firm about is that, finally, it is Parliament which has to decide—


My Lords, with all respect, I feel that the Peer who has been speaking to us for a considerable period has greatly overstepped his time and we should proceed to the Statement.


I am sorry, my Lords; I shall be as brief as I can. But if I may say a word about the junior doctors, I know that they work long hours and that their work has become much more complicated. But that is one of the reasons why people take up medicine. We went into medicine because we did not want to work in an office from nine till four. We took up medicine knowing that there would be quite long and irregular hours, that we might have to work in the theatre, that we might have to give up a dinner party, and so on. But the young doctors have now been either out-manoeuvred or badly led into a position where they have a fixed day with overtime. Clocking in is something which we have always resisted up till now and overtime will lead to a large amount of jealousy among the doctors. Also, I should much prefer it if, instead of talking about industrial action, people talked about a strike and had done with it, because that is what it is, and one fundamental principle of all our teaching is that doctors do not strike.

The decision to treat only emergencies is, I am afraid, not much more than humbug, because one cannot really tell what is an emergency or know when what does not seem to be an emergency suddenly becomes one. Therefore, I have no sympathy at all with that argument. I had hoped that the senior members of the profession might use a restraining hand upon some of their juniors, but they now seem to be following the same disastrous course—unless, as the noble Lord said, something new is to emerge. Finally, there was a letter in The Times on 1st November signed by about 50 doctors working in academic medicine, condemning the present action of the doctors and saying: We deplore the division of the profession into various factions and plead for a return to sanity on the part of the Government and the profession.