THE NATIONAL HEALTH SERVICE

HL Deb 03 December 1975 vol 366 cc624-744

4.0 p.m.

Debate resumed.

The Lord Archbishop of YORK

My Lords, I have to crave the indulgence of the House for a maiden speech which I hope will be of a non-controversial kind on what is, I am fully aware, an exceedingly controversial issue. I myself would not presume to comment on the present dispute between the Government' and the doctors because there are many others with information and experience at their command which I cannot command. I would simply allude to two matters which I believe have contributed to what is generally recognised as a collapse of morale in the National Health Service. One I think we can do little about, and that is simply the pressure which is applied to those serving within the Service.

I recall still with some regret the occasion when a general practitioner friend of mine withdrew altogether from the National Health Service, not because he was seeking better rewards elsewhere but because, as he said, "I could no longer face walking through the waiting room with a queue there, knowing that I should not be able to minister to them as my profession requires me to do". That is to say, the pressure is so extreme that little more can be done. Another doctor friend of mine told me that all he could say was, "Keep on taking the pills and come back in a month's time". I know that if we have a National Health Service carrying the appellation "national"then clearly we create very large expectations from the general public and I see no possibility of reducing their expectations and therefore reducing the pressure upon the medical services of this country. But I would hope that every attempt would be made by those in charge of administration at least to help doctors to live with that pressure.

The second matter I think permits of some adjustment. It is the whole question of the application of managerial techniques to a profession. This is a danger which was perfectly well seen with the first Green Paper in 1968, which was then criticised fairly widely as an attempt to apply managerial techniques to something which was not really susceptible to them. This was quoted again from the Opposition Benches when it was remarked that the managerial aspect of the reorganisation of the National Health Service was an exceedingly undesirable element in it. It is true that Sir Keith Joseph said that in the selection of people for the Regional Boards managerial expertise would be regarded as the criterion. I just wonder therefore whether one really can apply managerial techniques to a service of this kind and I believe it is the sense of being trapped in such a system that causes a great deal of unrest among the medical profession—a feeling that they are no longer in control of the medical services.

It is a dangerous thing for any profession to be trapped in that situation, where in a sense they have to take the responsibility for the medical health of this country and at the same time, whatever degree of representation they may have, feel that they are not involved sufficiently in the ultimate decisions about it. I hope therefore that any Royal Commission on this subject really would take a serious look at the attempt to apply managerial techniques—perfectly adequate in commerce and industry—to something which, after all, remains a profession.

When this particular crisis is over I hope we shall not forget that there is a much larger crisis of confidence in the National Health Service which has something to do with this particular issue. My own feeling is that it is as impossible to apply wholehearted managerial techniques to the medical profession as, I am happy to say, it is impossible to apply managerial techniques to the archbishops, bishops and clergy of the Church of England.

4.4 p.m.

Baroness GAITSKELL

My Lords, I have great pleasure in being the first to congratulate the most reverend Primate on his maiden speech. I would dearly love to take up some of the issues which he raised, but I do not think this is the occasion to do so and it would not be at all popular because I do not agree with him about some of the things he has said.

Despite the strife that exists today in the National Health Service, and despite the fact that the perfect comprehensive National Health Service has not yet been realised, Nye Bevan's Act of 1948 will be remembered as the historic Act of this century. From the beginning, in 1948, it was only possible to get the medical profession to accept this legislation on their own terms, and we have to go back to the beginning—to "original sin" perhaps I may say—which meant that the consultants scooped the pool. They were given the "most favoured son" treatment: they were given the benefits of part-time service in the public sector, and were also allowed private practice. In addition, they were allowed a scheme of secret merit awards that was difficult to justify and which remains something that in this industrial relations climate must be a constant source of resentment and injustice vis-à-vis any other worker. whether he be lawyer, plumber. teacher or anyone. What can they think of a secret scheme to give doctors awards that are not generally publicised?

The general practitioners had a raw deal. After the war there was unemployment among the general practitioners because the number of patients they were allowed was set too high in relation to the number of doctors. It has taken nearly 20 years for them to obtain justice, but now we have another unjust state of affairs in regard to the junior hospital doctors. Under private medicine they suffered many lean years before they achieved promotion. They had then a great fidelity to their training, their work and their responsibility. Is it not ironic that when they had to wait years to get a really good living they displayed all these attributes? But times have changed and these people are no longer silent and they take advantage of a Labour Government. When in 1973 there were massive cuts in the Health Service they made no move. They have also been unfortunate in being caught by inflation and the economic "squeeze".

I have enormous sympathy with the junior hospital doctors, but I think the action of the consultants is quite reprehensible. Their fears about the abolition of private medicine are exaggerated—almost paranoid. Until now, this branch of the medical profession has had preferential treatment. If they are so frightened about some checks on private practice, how do they imagine the worker feels who is made redundant and who loses his job at a time like this? What are such workers supposed to do—go on the rampage? They cannot go on strike because they have lost their jobs.

Though I must admit that pay beds in National Health Service hospitals are something of an anomaly, I still feel that the consultants are paranoid in thinking that private practice is to be abolished. I do not believe this to be true, but I feel that the Government are also somewhat perverse about this because I do not think that a small percentage of private beds would pose a threat to the National Health Service. In my view that also has been exaggerated. The resentment and fears and the behaviour of NALGO and NUPE—especially the latter, who refuse to help a few private patients in a private ward—are both petty and spiteful.

My Lords, medicine today is changing. Diagnosis is changing and is becoming much more technical. In years to come, it may become completely computerised and it will be interesting to see whether the dedication that the medical men have shown up to now will keep pace with the increase in technology. It would have been a good thing, if the right honourable lady, Mrs. Barbara Castle, had insisted on referring the pay bed dispute to the Royal Commission. Here, I must say that I disagree with my noble friend the Minister, who simply says, "This is a political decision and we must adhere to the Manifesto". I often feel I should like to respond as some of my Roman Catholic friends respond when they say, "I am a Catholic, but not a very good one". There are times when I should like to say, "I am a Labour Party Member, but I am not a very good one", because I disagree with some things that are done in the name of the Manifesto.

The Royal Commission must look into every aspect of the medical profession. I hope it will look into the question of pay beds and I hope it will look into prescription charges. After all, in the past, as the noble Lord will remember, there were great battles about prescription charges when my husband was alive. What happened after he died and the Labour Party came in?—prescription charges were put on by the very people who had fought him so hard, so there is an irony about things that happen in this way.

The Royal Commission has far more serious things to deal with than just the question of a few pay beds—say, 1 per cent. of pay beds. We have great inequalities in the regions, and between regions. In the South, sometimes we have better services than in the North, and so on. We may have had value for money up to now, but I am told that the health of the nation has not improved. We have spent a great deal of money, but the improvement in health does not quite match up to the money we spend; it does not reflect 100 per cent. the money we have spent so far. That may not be the fault of the National Health Service—I am not saying that; it may be a fault in the way our society is going. But there is a great deal of work to do and I hope it will not he long before it is started.

My Lords, I should like finally to apologise to the noble Lord, Lord Aberdare, because I have to leave before the end of this debate. I have a small official engagement. I hope the noble Lord will forgive me for leaving early, because that is something I do not like doing.

4.12 p.m.

Viscount KEMSLEY

My Lords, I have been a Member of your Lordships' House for some years and have not hitherto addressed your Lordships, a matter for which I feel some explanation is necessary. First, for much of my life I have been in the fortunate position of being able to express my political views through the medium of an anonymous Lobby Correspondent, a Parliamentary sketch writer or, indeed, a leader writer, and the habit dies hard. Secondly, and more particularly, I have the reputation of being a good listener. I am sure those of your Lordships who speak frequently in this House will be the first to agree that the speeches are well worth listening to. Today, I am very grateful to my noble friend Lord Aberdare for introducing this debate. I promptly declare my interest, although it is not a financial one. I am chairman of the committee of management of a large independent hospital, and a member of the Executive Committee of the Association of Independent Hospitals. I should like to say something about the role of the independent hospital today, but before coming to that, may I be allowed one moment of nostalgia in which to relate a curious coincidence.

My Lords, my thoughts today, quite naturally, go back to the occasion on which, many years ago, I made my maiden speech in another place, although in fact it was not literally in another place, as it was in this Chamber, not 10 feet from where I am standing now. It was during that period when your Lordships very generously allowed the Commons to use your Chamber after theirs had been destroyed in the blitz. The debate was on an Amendment to the loyal Address in reply to the gracious Speech. The Minister who replied for the Government was the then Solicitor-General, later known to your Lordships as the noble and learned Viscount, Lord Kilmuir. Sitting beside me and giving me much needed moral support as I spoke was the then honourable Member for Daventry, recognisable today to your Lordships as the noble and learned Viscount, Lord Dilhorne. When I sat down, the next honourable Member to catch the eye of Mr. Speaker was my fellow Back Bencher, the then honourable Member for Oxford, known now to your Lordships as the noble and learned Lord, Lord Hailsham of Saint Marylebone. What more auspicious send-off could one have, being so closely associated with three future Lord Chancellors in the same afternoon! But to avoid any possible misunderstanding, I assure your Lordships that I have no aspiration myself in that direction.

My Lords, at that time there was no National Health Service. It is often forgotten by some, and unknown by many, that hospital treatment was, and had been for many years, free for all and sundry—and that included full attention from the best specialists and surgeons. The hospitals were run by voluntary committees responsible for the collection of funds and the management of the hospitals, at no cost to the Exchequer. Indeed, when the National Health Service was introduced, many regretted the disbandment of all those voluntary workers. It is true that some hospitals, such as the one in which I am interested, remained outside the National Health Service, and are still run today by unpaid committees.

It soon became apparent that the National Health Service alone could not cover all the amenities of hospitals and various voluntary organisations such as the Friends of the Hospitals, in which the noble Baroness, Lady Macleod of Borve, takes such an active interest. The two hospital services continued over the years to work amicably together, and in many ways were complementary. They shared many services. It is not generally realised that most of the independent hospitals today retain a fair proportion of their beds—no less than 3,500 in the country as a whole—for National Health Service patients, an arrangement much appreciated by local health authorities. But now, uncertainty about the future is causing us great concern, and to my mind this is not only dangerous, but is quite unnecessary.

The political argument in favour of phasing out pay beds at National Health Service hospitals I can understand, even if I disagree with it. But for the life of me I cannot see the logic in restricting the independent hospitals. The Consultative Document makes it painfully clear that licence to operate existing hospitals, and any new ones, will be granted only by the Secretary of State, after complying with many complicated conditions, and that in any case the total number of beds for short-stay patients shall not substantially exceed the number of National Health Service pay beds and beds in private nursing homes and hospitals in March 1974. I know of several projects for building new hospitals today, but work is held up because no one can be sure that a licence to operate will be granted. The money is available to build, equip and run them at no expense to the taxpayer. I would emphasise that these are small units—20-bed or 30-bed hospitals. They are not large commercial institutions referred to by the noble Lord, Lord Wells-Pestell, just now. Surely, at a time when the waiting list for the National Health Service beds grows longer and longer and cash is in such short supply, every encouragement should be given to the independent hospitals. One cannot get away from the fact that every bed occupied in an independent hospital means one less bed required in an NHS hospital.

After the Chequers conference the other day, the Prime Minister announced the policy of full partnership between the Government, the CBI and the TUC, which he considered essential to ensure the survival of our country. Is it too much to hope, after the talks today at Downing Street and those which are still to come, that he can state that a full partnership between the Government the BMA and the voluntary organisations is equally vital to the nation's welfare? My Lords, I appreciate that a maiden speech should not be controversial. If I have offended, I apologise, but what I have said I feel very deeply. I am, and have always been, of the opinion that the health of the country should be above Party politics.

4.21 p.m.

Lord PORRITT

My Lords, it falls to my happy lot to congratulate on your behalf the noble Viscount, Lord Kemsley, on his maiden speech. In some ways I am sure your Lordships will agree that this seems rather an anachronism, if I may put it that way; one can see by the extremely fine and brief and succinct speech he has made to us that he is not new to the game. I was going to sympathise with him on that horrible "new boy" feeling that even at a very mature age I myself felt when I made my maiden speech, but my sympathy with the noble Viscount is not very great. However, I can assure him on behalf of the House that we listened to that brief little gem of a speech, putting forward an aspect that is probably unlikely to be touched in the rest of this most intriguing debate, with the greatest of interest, and we are deeply grateful to him. Even if the noble Viscount says that he has over the years proved to be a good listener, we in this House hope that he will also be a good speaker, because if we could have another series of jewels in that little necklace he started for us we should be indeed grateful to him. I am sure when I congratulate him I do so on behalf of every Member of this noble House.

My Lords, I am sure it is not necessary for me to declare an interest in this particular debate, but I would say that that interest does go back to the days before the beginning of the NHS and to the first 18 years of its life when I had what I still like to call the privilege of working in it, until I went overseas and had to leave it. When I came back, in view of what had been happening in the intervening years. I can assure you that my interest had not dimmed in any way and in fact it has been rather actively rekindled. I have noticed with the greatest of pleasure this afternoon that this obviously difficult debate, so introduced by the noble Lord, Lord Aberdare, at such a timely moment, has been conducted in the usual atmosphere that one expects now in this noble House, because it is very easy to fall into the difficulties of contentious exchanges and even acrimonious remarks.

So far, I am delighted to see that they have been conspicuous by their absence; because—I say this very definitely—I think it is right that we should all remember that the National Health Service is, and always has been, a unique socio-economic experiment carried out on the grand scale, and of primary and vital importance to the well-being of this country. It is easy enough to say, but many of us forget, that without health not one of us can realise his individual potential, either in living a life or in enjoying it. Taking a completely unbiased and apolitical view, a view which I would suggest is held by far the majority of the profession, I would say that the National Health Service during its somewhat chequered career has achieved a very considerable degree of success and quite a degree of importance, and this despite both the largely unforeseen financial limitations and a radical alteration in the pattern of social life in this country. So, my Lords, I do not think the National Health Service is dying, again I think a view that would be shared by pretty well the whole profession. But we would indeed be hiding our heads in the sand if we did not face up to the fact that it is seriously ill.

The underlying causes of that illness are what this debate should be about. If we can rationally pinpoint these, we are well on the way to an accurate diagnosis, and once we have made an accurate diagnosis, then the treatment is consequential. To understand the causes, I think it is necessary to go back a little way into history. The concept of the National Health Service came from the fertile brain of Lord Beveridge. The implementation of the concept was the work of that practical visionary, Aneurin Bevan, to whom the noble Baroness, Lady Gaitskell, has already referred. With the knowledge of hindsight, we see, rather sadly I think, that the primary assumption of Beveridge has proved to be untrue; namely, that the introduction of a comprehensive National Health Service would lead in due course to a reduction of the need for health care.

There are several reasons why this original premise has over the years proved to be false. First, the practice of medicine has advanced so rapidly, and now demands, if standards are to be maintained, complex and sophisticated machines, instruments and facilities that require a trained team of medical and paramedical experts to use them efficiently. Both the equipment and the staff are very expensive luxuries. But the preservation of standards is an all-important matter, how important I think you will realise from the fact that for the first time in the history of the Service the Royal Colleges and Faculties felt they should intervene in discussion, because they feel that their prerogatives are something that they must guard. Secondly, there is the factor of an informed and educated public which has become increasingly more discriminating, more demanding. I would suggest to your Lordships that it is very much human nature for what can be demanded by right to become over-used, even abused and unappreciated.

There is one factor I would mention, because I do not think it is nearly sufficiently appreciated, and that is that the National Health Service was the first major attempt, at any rate in a Western country, to nationalise a profession. Perhaps it is significant that no attempt has been made to follow this up in respect of the law, the Church, as we have heard, architects, accountants and so on. At first, the medical profession reacted well to the ideal if not quite so happily to the idea, of a national service and went on their simple, uncomplaining, overworked and marginally paid way; but after ten years, in the late fifties and early sixties, what one might call the yellow lights began to flash. Relativities were beginning to raise their ugly heads, and by this I mean that in the beginning of the Health Service the profession, like Gaul, was divided originally into three parts, the Hospital Service, the general practitioner service and the Public Health Service.

It was becoming obvious how easy it was politically to play one of these against the others. It was proving difficult, as it always will, to quantify professional work, which the most reverend Primate remarked on a moment ago, particularly if that work was increasing very rapidly in its scope. Operational research into cost-effectiveness, words that are now bandied about, was hard to define and to organise compared to the same exercise in industry. Doctors in the main were showing an inability to accept, if not a growing antagonism to, a managerial concept of their work, a concept for which they had not been trained. At the same time they were becoming increasingly aware of the frustrations of bureaucratic control and the delays that are associated therewith.

To deal with the remuneration problem, at this stage an independent review body was set up under the chairmanship of the noble Lord, Lord Kindersley, and at first achieved results which were agreeable both to Government and to the profession. But before long a series of extraneous circumstances began to intrude and, rightly or wrongly, its independence became suspect, and from that date it has not been the beneficent, mediating influence it was originally.

At this stage the profession itself, and on its own initiative, decided to take positive action to stem these trends and to avert the dangers which were now obviously threatening the basic ideal of the National Health Service. The Medical Services Review Committee was set up, representative of all branches of the profession at the highest level, to try and cope with a deteriorating situation, and, in the light of the ten years' experience of the Service working, to find practical means of improving it and safeguarding that initial objective. After four years of work a unanimous and constructive report was produced. To the considerable disappointment of the Committee, of its Chairman (myself), and of the profession in general, that report was quietly shelved by the then Government—I am not looking either way. I think it is fair to say, in the light of subsequent events, that if that report had been even partially implemented at that stage, many of today's difficulties would have been avoided. It was the first occasion on which a gesture of good will on the part of the profession was repudiated by Government. And so over the years the symptoms of the illness of the Service became more obvious, until the yellow lights turned to red.

But to be quite fair, no one Government are to blame for the present state of affairs, nor is the profession entirely blameless. Each Administration has indulged in sporadic tinkering with the mechanism of the ponderous organisational machine, until now we have a bureaucratic monolith in which—I think that the noble Lord, Lord Amulree, brought out this fact, and I should like my figure to be confirmed at sonic time —30 per cent. more people are working in administration than in the clinical work. There are 30 per cent. more administrators than there are doctors. And yet the reorganisation gives even less responsibility and less accountability, either clinical or financial, to the periphery, the consumer, the community, where medicine rightly belongs, being a humanitarian concern.

At the same time one has to admit, rather sadly as it emphasise one' svintage, that a new type of doctor seems to be evolving, created probably by the exigencies of the Service itself, in whom the vocational element of practice is perforce bowing to the materialistic. To find such terms in the medical vocabularly as "overtime ", "forty hour week", "negotiations", "industrial action", "strike" is shaking, if not shocking, to one of an older generation. Presumably it is the insidious result of being just part of the work force of the country's biggest employing agency of being at the receiving end of directive circulars which are sent out, at the rate of 208 in the first six months of this year (and some of them are very nearly clinical directives) of the frustration and delays that stem from under-financing and over-organisation; of not being permitted, because of the lack of resources, to carry out treatments which their training and experience have made doctors ready for, and of the soul destroying appreciation of the fact that in the provision of both facilities and services it would seem today that the aim is equality in preference to quality.

Now, on top of all this, has recently come even more sinister thought and threat of monopoly. I feel that it is not possible to shut this away. If one reads the Consultative Document and what has been said since, despite the fact that some of it has been partially retracted, the threat in due course of a complete abolition of private practice is contained in that document to anybody who reads it as I think it was meant to be read. This threatens the independence of both doctor and patient. The essential freedoms of both are thereby put at risk and, it would seem, quite unnecessarily. Surely we all, profession and public alike, want the National Health Service not only to be maintained but to be developed. It never will be so long as it remains a political football, and particularly a Party political football, to be kicked around to satisfy the doctrinaire and dogmatic dictates of warring political factions. Is it too much to hope that in such an aim as the proper care of the nation's health we can all—politicians, profession and public—sink our petty differences?

Thank heavens! it has been decided to set up a Royal Commission. But I am not at all sure that this Royal Commission, if it has a restrictive proviso in it, will do the good that it ought to do. It has much to do. It has much that it can do, but if it is restricted in its terms of reference it will be a tragedy. The National Health Service is in dire need of radical re-thinking from the top to the bottom and back again to the top. The re-organisation which we have seen—I know it is in its early days—I think has only accentuated the problems of the Service. I suggest that it needs honest dismantling and reconstructing—first taking due heed of the lessons so painfully learnt over the last 30 years and, secondly, being willing to study and to learn from other systems which are practised elsewhere in the world.

We are deluding ourselves, my Lords, if we think any more that we have a National Health Service that is the "envy of the world". If it is, why has not anybody else copied it? As we were early in the field many other countries in Europe, Australia and New Zealand, and even some developing countries, have seen our mistakes, have been willing to learn from them, and have set up less ambitious schemes producing nationally a much more viable and more valuable end product. Let us inject a little realism into the situation. I should like to try and be constructive in this difficult situation. The Government cannot afford the system they have set up. To me that seems a basic fact, despite, as the Minister has so rightly said, that 5.4 per cent. of our GNP—the greatest percentage ever yet given to health services—is now being provided.

If this is the case, it seems to me that there are three options open to us. We can either find new money, or we can economise on expenditure, or we can frankly admit the limitations enforced by lack of finance, and therefore, one would hope, in a meeting between Government and profession decide on a series of priorities for which the Government will be responsible, and for that list of priorities only. If such a reasonable decision should be made, then of course it is equally essential that that list must be quite honestly made available to both the insatiable profession and the insatiable public.

If today's Service is under-financed, is it not just plain common sense to welcome and encourage other methods of providing health care, even including private practice and insured practice? These could, and in fact have, run in parallel with the National Health Service, and have been stimulating it and enhancing its value. Have we ever really given full consideration to the possibility of a State corporation, Government sponsored but not Government controlled? Is it so ridiculous to contemplate a graduated board and lodging charge in hospitals as a small return for welfare largesse? Are we sure that the capitation fee system is not more expensive, more complicated, and more detrimental to the doctor-patient relationship than would be a fee for service system? Have we ever thought of working this out again? And, to economise, should we not radically rethink—this has been mentioned already, I forget by which noble Lord —the present emphasis placed on the hospital service, absorbing, as it does, some 70 per cent. of the expenditure of the Service and benefiting probably not more than 10 per cent. of the population?

Perhaps the time has really come, as suggested by the noble Lord, Lord Aberdare, when we should promote the less expensive needs of community medicine—health centres, cottage hospitals and, very much so, of preventive medicine—which would, for the first time, make the Health Service justify its name; in other words, primary care. Such a policy could lead to fewer admissions to major hospitals and hence to less demand for expensive buildings, equipment and facilities, to say nothing of reduced staffs and quicker patient turn-over.

Should we not consider cuts in routine hospital in-patient investigations and the question of the masive wholesale drug prescriptions, which has also been mentioned? Could not out-patient facilities be developed and perhaps day-stay units? Could there not be more geriatric home care? And must the National Health Service itself be wholly responsible—I emphasise "wholly"—for the free provision of such frill benefits, if I may call them that, as pregnancy tests, family planning, screening clinics, holiday inoculations and sterilisation? Admittedly it is first-class that it should, but it cannot afford it, and there are voluntary bodies which are willing to help. Is the ambulance service over-used, even misused? As I have said, there is much that can be done, and with such savings, of which I have given only a selection, one could hope to bring the essential hospital services up to the standards comparable with those that are already statutory for factories, offices and shops, but not for hospitals.

All of this excludes the major possibities of economy in the administrative field. Much as I hate to differ from my old friend the noble Lord, Lord Aberdare, I believe that the removal of one complete tier would be a very good thing; one complete tier from this enormous organisational set-up which we have produced. The savings on new buildings and staff alone would give a great lift to the failing funds of the Health Service. Anything to lessen the inertia of the Departmental machine would, I assure noble Lords, be greatly welcomed by the profession. Such programmes—they could doubtless be multiplied a hundredfold—would, at least, put the Service on the right road to financial stability, which is what it wants more than anything else. Do noble Lords realise that the system of financing the Service today is exactly the same as it was in 1948? I am no business man, but this seems an incredible fact in this day and age. Can one really just hope for the requisite full, frank and honest admission by Government that it can, in present day conditions, be responsible for only certain limited services financed from public funds, that priorities would have to be laid down, and that full explanation of the situation would have to be made to the public?

The other vital necessity in bringing about a renaissance in the National Health Service is a re-establishment of trust and faith as between Government and profession. It is the insidious seeping away of this over the years that has led to the present low morale, of which we hear so much, in the profession. Unkept promises—not deliberately—dilatory dealing difficulties, a cheese-paring approach to development and the necessity to swallow increasing amounts of political dogma have all produced a serious state of depression in a profession whose only aim is to treat patients to the best of its ability. I said originally that I wanted to avoid contentious matters; but, in the ambit of low morale, could anything be more foolishly devisive, more guaranteed to sap confidence, than the dangerous dispute over pay beds? At least 90 per cent, of the profession want to retain them, and most of these—nearly all of them, including full-time staff—want to retain them in National Health Service hospitals.

What has happened to that wish? Where has it got us today? I am sure that the majority of noble Lords believe in their heart of hearts that all men are unequal; it is a simple and well-known genetic fact. But the last straw which has broken the profession's back is the recent threat, sadly perpetuated in the statement in the Queen's Speech, to restrict and, it is very widely believed, ultimately to abolish entirely private practice as a whole. I know this will be denied, but it must be more than denied; it must be shown to be untrue.

This has been the last straw. This is recognised by doctors as a direct attack on their professional freedom and that of their patients, which is just as important. How sad it is that medical good will and the urgently needed refurbishing of the original ideal of the National Health Service should be so unnecessarily put at risk just when it is most needed. If, as I believe to be the case, all of us—politicians, profession and public alike—want a National Health Service, then surely we can still hope for a little light to be thrown on this somewhat murky scene and that inflexible dogma and confrontation will give way to friendly and reasonable compromise and a meaningful and genuine friendship. It will mean a lot of common sense, a lot of mutual trust and cooperation and a lot of very hard work, but I believe it can be done, and the time is now. A Health Service is not for politics; it is for patients.

4.46 p.m.

Baroness SUMMERSKILL

My Lords, first I wish to thank my noble friend Lady Gaitskell for kindly taking my place in the list of speakers, so enabling me to attend a very important meeting. The names of 31 speakers are down for this important debate and, having listened to many speeches similar to those which have already been made, I have observed that there is already a danger of tedious repetition. I hope, therefore, to be brief so that other noble Lords may have an opportunity to take part in this debate.

I listened to everything the noble Lord, Lord Porritt, said, but he made one major error. He stated that Lord Beveridge was the author of the National Health Service, but that was an amazing error on his part. Lord Beveridge had nothing to do with it. The noble Lord must surely know about the meetings of that little group of the Socialist Medical Association which took place in the early 'thirties at 13 Devonshire Street, the home of Summerville Hastings, who was the ear, nose and throat surgeon at the Middlesex Hospital. I had the honour of being one of that group. A group of doctors, exhausted after their day's work, went along to that little room, which was the dining room of Summerville and his wife—we had some of the finest coffee the world has ever produced—and we planned the National Health Service. It was then submitted to the Labour Party, the policy committee of which considered and accepted it as the policy of the Labour Party. At our first opportunity, in the 1945 Attlee Government, it was included in the programme. I am sorry to have to correct the noble Lord, who I know is a repository of information of this kind, but that was a major error on his part.

Lord ROBBINS

My Lords, may I just put a gloss on what the noble Baroness has said? I think it can be said that Lord Beveridge was the first person to introduce the assumption of the National Health Service in his Report.

Baroness SUMMERSKILL

That is an entirely different matter, my Lords.

Viscount ECCLES

My Lords, would the noble Baroness remind us of the date of Lord Dawson's Report in which the whole thing was adumbrated? It went far beyond the little coffee meetings which she attended.

Baroness SUMMERSKILL

My Lords, the thing about those coffee meetings was that they were composed of dedicated people who were determined to get it on to the Statute Book. I was very pleased—I regret that he is not in his place—to listen to the remarks of the noble Lord, Lord Amulree. The noble Lord, Lord Porritt, said that he was very impressed by the way in which this debate was conducted and that no harsh words were being used. I am sure that noble Lords will agree that the noble Lord, Lord Amulree, is a very mild man, and he said exactly what he thought about these "infamous young men" who are now on strike; "doctors calling themselves professional men." I am glad to see the noble Lord in the Chamber now. Perhaps I should explain to him that I was saying how right he was in believing that this refusal of doctors to look after the sick of the country because they want more money and because, by neglecting them, they can bring pressure to bear on the Government is quite outrageous and that their withdrawal of labour is nothing less than a strike. I use the example of the noble Lord, Lord Amulree, because people may think that I myself am more fierce and may be expected to say such things. To me, it is very pleasant to have someone like the noble Lord, with all his experience of medicine, recognising what is happening.

I believe that it is not an overstatement to say that we see today the most shameful and unprecented behaviour in this strike of doctors. These are doctors who have lost their consciences and, by putting the health of the country at risk, discarded their professional obligations. They have violated the Hippocratic Oath and, indeed, I wonder whether some doc- tors have ever heard of it. Certainly, the Hippocratic Oath is not always taken verbally today, but it is always taken in spirit. Doctors may like to know, if any of them read Hansard, that the Hippocratic Oath is dedicated to the belief that the health of the patient must be the first consideration. The doctor says, "My first consideration in life is the health of my patient."

British doctors have never behaved as clock watchers. How can they say that they must work only from nine to five when sitting outside in the outpatients' department, perhaps waiting near an operating theatre, is a sick, possibly near dying person, desperately in need of help? How can they look at the clock and say, "It's five, I'm off"? This is a deplorable state of affairs.

This violation of our customary standards will, in my opinion, have a damaging effect throughout the world on Britain's high professional reputation. I was fortunate enough to be one of the first people to go on a Party delegation to China. I went there in 1946 with Mr. Attlee, as he then was. I was invited to a dinner party of doctors in the centre of China and I told my interpreter that I felt most upset and embarrassed to think that we could not communicate with each other, that they could not speak English and that I could not speak Chinese. These courteous men—and the Chinese are such a courteous people that one always wonders just how it is that they are always so polite—were sitting round and heard me say this to the interpreter, and suddenly the chairman said in perfect English, "Don't worry yourself. We all understand. We were all qualified in Britain, he in Liverpool, I in London, he in Edinburgh and so on." This wonderful group of Chinese doctors then talked about medicine and what they hoped to attain in China, and they spoke with the highest respect of Britain's standards of professional behaviour. Later, the Chinese Minister of Health visited my home and I took her to Great Ormond Street. I must admit that I showed her one of our show places. She also spoke of her admiration of Britain's high standards, but I very much doubt whether our reputation will survive the attack which is being made on it today. Every country in the world will know how the medical profession of Britain has behaved.

The representatives of these disgruntled men have decreed that only those suffering from some emergency diagnosed by their own GP shall receive treatment. What is an emergency? I have been in this House and the other place since 1938 and during that time I have had—I will not say the pleasure—but I have appreciated being called to attend many of our Members, and I believe that I have probably attended most illnesses except a confinement in these two places. I have examined these people and it is quite impossible in many cases to say precisely what is wrong and whether a second opinion is needed. Many of these patients have gone in ambulances to our hospitals round about and had that second opinion which is necessary when there is any doubt as to the diagnosis. What is an emergency? The Secretary of the BMA ruled out long-standing conditions, but who can say that a grumbling appendix may not rupture, that a hernia will not become strangulated, that a duodenal ulcer will not perforate? Most coroners can find in their records histories of patients whose condition was not regarded as serious until it swiftly deteriorated and a delay in obtaining treatment was a determining factor in a fatal result. So to tell the country that all is well because only the long-standing patients are experiencing delay in receiving treatment is sheer nonsense.

Time is going on and I want to speak on only one other subject. I cannot forbear to mention it. Noble Lords who have listened to me before will agree that every time I mention it I receive little support but today at last wisdom and common sense have prevailed, I am glad to say. Everybody knows what I am coming to. I refer to the shortage of British doctors which stimulated the introduction of foreign doctors, many of whom had a poor knowledge of English and lacked professional competence. They came from all over the world. Our doors were open to them. Provided that they had a medical qualification of some kind and—and I say this in a low voice—provided they were male they could come and treat the people of Britain.

I argued that this state of affairs could not have come to pass if the brilliant girls in our sixth forms who were vainly seek- ing a medical education had not suffered discrimination. Indeed, the extent of the discrimination, which almost amounts to a conspiracy, was only revealed to us on the Select Committee on Sex Discrimination. I was astonished—and I thought I knew all about this—to receive a letter from a professor in Leeds asking whether I knew about the means by which medical schools were keeping girls out, however brilliant they were. It appears that, for years, the medical schools, besides preserving the unjust quota system of having only a small percentage of women (for instance, St. Thomas' tried to keep to 10 per cent. a year and my hospital was wonderful and at one stage introduced a level of 25 per cent.) which meant that a nice but very bright boy could get in before a brilliant girl, were—it appears from this letter from Leeds—demanding for entrance a higher standard of A levels from girls than from boys. The girls were expected to have so many A levels that it was easy to turn them down. A boy need have only a few. After all, he had the male reproductive organs and that was the essential to get him into a medical school.

One cannot assess the deplorable waste of talent which has stemmed from this policy over the years. It reflects the prejudices of those men who were in charge of the medical schools, and it has resulted in the country being swamped with foreign doctors, irrespective of whether they could speak English or knew medicine. This is what discrimination led to. I am pleased to say that I suppose we have advanced since Elizabeth Garrett Anderson. We must remember that she was pelted with rotten vegetables and the doors of the examination room were barricaded against her by the men. The methods used now arc certainly more subtle, but prejudice and a determination to discriminate against women are still powerful among the male doctors who dominate the medical world in Britain today.

I am glad that International Women's Year has been marked by a new liberal attitude—and "liberal" in this respect is relative—in the medical schools, particularly in the Provinces, as foreign doctors now (and this is only a recent decision) are being subjected to a professional and language test, and the failure rate is high. No doubt this will convince those in authority that a qualified British woman, speaking her own language perfectly, will provide an adequate substitute for a foreign male who cannot speak English, or who does not know his job.

My Lords, while we have striven this year, in this place and in the other place, to get the Sex Discrimination Act on the Statute Book, it will prove successful only if men doctors change their attitude towards their would-be women colleagues and help provide every opportunity for their advancement in their chosen profession.

5.2 p.m.

Lord HUNT of FAWLEY

My Lords, the first week of December 1975 is likely to be looked upon by social historians as one of the most sombre and unhappy chapters in the long story of British medicine. My unfortunate profession has now found itself in an unaccustomed and unenviable situation—in the middle of a battlefield of Party politics. Our long-suffering patients will remember this week for many years; it may be the beginning of a long and difficult time for some of them. I suspect that I may be the only fully-practising doctor who will speak in this debate. My work and my patients will be affected by what Her Majesty's Government, the consultants, and the junior hospital doctors are doing; and I hope that your Lordships will bear with me if I take a broad view of some of the problems involved in the relationship of our National Health Service to private medicine. I shall leave to others detailed discussion about the advantages and disadvantages of pay beds, as I spoke about those in a debate on this subject in your Lordships' House 16 months ago.

One aspect of the pay bed problem, however, I should like to mention is the ill-feeling which has been engendered by them. This is out of all proportion to their number—only about 1 per cent. of the total hospital beds in this country. The Minister of State at the Department of Health and Social Security, Dr. David Owen, described them (so we are told) at the last conference dinner of the Socialist Medical Association as a boil on the face of the Health Service. Those were hard words, my Lords, for the thousands of generous folk who sub- scribed towards the building of private wings of nearly all our famous teaching hospitals. A great number of people of moderate means have been treated in them well for years by dedicated doctors, many of whom have been working there "geographically full-time", as it is so well called. In these hospitals National Health Service patients and junior hospital staff have often been greatly helped by having consultants nearby and readily available.

However, one must not exaggerate the ill-feeling and concern about pay beds, as has been done in some quarters. In the majority of hospitals, especially in country districts, there has been little trouble; difficulties have been ironed out by all parties with good will. There are many trade union leaders who are wise, responsible and reasonable people who have co-operated constructively in these matters. However, we have known that in other hospitals a few junior doctors, and some National Health Service nurses, have for a time been averse to caring for patients in pay beds. More recently this feeling has spread to cleaners, porters, cooks and other domestics, to laundry staff and laboratory technicians, some of whom at times, backed by their unions, have refused to work for private patients, although they were paid to do this as part of their contracts. While appreciating that everyone should have some say in how the National Health Service is run, it is as absurd for porters and cooks to tell surgeons when and where they may operate, as it would be for doormen and cleaners at the Foreign Office to try to dictate our foreign policy.

From what Her Majesty the Queen said in Her gracious Speech on 19th November, it seems clear that members of Her Government are now poised to do their best to eliminate pay beds soon from National Health Service hospitals, despite the carefully-considered advice of almost the whole of the medical, nursing, and dental professions, hospital administrators, and of patients (of all shades of political persuasion) as reflected in opinion polls; and after refusing, so far, to include consideration of pay beds in the terms of reference of the Royal Commission, or waiting for that Commission's Report.

To my mind this is just one more unfortunate symptom of the present general ill-will. As my noble friend Lord Aberdare said, doctors have lost some confidence in the Government, who seem to be inflexible and relentless apparently for doctrinaire and political reasons, and insensitive to the feelings and wishes of a great and learned profession. There are about 11,000 consultants in Britain. About one half of them see some private patients, although the majority work most of their time in National Health Service hospitals. I have wholeheartedly supported their bid to keep their pay beds. I still hope that they will do so, if possible with the blessing of the Royal Commission. If that Commission is now given the chance by Her Majesty's Government of finding some way of retaining pay beds in NHS hospitals with good will all round, or if it can suggest an alternative solution to this problem which is acceptable to most people, it will do British medicine a great and lasting service.

Those consultants who oppose the orderly phasing out of pay beds from National Health Service hospitals might not be so worried or so antagonistic to this move if they knew that there were enough other private beds to replace those they will lose. But for almost half of these consultants, covering about three-quarters of our country—those away from large towns—there are at present no alternative private beds within reasonable distance. Consultants would be less worried, too, if they did not suspect that some members of the Labour Government and some trade unions hope to make the phasing out of pay beds the first step towards the destruction altogether of private medical practice in Britain.

Several resolutions passed at the Labour Party Conference about the abolition of all private practice and private insurance schemes, and the recent Consultative Document from the Secretary of State for Social Services did nothing to allay this fear—especially her suggestions about licensing and controlling the number and size of private hospitals and nursing homes, regardless of demand, so that they cannot in future embarrass the resources of the National Health Service. On the other hand, the Prime Minister said recently (on 20th October) in another place that he intends to encourage private practice to carry on alongside the National Heatlh Service. His words were: I have made it clear…that the Government are committed to the continuation of private practice."—[Official Report, Commons, 20/10/75; col. 39.] He referred to the important and continuing contribution which we expect and want private practice to make…"—[Official Report, Commons, 20/10/75; col. 37.] He also said: We expect to see it continue…we want to see it continue, and we shall guarantee it in our legislation."—[Official Report, Commons, 20/10/75; col. 39.] While talking about pay beds, the Secretary of State for Social Services said in another place: …the phasing out proposals must be reasonable and we must do everything in our power to ensure that those who wish to practise privately can continue to do so". —[Official Report, Commons, 21/11/75, col. 356.] Therefore, in those country districts where the small number of private beds in National Health Service hospitals would not justify the building and staffing of a private hospital, where there are no convenient alternative private beds nearby and where consultants would have to travel 30 miles or more to operate, the pay beds should be kept as they are until another solution has been found. Surely that would be just.

Also, it would be logical for this Government and succeeding Governments to indicate that they would set their faces against trade union militant actions, or obstruction by local authorities or by others, which might interfere in any way with the building or running of independent private hospitals, with the work of private medical insurance organisations or with the healthy future development of the private sector. Such moves by Her Majesty's Government now would be sensible and diplomatic—an enlightened approach and a gesture of good will in the present crisis which would go far towards allaying the fears of all doctors (and, indeed, of members of other learned professions, too) about their future freedom. My Lords, if ever there was a time for diplomacy and compromise, surely it is now.

The licensing of quality and standards in private practice is a good idea. To some extent it has been in force for years, and I agree that it should be brought up to date. We do not want to return to having a multiplicity of small nursing homes, as we had in London and elsewhere before the last World War. Excellent work was done in some of them, but under conditions far from perfect. Some had operating theatres in converted bedrooms, others were without lifts and with narrow staircases up and down which it was difficult to carry unconscious patients.

On the other hand, a complex licensing system aimed at controlling the size of the private sector and blocking the growth and development of its hospitals and clinics, as suggested in the Consultative Document, is quite another matter. I agree with what my noble friend Lord Kemsley said on this matter in his excellent maiden speech. That sort of licensing would give the Government, the Secretary of State for Social Services, the Department of Health and Social Security, Regional and Area Health Authorities (Health Boards in Scotland), local health authorities and others a stranglehold on the private sector. Moves to introduce such licensing would be a very real threat to the essential, fundamental freedom of the medical profession. Most doctors look upon such a suggestion as a real danger to their independence, a possible infringement of their professional and individual liberty and a threat to their and their patients' freedom of choice and of action which would have to be firmly resisted in every possible way.

The better the National Health Service the less need will there be for a large private sector; but the Prime Minister knows, the Secretary of State for Social Services knows (as she mentioned on television on 31st October), many of your Lordships know and I know, that private medical practice in Britain will never disappear altogether. There are many good reasons for this. About 1 in 22 people in this country who have found the National Health Service insufficient for their needs, many of them old and not at all well-off, are covered by BUPA, PPP, the Western Provident Association and other insurance organisations for private treatment in case of illness or accident. Some have paid premiums for nearly 30 years; others, who previously supported local provident associations, for nearly 50 years. Not only would it be extremely unkind, unfair, unpopular and unwise to abolish this private medical insurance altogether, but it would also be a breach of faith. Another 1 in 20 of our people seek private care without being insured. This means that roughly 1 person in 10 in this country at present relies on private medical help at times.

Some religious orders have their own hospitals outside the National Health Service, such as the St. John and St. Elizabeth Hospital. There are other private hospitals, such as the Freemasons' Hospital, the King Edward VII Hospital for Officers and the Italian Hospital. I know of several excellent private institutions which are largely reserved for trade union members—the Manor House Hospital, run on a subscription basis; a NATSOPA Rehabilitation Centre at Rotting dean near Brighton; the Benenden Chest Hospital, and several convalescent homes. Industrial firms sometimes provide certain medical, dental and other advice and treatment for their workers outside the National Health Service, which has proved popular, especially among women—an investment in the care of their personnel which greatly helps towards good human relationships between employees and management.

Many overseas visitors on holiday or business are insured in their own countries for private treatment anywhere in the world. They want to receive it when they come here. Increasing numbers of patients from the Middle East and other countries come to Britain for treatment which is not available at home. They expect to pay for it. Their visits, often with their families or entourage, constitute a considerable source of income for our country and enhance the reputation of British medicine. I do not believe that it would be practicable for the National Health Service to treat all our ill foreign visitors either as out-patients or as in-patients (in pay beds from which our own citizens may he excluded) even if a satisfactory method were found for them to pay for this. Even in Russia, according to a recent report from there, private practice continues for some of those who are dissatisfied with their medical service, many of whose hospitals, like ours, are over-full and their doctors overworked. It is interesting that part of this private practice in Russia is carried on in Government-sponsored private hospitals and clinics.

Just as no public transport in any country can ever be efficient enough or wealthy enough to take all people from door to door by car whenever they ask for it, so no State medical service can ever be so good as to give everyone all the medical care and attention they need, at once, whenever they call for it. Private transport and private medicine are there to fill the gaps. I have always said that the last private patient will disappear in Britain only after the last private car has left our roads, because most people consider their health to be more important than their method of transport, and almost everyone who runs a car can afford some private treatment at times if he wishes.

Those who call for the end of all private medical practice in our country do not understand the intricacies of this problem quite as well as do the Government. One enlightened speaker at the recent Labour Party Conference in Blackpool summed up the situation well when he described it as, "a senseless vendetta against the private sector". At that same Conference the Secretary of State for Social Services is reported to have said, on 1st October: I am not proposing to abolish private medicine; I am proposing to make it stand on its own feet". That will do little good, my Lords, if her next intention is to cut those feet down to size by harsh restrictive licensing or knock them away from under the private doctors whenever she wishes. It is likely to be called "phasing out."

In conclusion, my Lords, may I say that for doctors to strike in any way—go slow, work to rule, refuse to do overtime duty, treat only emergencies or threaten to resign from their jobs in large numbers—is quite out of character with the traditions of our old, honoured and respected profession. Most medical men and women dislike intensely doing anything which will hurt their patients. But they value their independence, their freedom of action and their personal liberty very dearly. If their arms are twisted too much over any of the really important issues I have mentioned, in spite of the recent statements by the Prime Minister and the Secretary of State for Social Services about maintaining a healthy private sector, the doctors will feel compelled to react (as, indeed, some have already begun to do during the past few days) by taking counter-measures which no one will like, least of all the doctors themselves. They will harm the National Health Service, cause much unhappiness, difficulty and even danger to patients and they will erode that mutual confidence which has been for so long such an important feature in the relationships between doctors and patients in our country. It will be quite wrong then to say that this lamentable confrontation is all the doctors' fault; those who drive them to it will have to take their full share of the blame.

However, I am sure that we can all agree on one thing: we want the best possible National Health Service for our country. This cannot be achieved while there is so much ill-feeling in the air. The sooner politicians, trade unions, doctors and everyone else concerned with my great profession learn to work together once more in harmony, with mutual understanding and sympathy, and with a new spirit of co-operation and tolerance, the sooner will our patients be better treated—and I speak largely on their behalf—and the sooner will British medicine recover from the disgruntled, disorganised and disrupted state in which it is today.

5.22 p.m.

Lord STAMP

My Lords, there can be no one in the medical profession who is not deeply saddened, indeed utterly appalled, at the situation it is in today compared with that when the National Health Service was introduced some 27 years ago. What has gone wrong with this great profession, of which I have the honour to be a member, that it has come to this sorry pass, with junior doctors in conflict over pay and overtime and consultants banding together by the thousand to leave the Health Service? It seems a world apart from the American, "Horse and Buggy Doctor" and our, "Doctor Finlay's Casebook." Has this generation of a dedicated profession fallen from the high ideals of Hippocrates which have been upheld by doctors throughout the centuries; and if so, what is the reason for this? If it has done so, it would not be entirely surprising in this age of every man for himself, epitomised by the phrase, "I'm all right, Jack!", with all the squabbles going on in intra- and inter-union disputes, and those involving the unions versus the rest, as to who should have how much and for what, with the law of the jungle taking over.

My Lords, it is also a time when personal freedoms are being threatened as never before in peace time, with a minority seeking to impose its will on the majority—an aim which is only made possible owing to the undemocratic working of our electoral system. This is the measure of the divisiveness that is racking our nation and tearing it apart.

I have drawn this picture of the background to the doctors' dispute as I feel this to be essential before judgment is passed on them, even if in so doing I may be accused of being contentious. The fact is that never have they been under greater strain to uphold the high standards of ethics and practice and dedication that distinguish them from practically the whole of the rest of the community—religious bodies and others dedicated to voluntary service excepted—and never have their basic freedoms been in greater danger.

My Lords, for everyone, however dedicated, there comes a breaking point; and in the case of the consultants, it is this threat to their freedom to practise, as they see it, in the best interest not only of their patients but also of the whole community. It is a breaking point that involves blatant bad faith. If anyone doubts the intensity of their feelings he would have only to have been present at the meeting of the consultants—about a thousand of them—just over the road from your Lordships' House a few days ago, as I was, as an ex-consultant of Hammersmith Hospital, and heard the famous Churchillian war-time rhetoric adapted to the present struggle of doctors to maintain their rights and freedoms—with hardly a dissentient voice. In this, my experience has been somewhat different from that of the noble Lord, Lord Hunt of Fawley.

My Lords, if anyone doubts also that there has been a breach of faith, he has only to recall the understanding that was given to doctors about the terms relating to private practice that finally persuaded them, many unwillingly, to join the Health Service and thus make it possible. I have read the relevant volumes of Hansard recording debates on the National Health Service Bill in both the House of Lords and the House of Commons and have found no evidence whatsoever to suggest that the pay-bed system was not to be regarded as a permanent and basic feature, even though it might have to be modified in some respects from time to time. The most relevant passage occurs in the House of Lords Hansard (Vol. 143, col. 355) recording a debate in Committee stage on Clause 5, headed "Accommodation for private patients" In that debate some Amendments were discussed, the first of which was moved by the then Lord Chancellor, Lord Jowitt, dealing with the question as to those doctors who should be eligible to use private accommodation. My Lords, it is inconceivable that such a debate could have taken place if the present proposal had been considered remotely possible; and if it had been, as I have said, the Health Service would never have got off the ground. It would have been moribund from the start.

But, my Lords, returning to the present time, it is said that phasing out pay beds is in the Labour Party Manifesto and therefore represents the will of the people. I dealt with the basic fallacies inherent in this argument when I spoke in the debate on the abolition of direct grant grammar schools in your Lordships' House a few weeks ago and I shall not enlarge on the subject further, except to say this. Even if one were to accept the Manifesto argument, it was still a flagrant act of bad faith to the doctors that the policy of phasing out pay beds should have been put in without consulting them and getting their agreement. So, my Lords, bad faith has generated in many cases a bitterness amounting to hate and to such an extent that I cannot see the attitude of the medical profession to Governmental control of medicine ever being the same again. whatever happens over the present dispute; although I sincerely hope that I shall be proved wrong in this.

One thing I shall never be able to understand is how those who support the pay bed proposal can ever have the effrontery to go to those who feel so bitterly about it for advice for themselves and their families—and that goes particularly for the one responsible for handling negotiations herself. This demanded qualities of tact, reasonableness, a true understanding of the feelings of the doctors and of what had gone on before, that have been completely lacking. In my view, only one thing can defuse this explosive situation and save the National Health Service from further deterioration with all the needless discomfort and inconvenience, if not actual suffering, that this must mean for so many. That is, as has been urged from many quarters, that the pay-bed issue should be included in the terms of reference of the Royal Commission on the National Health Service. One can only hope that this will result from the meeting this morning that we have just heard about. By the time the Commission has reported, one can only pray that the Minister responsible for the present negotiations will have been moved to another post where her talents can be used to better advantage and her shortcomings may be not so evident.

Until now I have concentrated on the pay-bed issue. It is the one which particularly affects hospitals such as Hammersmith Hospital with their large intake of paying patients from overseas, as I pointed out in the debate on the subject in your Lordships' House on 29th July last year. I then stressed the effect that this must have on the standing of British medicine throughout the world and on the funds available for research derived from consultants' fees. With regard to the separate issue of the grievances of junior hospital doctors, these are so well known as to need no emphasis. Incidentally, it is a somewhat misleading description of them in view of the long service that many of them have, some of them in their forties. Many of them have been, and still are, frankly, exploited, working under conditions of hours of work and also of pay that would not be tolerated for a moment, particularly having regard to their responsibilities, by any other section of the community, least of all those who are the most vociferous in their criticism of them. It is a measure of the lack of foresight and proper priorities and mismanagement of successive Governments, particularly the present one, that their grievance, at least so far as pay is concerned, was not fully rectified before the inevitable restriction on pay increases was introduced to beat inflation.

They should be the last to suffer injustice for this reason, which in their case has been the breaking point to which I referred. However inexcusable their actions may seem to many—and I cannot endorse them—I feel that the extent of their provocation should, in fairness, be put on record. The responsibility for this deplorable state of affairs must be fairly and squarely on the shoulders of the Government, and it is their responsibility to do something about it. As has been suggested by the noble Lord, Lord Aberdare, one approach must be to reconsider the figures on which total allowable over, time pay is based, referred to in the letter to The Times on 1st December from the Chairman of the Junior Hospital Doctors' Association. It is a letter, incidentally, that I hope will be read widely as it is very revealing. I hope that this suggestion will also result from the meeting this morning.

Time will not permit me to dwell on another major grievance, which is the appalling increase in bureaucracy in the Health Service, so well described in an article in the Sunday Times on 15th November, and which has been referred to by the noble Lord, Lord Porritt. I should like to conclude by remarking on the singular aptness of the location of the headquarters of the National Health Service—symbolising as its does so much of what is wrong with it—a lumbering, elephantine bureaucracy, and also the person responsible to Parliament for not only seeing that it is working efficiently but also for maintaining its morale. What address could be more appropriate than, "Elephant and Castle"?

5.32 p.m.

Lady RUTHVEN of FREELAND

My Lords, may I be allowed to offer my thanks and congratulations to the most reverend Primate and to the noble Viscount, Lord Kemsley, for their brilliant maiden speeches. The speech of the noble Viscount appealed to me because it covered so many things that I would have said, but he said them so much better that I will not do so. I want to speak on a different line. We hear a great deal these days about what is wrong with the National Health Service, and if we believed everything we read or heard we could easily believe that the Service is in imminent danger of total collapse. I have been closely connected with the Service ever since its inception over 27 years ago, and I do not believe that it is about to collapse. But that does not mean that I think there is nothing wrong with it. There are many things wrong with it, and three things in particular.

The first is this. Whatever the rights and wrongs of the National Health Service reorganisation (and I hope to show in a minute that there were things that were right about the reorganisation as well as some things that were wrong), there seems to be no doubt at all that the whole reorganisation was carried through in much too great a hurry. From Royal Assent to implementation in only just over six months was far too ambitious, and we are paying the penalty for this now and we will continue to pay this penalty for at least another three or five years, for it will take all that time before we can expect things to settle down. We can hope that there is something which will grow from that during these next few years. But we will not get rid of the other two major faults so easily.

One of these is the chronic under-financing which the Health Service suffers from. This has always been with us, and its effects are now more acutely felt than ever as a result of inflation and economic crisis. I do not want to spend any time on this today because your Lordships are only too well aware that these problems of finance exist, and I hope very much that the Royal Commission will be able to help us here. I do not pretend that there are any easy solutions to these problems, but at least for the first time since the Health Service came into being we are going to have a Royal Commission examining its working. I hope very much that, as a result, we shall have some suggestions which Governments can implement so that we shall not have to suffer the evils of under-financing for another 25 years.

Finally in my short list of what I think is wrong with the Health Service is the present industrial unrest. This is something which is comparatively new to the medical service, and it is a sad reflection of the times we live in. Again, there is no easy solution. People in all walks and levels of life are apt to react when they think that their livelihood is threatened, and in the Health Service this means the consultant as well as the porter. It will take a long time to restore confidence and to repair the damage that has been done, and a little less abrasiveness and a lot more consultation at the top would help in this direction. And may I, as someone who has worked voluntarily for the Health Service ever since it came into being, add one plea addressed to those who are acting or planning to act to protect their own interests: you may be right in whatever you are doing or you may be wrong, but never forget that the Health Service does not belong to politicians or to doctors or nurses or to any other professional or ancillary workers; it belongs to the patients. Any action by politician or worker which does not put the patient at the centre of the picture is bound to be wrong.

In saying what I think is wrong with the Health Service I do not want to suggest for one moment that all is gloom. In spite of the speed with which the reorganisation was carried out, in spite of the shortage of money and in spite of the industrial unrest, there are already signs that the reorganisation is paying some dividends, notably in developments in integrating community and hospital care—particularly in the fields of nursing, home visiting and so forth. There is also some evidence that the experience of working in units larger than most of the old hospital management committees is allowing better use to be made of existing resources, and that the improved opportunities for discussion and action between the authorities of the health and the social services are beginning to show results. There are signs that we are beginning at last to have a Health Service and not just a sickness service.

One of the most important innovations in last year's reorganisation—if not the most important—is the introduction of the health care planning teams in which people of different disciplines and interests, and from different statutory authorities, could discuss and plan the total health care of the different categories of people—the young, the old, the mentally the handicapped, and so on. I think that in many ways it was a pity that these teams were the last of the new bodies being set up, but at least they will, in most parts of the country, have started work and this will continue.

We are told that the new Health Service is a bureaucracy. But this is nothing peculiar to the Health Service. Whether we like it or not, as a country we have been becoming more and more of a bureaucracy for some years, and the Health Service is affected in this way as are most of our other institutions. Bureaucracy is not necessarily a dirty word and there need be nothing wrong with it provided it can be made to work well in the interests of its users.

How can we make the Health Service bureaucracy work better? It is very often said that there are too many tiers in the reorganised Service and that if we could only remove one of them everything would work much better immediately. I do not for one moment believe this should happen. There are three reasons: the first is that although many people say that one tier ought to go, there is no agreement as to which one. I have spoken to consultants, nurses, doctors, social workers and everyone I can think of in the medical world, and they all agree that somebody else's tier should move but not theirs. They all believe that their own tier is the most important and that somebody else's tier must be the one to go. There would have to be another exhaustive inquiry, followed by more organisational upheaval. I suggest that is precisely what the Health Service does not want. It is already suffering from a surfeit of inquiries and reorganisations. We have gone through Seebohm, Salmon, Cogwheel, the National Health Service Reorganisation Act, and so on. What is badly needed now is a Period of stability in which it can digest all that it has had to absorb. In any case, one of the main benefits of the reorganisation was that it brought health and local authorities closer together. What is the sense of unilaterally changing the structure of the Health Service before we know more about what the structure of local government is going to look like in England in a few years' time?

I believe that we should let things alone for the time being and concentrate our energies on making what we already I have work better. I would suggest there is one thing which, if we could only, bring ourselves to do it, would help tremendously in getting things to work better. We must learn to delegate. Each level of the Health Service must learn to do its own job and monitor the level below, but not to interfere with the level below. This applies at all levels. I believe it is notorious that Whitehall, and particularly that part of Whitehall which lives in the Treasury, finds it very difficult and unattractive to release its grip and to allow there to be a proper delegation of responsibility. But Whitehall—Ministers and officials alike—must learn to delegate, and so must Regions and Areas. They must set the policies, give the necessary decisions and monitor the results, but they must leave it to the people in the level below to get on with the job.

I now want to refer to a matter which has not so far been mentioned. I do not want to make too long a speech, but I should like to mention this. It concerns my worry about dentistry. I should like to ask the Department of Health to consider this as a very important medical subject. It has been sadly neglected and, as I say, nobody in this debate so far has even mentioned it. I was hoping that other, well-qualified people would have done so. I know that a dentist or dental consultant is to be called in when the subject of dentistry is being considered at whatever level may be appropriate. But that is not enough. The teeth of our people, and especially of the young, are deplorable. This is something to be considered from an early age, but without dentists how can it be done? Should not a dental consultant be included in the district or the Area as a matter of course? I feel strongly about this because for many years I was Chairman of the School at the Royal Dental Hospital in London and I have heard this discussion of the lack of attention to teeth from childhood onwards. Therefore I should like to ask the Department to consider this matter.

I end by saying that I do not believe the Health Service is in danger of collapse and I do not believe that it needs any more drastic surgery, which I think is likely to do it more harm than good. I have great faith in the Health Service and in the people who work in it. They are all going through a very difficult time at the moment, but I do not despair. I think that if they can be left alone, free from political and what I would call managerial interference, we could trust their natural good sense to see that what we have already is made to work efficiently and effectively.

5.46 p.m.

Lord HILL of LUTON

My Lords, if I seek briefly to address your Lordships on this subject—one on which I have not spoken in either House for 25 years—it is because I think that some of the happenings of 30 years ago, prior to the inception of the Service, have relevance to the lamentable and potentially dangerous situation in which we are today. I would make three points to your Lordships. The first is a negative one: so far as I can recall there was no reference whatever throughout those tempestuous years—when there was often more heat than light and some intemperate remarks were made—to junior hospital doctors. I suppose this was because, both pre-War and in 1945. the position and attitudes of junior medical officers were entirely different. There were fewer of them and there were fewer layers; certainly there were fewer senior layers. But in those days—I go back to my own qualification nearly 50 years ago—we competed for house jobs, we fought for hospital jobs. We regarded them as essential to the completion of our education. We did not resent being on call: indeed, we did not want others to intervene in the treatment of our patients. That was the old world, and indeed the world has greatly changed since then. There was no mention of overtime in those days. I suppose what has happened is that the junior medical officers have been looking around and seeing what has been achieved elsewhere by militancy and muscle, and have decided to follow the lead of others, something which my generation inevitably deplores.

The second point is this: in those years of disputation which were lively, vigorous and, with Nye Bevan as Minister, often exhausting, the basic issue was the fear of the profession that it would be converted into a whole-time salaried Service. Although there were many variants of that theme, that was the basic fear. As the noble Baroness, Lady Summerskill, has said, that was Labour Party policy, which she helped to make. It was Labour Party policy, and they feared that Mr. Aneurin Bevan would apply that Labour Party policy in devising the Scheme. In the event, Mr. Bevan was far wiser than to take items of policy pronounced before an Election and seek to apply them to his Scheme. Even when the Bill was first published and it was evident that it was not a whole-time salaried service that was being proposed, still the fear continued.

Doctors fought in those days for the free choice of doctor and patient, for clinical independence and against any kind of scheme in which the doctor's responsibility would be to the State and not to the patient. I am not now arguing that case or reviving old controversies; I am stating that that was the theme behind all the many and varied forms of opposition. It was not satisfied even when an amending Bill was introduced, which ensured that there could not be a whole-time salaried service by regulation under the National Health Service Act. That weakened the opposition of doctors although there was still a majority against entry, but not of sufficient size to justify the BMA's advising doctors not to enter. That was the fear, founded or unfounded, real or imaginary, which led to that violent, prolonged and disorderly conflict.

The third relevant item is this. At the outset of the controversy—I must choose my words carefully—the consultants were not, for the most part, particularly interested. They had not been accustomed to discussing bread and butter issues with Governments. That was lowly work for the BMA. There were even some consultants who thought that, because of its preoccupation with political work, the BMA was just a trifle common. But the main factors arousing the enthusiasm of many consultants for the Service were twofold.

Mr. Aneurin Bevan did not do what had been urged upon him by many of his own Party; that is, to place the voluntary hospitals under local authorities. Mr. Herbert Morrison, a good local authority man if ever there was one, believed that the way to unite local authority and voluntary hospitals was to put voluntary hospitals under the State. Nye Bevan had the courage and the imagination to produce a new hospital service in which voluntary and local authority hospitals were married into one new service. That profoundly relieved many consultants and specialists.

The second thing he did was to decide that private consultant and specialist practice would be permitted inside the National Health Service hospitals. This was not a subject for argument or negotiation. Mr. Bevan produced this as a decision and gave his reason. Above all, he wanted to avoid a rash of nursing homes. He wanted the whole of the consultant's work, public and private, to be done within the same hospital. It was those two elements in the hospital scheme which led to the acceptance in general, by consultant and specialist, of that new hospital service. I shall not argue that that was an undertaking which he gave in perpetuity; he was not in a position to give an undertaking in perpetuity. But the reason he gave then is relevant to the issue today, that there should not be developed outside the Service a rash of nursing homes.

I gather, from what the noble Lord, Lord Wells-Pestell, said, that the view of the Government is not against a continuance of private practice, but against a continuance of private practice within the boundaries of National Health Service hospitals. I am glad that that has been said. It is not the view of every policy-maker in the Labour Party. It ought to be said that there is a powerful case from the angle of the citizen, the potential patient, in favour of a continuance of private practice. Put simply, there are people who want privacy who are willing to pay for privacy, who would rather spend their money on BUPA than on bingo. They are willing to do so—indeed, they are anxious—and 2.3 million people have expressed the desire to be insured against the need for consultant and specialist treatment, and insured so that they can have it privately.

Let us face it, my Lords. There are busy men in responsible positions—not excluding Ministers—whose lives, whose responsibilities, whose need to keep in touch with the outside world demands a kind of privacy and separation. I know Ministers who go into amenity beds or into pay beds, the sole difference being that in amenity beds they have to pay only for the board and lodging; they do not have to pay for the consultant and specialist service. There is a strong case. But what the Consultative Document says is that private practice shall not take place in, and shall be phased out of, National Health Service hospitals.

I believe that to be wrong for a number of reasons. I believe it to be wrong for Nye Bevan's original reason; that is, that it will encourage a rash of nursing homes, despite the licensing provisions on which I shall say a word in a moment. I believe it to be wrong, because it departs from the present position in which the consultant, in the one place where he spends the bulk of his time, can treat all the patients, public and private, alike. This proposal means a great deal more time spent in travelling.

I believe it is a proposal which will lead to the person who wishes for privacy and is willing to pay for it—the person who, in the Minister's view, is entitled to have it—having a service which is often inferior to the one that can be obtained in the National Health Service hospital. Such is the cost of modern services, such is the cost today of all the apparatus of modern medicine, that it will be highly expensive to repeat those services in private establishments; I doubt whether, apart from a few establishments, it will ever be done. I believe that this substantial section of the community is being relegated, in some cases, to a lesser service.

But there are three embellishments on this. The first is perhaps a rather minor but remarkable one. If you are a foreigner, an incomer, you can go into a private bed and pay the professional fees. Mind you, my Lords, no member of the profession will get the fees; they will go into the national kitty. In other words, if you are an Arab sheikh or an oil millionaire, that is fine. But if you are a modest fellow of medium income, who is insured with BUPA or PPP, you cannot go in. What a remarkable thing for a Labour Government to produce! If you are foreign and moneyed, that is fine; if you are poor but insured, No. That is contained in the Consultative Document. I do not attach a great deal of importance to it, but it is worth mentioning.

Secondly, there is the licensing scheme of which I am extremely suspicious. Licensing for quality, Yes. Another look at the licensing provisions for nursing homes generally, Yes. But, in this case, power is taken to freeze the level of acute beds, beds for acute sickness—they are called "short stay beds" in the Document—to the level which obtained in March 1974; I should add, the number of pay beds in hospitals, plus external beds in nursing homes. When we see the Bill I suspect that it may provide power for the Minister to change that limit either up or down, but I believe this to be wrong. How can Parliament now decide, by mystic guidance, that the level of March 1974 is right for those private patients who, denied National Health Service hospitals, have to go into private accommodation? I think that the temptation is far too great for a Minister to use that licensing power and a very complicated procedure is laid down in order to make the National Health Service incomparable by destroying its competition. This is an extreme statement, but I believe that this could be in the minds of certain people.

Thirdly, private practice is to disappear from the outpatient departments, with certain exceptions. Radiotherapy is mentioned and during the discussions no doubt there will be others. I find this a little odd. If private hospitals have to seek to provide services similar to those available in outpatient departments today, an expenditure far beyond their means will be incurred. Again, this will worsen the service that is available to the private patient and deny outpatient services to him which it will be difficult to provide in other places, It is a curious situation. If you go as a National Health Service patient and pay nothing you can have it all, but if you go as a private patient—well, you cannot go as a private patient; you have to go as a National Health Service patient unless you go to what may well be a less adequate service elsewhere. Therefore, the conclusion I reach is that this could be a first step towards the destruction of private medicine.

There is a passage in the Consultative Document which has been mentioned but not quoted. It is ambiguous but it ought to be heard: It is the clear and openly stated policy of the present Government that it does not believe that private medicine is something which deserves the support of the State. The Government does not, however, believe it is desirable to express such a policy in the form of legislation designed to ban private medicine. The Government is, therefore, not proposing to abolish private medicine but is committed instead by its Manifesto of February 1974 to phase out private practice from the hospital service. I frankly admit that this passage is rich in ambiguity, but I suggest that behind it is the ill-concealed intention that instead of going straight at it by legislation and arousing widespread opposition in the country you should go at it bit by bit, first by the destruction of private beds within National Health Service hospitals.

Finally, what bothers me is that this is where I came in 30 years ago. It was the very fear of what was believed to be a move towards a whole-time salaried service, with the loss of professional independence and the absorption of private practice, that led to what I was about to say was a frightful experience but which nevertheless was a difficult, prolonged and unsatisfactory phase that did very little good. Why are the Government doing this now? Have not they enough problems on their plate? Is not the country confronted by enough problems without inviting this confrontation that will do no good either to the Service or to the Government?

As for the answer that it cannot be referred to the Royal Commission because it is a matter of political policy, I have never heard such bunkum in my life. Of course, political issues are reported on by Royal Commissions. What about the Royal Commission on the Distribution of Wealth? If ever there was a potentially explosive issue that was it. This is nonsense. It means that such are the political pressures on the Government that they are afraid to do the sensible thing and refer this, with the other questions, to the Royal Commission. Are the Government afraid that a Royal Commission of independently-minded persons may advise them that this is a bad thing to do? If it does, they are not bound by the Royal Commission. Although, with the Minister, I hope that today's muted communiqué means hope, it might lead to a disastrous situation if the discussions are not successful.

The whole position can be defused if the Government are sensible, do not depart from their policy and remember how Nye Bevan interpreted Party policy in the early days. He would have used the same kind of ranging intelligence and imagination today and would have referred this, with the other matters, to the Royal Commission to report on all the problems. Is that too much for the Government to do? It would bring to an end one aspect of this problem that disturbs me most because it is based on fear and emotion. One can be so illogical in both discussion and action. If the Government cannot find a different and a better formula, I appeal to them to take the simple step not of retreating from the policy but of deciding that this problem is so bound up with the other problems that the sensible thing to do is to refer it to the Royal Commission.

Baroness GAITSKELL

My Lords, before the noble Lord sits down may I ask him whether he is quite sure that when the Labour Party introduced the National Health Service Act it was against private practice? I have never heard that said.

Lord HILL of LUTON

My Lords. I must apologise to the noble Baroness if I gave that impression. What I sought to say, and it must be my own fault if I have not made myself clear, was that when the Act appeared it was clear that it did not involve a whole-time salaried service. Despite that, the controversy continued because emotions and fears had so unreasonably been aroused. That was my point.

6.8 p.m.

Baroness STEWART of ALVECHURCH

My Lords, I listened with very great interest to the maiden speeches of the most reverend Primate and the noble Viscount, Lord Kemsley, and I hope that we shall have many opportunities of hearing them in the future. In the pay bed dispute I support the view of my Party that the aim of the National Health Service must be to provide the best possible treatment for all members of the community, irrespective of their occupation and income level, and I do not think that the present system of private pay beds is compatible with that aim. The advantage to a private patient in a private pay bed is not only that it provides privacy but, far more important, it enables the patient to obtain treatment at the time it is required. In many cases that are dealt with by hospital doctors, early diagnosis and immediate treatment are essential for full recovery. Unfortunately, owing to long hospital waiting lists many people suffer much pain and discomfort while waiting for hospital beds. In addition, the treatment that they ultimately receive may not be as effective as it might have been had it been given at an earlier stage.

We have to face the fact that despite the ever-increasing skills of the medical profession it is still not possible to assess, in advance of hospital tests, the exact degree of priority, in medical terms, that a patient should be given. Since medical treatment is not a luxury like a holiday abroad, there can be no justification for a pay bed system which enables some patients to jump the queue. But I hope most sincerely that during the next few years there will be a significant increase in the number of single and small wards for patients who need and want privacy. As your Lordships will know, in some of the new large hospitals there are many small wards, varying in size from one to six beds, so that patients can have the degree of privacy that suits their illness and their temperament. Other hospitals have amenity beds available at a small cost. We still have a long way to go, but in a period of economic crisis quite clearly we must accept that such funds as are available must be devoted to the patients' essential needs, and I think they do not normally include a private ward.

We must all welcome the setting up of the Royal Commission on the National Health Service, and as its aim is to consider the interests both of the patients and/or those who work in the National Health Service I hope its members will include not only representatives of the professional bodies and the voluntary services but also the general public, who include a high proportion of manual and clerical workers. I should like to suggest also that the Royal Commission should contrast the system of management and communication in the Health Service with that of other public bodies, and perhaps, particularly, education. Education seems to manage very efficiently on what I would call a two-tier system, and I think perhaps the Health Service might learn a lot from a comparison of their ways of working.

In conclusion, may I say that I agree with the noble Lord, Lord Aberdare, that we should look at the good as well as the bad in the Service, and also that I personally continue to believe, in spite of the present crisis—which I hope is nearly over—that our Service is one of the best in the world.

6.12 p.m.

Lord COLWYN

My Lords, I should like to thank my noble friend Lord Aberdare for introducing this debate today, and also to offer my congratulations to the excellent maiden speakers. As a practising dental surgeon, working partially within the National Health Service, I have a strong personal interest in the present state and the future of the Service. I still believe, and agree with the noble Lord, Lord Porritt, that we have a Health Service which comes close to being the envy of the world: certainly from its patients' point of view, if not immediately in the view of the Government or its health workers. It has an impressive record of giving the community value for money. To the people who work in this Service it gives a remarkable degree of freedom to do what is best for patients without having to worry about whether or not they can afford to pay. All recent Governments have recognised that the Health Service is a national asset of immeasurable value. There is only one thing that has ever really been wrong, and that is we have never given it enough money.

Times are hard, and we cannot improve the Health Service until the economy is back on its feet again. But if we cannot give the Service the one thing it needs—more real, as opposed to inflated, money—then let us not pretend that anything else will do it any good. The recent much-publicised pay increase, which the noble Lord opposite referred to, barely covered my increase in practice expenses. Too often Governments—and I include my noble friends on this side of the House—seem to be trying to persuade us that the real problem is not under-financing at all. The solution to the problem last year was reorganisation. The original tripartite structure seemed managerially untidy, and although it worked well enough no one could understand how. So the Service was overhauled, at enormous expense, in the interests of more rational decision-making and the more efficient use of resources. But does anyone now believe that a three-tiered structure is much better than a tripartite one, or that the upheaval amounted to much more than an administrator's bonanza, much the same as the local government reorganisation?

The management dogma of reorganisation was, I am afraid, largely irrelevant to the real needs of the Service; so—and to a much greater extent—is this year's dogma, the separation of private practice from National Health Service hospitals. Unable, for the time being, to improve the State-run health services the Government choose to restrict the development of any other sort of Health Service. The Consultative Document issued in August makes no attempt to justify the phasing out of pay beds or the quantitative restrictions on the licensing of private hospitals. And indeed, they cannot be justified in terms of resultant improvements in the National Health Service—only in terms of Party doctrine.

The amount the Exchequer will lose when pay beds are phased out has been estimated at £26 million worth of annual income. There will be no noticeable reduction of hospital waiting lists, which are largely the result of staff shortages and under-financing. Pay beds constitute but 1 per cent. of all National Health beds: if they were no longer used as such, then some at least of the patients who now occupy them privately would in the future require to use them as National Health Service patients. Moreover, the National Health Service at present hires from independent hospitals almost as many beds as the number of pay beds in National Health Service hospitals. Separation will certainly diminish the availability of this source of "reserve" beds and, on balance, there will be no gain in the total number of available National Health Service beds.

Some consultants, including some of the best, will be lost to the Health Service altogether. Others will waste time travelling between National Health Service and private hospitals, and there will be an increased risk of particular consultants being unavailable in emergencies. The private sector, separated from Health Service hospitals, will be forced to duplicate treatment facilities unnecessarily.

But the proposals do more than simply create inefficiency. However much the Government may now deny it, they are a first large step towards a complete State monopoly of health care, involving, I suspect, the total elimination of the independent sector of medicine. Will NUPE and COHSE be satisfied with mere separation? How soon will it be before there are picket lines around private hospitals? How soon before separation is extended to general practice?

This worry is not without sound foundation. As the noble Lord, Lord Hill of Luton, has pointed out, in a DHSS paper of September 1974 it is claimed that the controversy over private medicine has seemingly been heightened as a result of the inadequacies of the National Health Service. The simplest way, they say, of resolving these tensions and controversy is to abolish private medicine entirely. We are given to understand that the Government strongly disapprove of independent medicine and have declared their support for a monopoly State service. I will not continue with the quotation, as the noble Lord, Lord Hill of Luton, has already done so, but can it be doubted that this or a later Government will seek to put an end to independent medicine at the earliest moment that they think it politically expedient so to do?

Undoubtedly the proposals are the first shots in a major attack on the citizen's freedom of choice in health matters, and on the freedom of the medical and dental profession to do what is best for patients without State interference. To a degree which is quite unprecedented the bodies which speak for doctors or dentists are united in opposing the Government's plans. And let us be quite clear about it: they are motivated by professional rather than financial considerations. Many doctors and dentists work entirely within the Health Service. Most others have only a small amount of private practice. Three-quarters of my colleagues in the dental profession work in general practice, in premises and with equipment which they themselves own. They are paid by the National Health Service on a fee basis rather than by salary and are completely free to refuse to treat patients under the National Health Ser. vice. But in fact the average dentist earns more than 90 per cent. of his income from the Health Service and he works the equivalent of full-time hours for the Ser. vice, treating patients privately in what is in effect his spare time. So it is a principle, not a financial interest, which is at stake. The right to practise privately, even if not used, is the one thing which guarantees the professions their independence. The existence of a private sector is a stimulus, not a threat, to the Health Service.

Again speaking of my own profession, in most cases dental practitioners have complete discretion to decide what sort of treatment a patient needs, and the Health Service pays them known and nationally agreed fees for providing this treatment. But for a small number of uncommon, highly complex or new treatments, fees are at the discretion of a pricing bureau, the Dental Estimates Board. For some of the more expensive treatments, dentists must have the approval of the Board before starting treatment. Most of my colleagues, I think, would say that the Dental Estimates Board generally does a difficult job very efficiently, but there certainly have been times—and the early 1960s was one example—when the DEB has used its powers in a very restrictive way, by refusing to pay for certain treatments, or paying for them inadequately.

It is in circumstances of this kind that the provision of treatments privately shows the public what it is missing, and puts pressure on the Health Service to improve. This happened when chrome cobalt took over from stainless steel for making metal dentures; when porcelain took over from plastic for crowns, and when composite filling materials were introduced. It was quite uneconomic for these new materials to be used in Health Service practice when they first became available. They are now used extensively, and it is certain that it was the stimulus of private practice which brought this about in such a relatively short time.

My Lords, may I take up the point mentioned by my noble friend Lady Ruthven of Freeland. The same situation exists today in the case of preventive dentistry. Are your Lordships aware that the basic preventive measures of using topical fluorides or fissure sealants to prevent children's teeth decaying are not available under the National Health Service? They have to be provided privately. It is time-consuming and consequently expensive. Even the provision of a dental prescription for fluoride tablets is not available under the National Health Service. Eventually, the Health Service will have to relent. Of course, most rational people would agree that there is a better, cheaper and more effective way of preventing dental decay. For something like £5 million a year, we could fluoridate the water supply of the whole country, and cut the incidence of decay by half. Why do we not do it? Why do we not take this ridiculously cheap and elementary step towards making the community healthier? It might possibly have something to do with the fact that, as of right, dentists are not represented at any of the key decision-making points in the reorganised National Health Service. The requests of the dental profession for improved representation have been repeatedly turned down by both the present and previous Governments.

The Secretary of State announced on 11th July that the Government had decided to proceed with the proposal that there should be additional members on each Health Authority, two to be drawn from the nominations of local authorities, and two to be drawn from those working in the Health Service, other than those already represented. Despite continued requests from the British Dental Association, a representative from my profession is not yet included. I shall be most grateful if the noble Lord opposite will give me an explanation for that.

My Lords, I have spoken long enough, but my point is a simple one. If we cannot give the Health Service the additional resources it needs, let us leave it well alone; and, in particular, let the Government reconsider their misguided plans for the separation of private and Health Service practice.

6.24 p.m.

Lord PLATT

My Lords, the debate already has gone on for a long time. Your Lordships already have heard from six medical speakers, and there are two more to come. Therefore, I have torn up the notes of most of what I was going to say—in any case, others have said most of it already. I should like to congratulate our two maiden speakers, both of whose speeches I enjoyed very much indeed. I congratulate the noble Lord, Lord Colwyn, on having brought money into the subject. I think that is what the Health Service needs, perhaps more than anything else. For the rest, I would make one or two comments on what has already been said, and then say something about pay beds from perhaps a different point of view than has been dealt with up to the present.

Some of my noble colleagues give the impression that all was right with the Health Service until quite recently. Of course, this is not true. They give the impression that this strike mentality, which is so grievous and so horrible to me as a medical man, is also something new. But do they forget that once every few years the British Medical Association has collected signatures for a mass resignation from the Health Service? Do they forget the days, about which the noble Lord, Lord Hill of Luton, reminded us in a notable speech, when the BMA was, until the last minute, advising the profession to keep right out of the Health Service altogether? Then, the noble Lord, Lord Porritt, seemed to think that after a few years in which it worked well things began to go wrong, and that was why the Review Committee was set up. But does he forget the leaders in the British Medical Journal during those ten years, and the vicious attacks which were made on the Health Service—which I remember 20 years ago or more—saying that it "was grinding to a halt"?

However, those are just comments on history which are not really very relevant to the present situation; except for one more, which I had forgotten. Other noble Lords have spoken about the junior doctors, who surely did not start striking until after that degrading fiasco of the consultants' work-to-rule. If people begin to wonder why junior doctors are behaving in this peculiar way, it is possibly because their seniors are behaving in a very similar manner. The noble Lords, Lord Stamp, in what I thought was perhaps a rather too personal attack on the Secretary of State, spoke about the necessary standards of tact and understanding. Does he think that the BMA in all their transactions with the Government have shown the necessary tact and understanding? If so, then he and I will have to differ on that.

As to pay beds, my only excuse for bringing this matter in once again, because it has been spoken about a great deal, is that I have had the experience —and I may be perhaps the only one in this House who has had that experience —of being in consulting practice as a physician, making my living entirely from private fees, because in those days we were not paid for our hospital work; and I have later spent many years as a Professor of Medicine receiving no fees whatever, although I was paid a salary. So I see it from both sides. The point which I think deserves mention, and which has not been mentioned—or certainly has not been emphasised—is that private practice is an extraordinarily good education for a doctor; it really is. You are on your own. You have not got a staff of people to whom to delegate jobs. You cannot tell them to go and talk to the parents of a sick child; you have to do it. All these things you have to do yourself. You stand on your own, and you feel a sense of personal responsibility to a greater extent, I would say, than you ever feel in a hospital where there are so many other people who can act with and for you.

I personally feel that most of the men and women in medicine whom I have admired in my time have been those who have spent most of their working life in hospital but who have nevertheless also been engaged in private practice. They are the people who I think carry an enormous reputation for British medicine, both at home and abroad. I think that it would be a disaster if they now started to do their private work elsewhere than in the hospitals, if that is where they are doing it now. I really think it would be a disaster. I think gradually it would build up two kinds of consultants, those who are after the money in plush private hospitals, and those who have not the patience to do that kind of work and will devote themselves entirely to the hospital, to the great detriment of both to my mind. The ones who remained entirely in hospitals would be of two kinds, those devoted to research or those who are doing laboratory services and so on, who are normally whole-time hospital people, and those who are perhaps a little second-rate and not able to build up a lucrative private practice. I think it would bring back all the worst features of medicine before the Health Service.

As for queue jumping, I do not see how this is going to he prevented by this means. There are other ways; there are ways, monitoring waiting lists and so on, in which this can and should be tackled. With regard to amenity beds, I always thought they were a fine idea. They never worked because no hospital that I knew ever had enough amenity beds. But if you say, "All right, I will come in when you send for me, but I want an amenity bed", then do you wait longer or do you wait a shorter time? Somebody is bound to jump some queue somewhere. Or if we all go on a common waiting list, and if, as sometimes happens, you wait for a year to have a hernia operation and then suddenly get a telegram to say there is a bed for you—probably on Good Friday and nobody will look at you until the following Wednesday, but bed occupancy has to be kept up—and you say, "I am attending a Foreign Ministers' conference at Helsinki on that day and I cannot come", do you go to the bottom of the waiting list? In other words, I think admission to hospital according to medical need and for no other reason is a fine phrase, but I do not think it will ever work, whatever system is put into operation.

What I think the Health Service needs most, apart from money, is a period of real co-operation between the profession and the Government because a lot of the faults are due to the profession itself and a lot of them are due to the Government. I think it needs a real, willing co-operation betwen the two, what the noble Lord, Lord Porritt, called at the end of his speech "a re-establishment of trust and friendship between Government and the profession". My only amendment would be to leave out the "re", because I do not think it has happened before.

6.34 p.m.

Lord COTTESLOE

My Lords, I do not go so far back as my noble friend Lord Porritt, but for more than a quarter of a century I have been deeply interested and involved in the Health Service, its well-being and its development. I have no financial interest that I should declare to your Lordships; I have never had such an interest. But as a layman, as Chairman of a Regional Hospital Board responsible for administering 150 hospitals, and also of Hammersmith Hospital, which draws doctors in large numbers from all over the world for specialist training at the Royal Postgraduate Medical School and at the British Post-graduate Medical Federation, which administers the teaching institutes of the specialist post-graduate hospitals, in these and in other capacities, I have been immensely proud to be given the opportunity to play some small part in the development of what was until recently quite certainly the finest Hospital Service of any country in the world. I say "was" because, as we must all admit, that Service, built up since 1948 by the enthusiasm and determination of the great host of devoted men and women working in it—doctors and nurses and administrators, porters and domestics and drivers, and the great army of workers with the common purpose of service to the community—is now very sick indeed.

The noble Lord, Lord Porritt, gave us a diagnosis of that sickness, and diagnosis is not really very difficult. The treatment that will restore the Service to health is not so easy. Some of your Lordships may recollect, in the Cautionary Tales, the doctors attending young Henry King: They answered as they took their fees, There is no cure for this disease Henry will very soon be dead. It is not quite as bad as that, but urgent and drastic steps must be taken if the Health Service is to be restored to health. It will be a long struggle, requiring first the restoration of morale, a spirit of unity and common purpose.

My Lords, the reorganisation of the Service that took place last year was the culmination of a long period of planning and discussion under successive Ministers of Health of both the main Parties. There were, of course, differences over detail; but it was broadly a bipartisan operation, initiated by Mr. Kenneth Robinson when he was Minister of Health—I am proud to call him my friend—later continued by, among others, Mr. Richard Crossman, and finally brought to birth by Sir Keith Joseph. For some considerable time before the reorganisation took place morale in the Service, which had been notably high during its expansion and development in the previous 20 years—remarkable development fed by the fruit of much wonderful research and the fine teaching in the schools of medicine and nursing—had latterly been undermined by the doubts and uncertainties about the future which resulted from this long period of discussion before the plans for the reorganisation finally crystallised.

The Service was then, even before the reorganisation took place at the end of March last year, in a condition of lowered morale that rendered it susceptible to the malaise of industrial unrest that was becoming widespread in this country. That infection began to manifest itself in the hospital service, even before the reorganisation, by small but significant signs. For example, theatre porters, when asked by the theatre sister to bring up the next patient for operation, said "Perhaps we will when the rain stops", or "When we have finished our game of cards". Those are actual incidents. Then, of course, the reorganisation itself was, as is now evident, in some ways ill-advised, throwing overboard overnight the great body of voluntary workers with much experience and much good will, and burdening the Service with a bureacratic, cumbersome and very expensive administrative organisation. It was, as it has turned out, most unfortunately timed, for the economic crisis with violent inflation had the effect almost immediately of eating up the resources that should have been available for the physical modernisation and rebuilding of hospitals and their re-equipment all over the country, which is most urgently needed. This of course further depressed morale and fostered industrial unrest.

But that was not the worst. The injection of political Party dogma in the most hamhanded way, particularly over the issues of pay beds and private practice, has reduced the whole Service, not only the doctors but everyone devoted to it, to a condition of frustrated exasperation, a condition of despair that is without any precedent. So far as the doctors are concerned, I personally regard their action in restricting their services as utterly unjustifiable, but it is possible to understand its origins—nothing less than a condition of extreme frustration and exasperated despair could have brought a body of men and women who, for the most part, are selflessly devoted to a noble profession, to unite in such an action.

What then should be done? There are two things that I think could and should be done as matters of extreme urgency which would create almost overnight a great upsurge of morale. The first is the inclusion of the pay bed issue in the terms of reference of the Royal Commission. It is, after all, not a matter of any extreme urgency. Although it is widely said and believed that they enable the long purses to jump the queue, the fact is that the number of pay beds is so small a part of the whole that their abolition would have virtually no effect whatever on waiting lists. And meanwhile their abolition entails throwing away a substantial sum, estimated variously between, we have heard, £26 million and £40 million a year, that would in the present financial constriction be of immense value in enabling at least some modernisation and rebuilding to go forward.

What could be greater lunacy—I can use no other word—than to appoint a Royal Commission and to prejudge, to exclude from its impartial survey, the most controversial and damaging question of the day? No doubt it may be said that such a reference would be a victory for the doctors. It would not. It would be a victory for no one. It would be a victory only for common sense. The other step that could and should be taken, a step that would produce an immediate restoration of morale in the Service would be, let us face it, a change of Secretary of State. Whatever her merits of energy and drive—and they are great—there can be no doubt that the deplorable fact is that those who work in the Service feel desperately frustrated, in the main because the Service has now become what it never should have become—a political pawn. There can be no doubt that their despair arises from the injection of politics into the Service, which they believe, rightly or wrongly, to be due to her. A change there would change the whole complexion of the Service overnight.

Baroness SUMMERSKILL

My Lords, may I ask the noble Lord a question? This is a very strong statement. He knows Parliament well, and he must know that the Secretary of State reflects the decision of the Cabinet. Changing her will not make any difference. We shall get somebody else who will reflect the same decisions.

Lord COTTESLOE

My Lords, I have chosen my words carefully. I feel bound to say what I think, as do other noble Lords when they speak. An upsurge of morale produced in this way would not of course solve the basic problems of lack of resources; the constant drawing away of the best professional brains, medical and nursing, from the immediate creative task of looking after the sick into the sterile field of administration; the egalitarian doctrine that would starve the Service where it is at its best in order to spread the butter more widely but more thinly—to reduce, in fact, everything everywhere towards the lowest common denominator; the denigration of higher education, postgraduate teaching, and the research in which this country leads the world. How tragic it is that research, of which the fruits provide the essential life blood of development in medicine, should have become in some quarters almost a dirty word.

The Royal Commission will no doubt have a good deal to say about these and many other matters, and there are, I think, many detailed aspects of the Service that might fruitfully be referred to King Edwards Hospital Fund or to the Nuffield Provincial Hospitals Trust for urgent examination and advice. The Hospital Service, we must hope, will steadily, though I fear at best slowly, recover from its present grievous sickness. But the essential prelude to that recovery must be a change from the present condition of despair to one of hope, a restoration of morale, which can in my belief only be restored by the measures of which I have spoken.

6.47 p.m.

Baroness ROBSON of KIDDINGTON

My Lords, may I take this opportunity of thanking the noble Lord, Lord Aberdare, for introducing this subject for our debate this afternoon, and at the same time apologise to him because I shall be unable to stay until the end of the debate. Unfortunately I have a National Health Service commitment at half-past seven. I regret very much that I shall not be able to remain.

Much has been said on both sides of the House, originally by the noble Lord, Lord Aberdare, and afterwards by the noble Lord, Lord Wells-Pestell, about re-organisation, and the reasons for the lowering of morale in the Health Service as a result of reorganisation. I think that what both noble Lords said was true, but I believe an additional fact which has not been mentioned this afternoon but which was responsible for the lowering of morale in the Service was the fear in the minds of people working in the National Health Service that, as a result of the change of Government, the new Government were once again going to reorganise the Service and change the present three or four tier system. I should therefore like to pay tribute to the Secretary of State for the statement she made in the other place at the end of October when she clearly stated that it is not the Government's intention to change the actual structure of the present reorganised Health Service.

I believe from my personal experience at the regional level that this particular statement will have, and has already had, a marked effect on the morale of the people working within the Service. It was certainly to a great extent that feeling of uncertainty, and the fear that they may have to go through the traumatic experience of applying for their own jobs yet once again, that was responsible for a large part of the lowering of morale which had taken place since reorganisation.

I appreciated very much the comments of the noble Lady, Lady Ruthven of Freeland, about the National Health Service because she was one of the first to concentrate on what is still good about the Service, and for those of us who are involved it is necessary to concentrate on what is good about it. I believe that the first signs of the results of reorganisation for the good of the Service are just beginning to come through; there are great signs that the working together of the community and the hospital nursing services is producing benefits for the patient and for the Service as a whole. All these things are heartening and we should remember them when we complain about the present state of the Service.

Something which I am anxious should be proceeded with and which, in my own way, I have attempted to impress on the Department is the need to delegate authority down the line. It is not possible for the Regional Authority to delegate authority until some authority is delegated to the Region from the Department. I feel that in the matter of the delegation of authority, the Department has been dragging its feet in no uncertain terms. I regret that I shall not be in my place when the noble Lord, Lord Wells-Pestell, answers the question posed by the noble Lord, Lord Aberdare, about the number of employees in the Health Department of the Department of Health and Social Security because I suspect that it has increased beyond all reasonable bounds. It seems to me quite unnecessary that in the regional division of the Department of Health there should exist an opposite number for every regional officer in the Regions.

Lord WELLS-PESTELL

My Lords, I do not want to stop the flow of the noble Baroness's remarks and I intervene only because as she said, she will not be here to hear my reply to the debate. My understanding is that it is difficult to give figures for the precise dates mentioned by the noble Lord, Lord Aberdare. However, I can tell the House that over the 20 months since April 1974 the number of staff in the Department's Health Headquarters has increased from 4,664 to about 5,000, which was mainly junior staff and many of them were filling vacancies which had been in existence for a considerable time: there had been difficulty getting staff. We have no reason to believe that in the fore. seeable future the figure will increase beyond that. I hope that that information will be of assistance to the noble Baroness.

Baroness ROBSON of KIDDINGTON

My Lords, I am grateful to the noble Lord for that information and I am glad to have received it before leaving the House. Nevertheless, if we are to make a success of the reorganised Service—and I believe that we can make a success of it—it is necessary to delegate authority to the greatest possible extent to the local level, and this cannot be done except by starting at the Department itself. I am, therefore, anxiously looking forward to the debates on the Working Party's Report on devolution, which I understand is now available for discussion. I hope that as a result of consultation about that Report, delegation and devolution can really begin, because in my view that was the whole point of the reorganisation of the National Health Service.

Many noble Lords have spoken about the present impasse among doctors, consultants and the Government and the Government's statement that they cannot withdraw from their Manifesto commitment to phase out private practice from the Hospital Service. In a circular issued by the Department of Health in September 1974—the first occasion, I think, when a reference was made to the Labour Party Manifesto; it was a consultative document for a joint working party—the Government stated: The Government's policy over private practice has not been changed by the action taken by NUPE at Charing Cross in July of last year. This action confirmed, as did similar action over the previous few weeks by COHSE, that some of the NHS staff were so dissatisfied with the present situation over private medicine that they were prepared to use it as an issue to further their pay dispute. To me, that was the saddest day that ever happened in the National Health Service because it created a most dangerous precedent; it happened, I believe for the first time, that political ideology interfered with the normal working of the pay negotiating machinery. I cannot help but feel that the present dispute between the Government and the consultants over private practice stems in some way from the introduction of political ideology at that time.

The Government have throughout claimed that they are determined to proceed with their policy commitment to phase out private beds while at the same time carrying on the fullest discussions with all parties concerned. The consultative document that has recently been issued on private practice and which is now circulating for consultation with all interests cannot in my view create the right kind of confidence which is necessary for true consultation because it is backed by an already taken political decision which the Government say is irreversible. I do not call that consultation.

I think it was Sir George Godber who said that because progress in the Health Service depended so much on the acceptance of chance by the health professions, it must be achieved by persuasion and support rather than by the direction and imposition of elaborate central plans. This is what the Government should do. They should be big enough to admit that private practice, private pay beds in National Health Service hospitals, is such a burning issue that it must be referred to the Royal Commission. I also believe that only the Royal Commission can look at this problem dispassionately, can assess it and recommend before this country takes a political decision which it may regret for a long time to come.

6.57 p.m.

Lord REDESDALE

My Lords, many speakers have their names down for tonight's debate and I think the best contribution I can make—one that will be welcome by many noble Lords—is to be as brief as possible. I shall also be as constructive as possible. We are in a situation where there arc a great many problems and recriminations, but I wish to concentrate on the one issue of morale. It has been spoken of many times in this debate but I feel that there are a number of lessons to be learned from the present situation. I hope, therefore, that the noble Lord, Lord Wells-Pestell, will not take my remarks as representing an attack; I am merely trying to build on some of the events that have occurred.

Morale is the sort of subject one hears about in after dinner speeches. One hears either that morale has never been so high or has never been so low. At the moment, morale is undeniably low and there are a whole lot of reasons for that. It is not just the pay of junior doctors, and many of the reasons—as the noble Lord, Lord Wells-Pestell, will accept because he is a fair-minded person—go back long before 1974. There are lots of little niggles. The problems of morale are cumulative; they build up. For example, in the past there was perhaps a greater team spirit in the National Health Service, but this has been rather depersonalised.

In giving a few small examples I hope that noble Lords will not consider that I am wasting the time of the House. Junior doctors' dining rooms are being abolished; but these dining rooms meant a lot to them because they could discuss patients in an area where doctors were alone. Now they are to be in big dining rooms, with lots of lay people present. They have lost that amenity. Another simple example is the pay-as-you-eat scheme that has evolved over the years. Tea and coffee on the wards meant that everyone could have a chat, but that amenity has disappeared. Tea and coffee on the wards is now frowned upon. It meant that people could talk, and the Health Service is about people and about team, work.

There are countless other irritating factors which have built up over the years, but I will not weary your Lordships by describing them tonight. It has been said that, in the past, junior doctors in private medicine waited years for promotion but they did not complain, whereas now, under a Labour Government, they are complaining. Perhaps the reason was that, in those days, they had a great deal to look forward to on becoming a consultant. Now, a senior registrar can take a cut in salary when he becomes a consultant. Therefore, the incentives are going. Doctors are human and, like everybody else, they must have incentives. Theirs is a vocation. They will work all hours, as we know, but they must be rewarded at some point along the line.

The junior doctors have been thoroughly castigated from various sides of the House for striking. I do not know whether all noble Lords are aware of the efforts which the junior doctors are making to see that their patients do not suffer. I do not believe that any situation is as black and white as it is painted in such a debate as this, and I believe that they are making considerable efforts and that those efforts should be understood and appreciated.

The pay structure has become extremely complicated over the years. I know that the extra duty allowance was brought in to try to help. Hours were reduced, but it has become an extremely complicated scheme. I waded through the explanation as to how the extra duty allowance works, but I wonder how many of your Lordships know what is being talked about when it comes down to a "notional half day off". I feel that the system is not satisfactory. It was probably a necessity as a way round a problem, but it has in turn created a great number of problems, and I believe that a system which relates not to free time but to hours worked would be far more acceptable to the doctors.

There has arisen quite a vocabulary on this matter; one has units of medical time and extra duty allowances, and, if we could simplify the system, I believe that it would be more acceptable. I agree that it is easy enough to criticise and much harder to work out a really positive system, but I believe that now is the moment when we should be planning. I am sure that the present problems will be overcome, but we should now be planning how the structure is to be changed. The junior doctors have felt let down because the negotiations were so complicated because of the complication of the structure. The name of the game changed as it went along. For instance, the contract started as closed and is now open, the "no detriment" clause was deleted, and it goes on and on. I believe that the root cause of the trouble is the complication of the structure.

With great deference to the noble Lord, Lord Wells-Pestell, I should like to query one figure which he gave. He said that the doctors, especially the juniors, had had considerable rises, and he quoted a figure of 30 per cent. I stand to be corrected, but as I understand the Review Body document, the 30 per cent. was for all doctors. If the noble Lord will look at page 37 of the document he will see that house officers had a minimum 17.6 per cent. rise and a maximum 19 per cent. rise. So I feel that, in quoting that figure, the noble Lord was being a little unfair to the junior doctors in terms of the rise that they had. I do not say that GPs are overpaid but, at the same time, they do better because they are on Schedule D. This is a point which goes back to 1947 when, under a High Court ruling, hospital doctors were disallowed for Schedule D.

I come now to a point which is made with the benefit of hindsight, and in making it from these Benches I may perhaps come slightly under fire. I believe that the cause of unhappiness in the National Health Service is its growing bureaucracy It is growing with the speed of Parkinson's Law. These bureaucratic layers grow rather like expensive layers of icing on a cake, but they are as hard to cut through as calloused skin. I do not agree with my noble friend Lord Aberdare that change should be delayed. I believe that changes should be made now. I believe that the "area" level is unnecessary and ought to be done away with. It would result in very considerable savings and I believe that it would also make the system very much more efficient.

Again, I know that it is easy enough to say that a level should be cut out and that it would require a lot of planning to do that, but I believe that we should be planning for it now. In an army, it is never very efficient when the support services outnumber the combatant troops, and I believe—though I stand to be corrected again—that there are 11 administrators to every 9 consultants. It seems that the system is becoming a little top heavy. Again, this is affecting nursing. I felt that the old "matron system" worked extremely well, and the ward sister really was the ward sister. Now, everything is very much more bureaucratic and we do not have matrons but senior nursing officers and so on and for a nurse to get ahead in the profession she has to get behind a desk. I believe that to be a pity.

Looking to the future, I feel that rebuilding the organisation, as outlined by the noble Lord, Lord Porritt, would be extremely valuable. One area in which we could try to make the system more economical is that of hospitals which have enormously expensive and sophisticated back-up systems. The money supporting each bed and the services involved are very considerable indeed. As a patient starts to recover, he does not need those services and, if we devoted some money from savings to convalescent homes with, out so many specialised services, they would be cheaper to operate and we could have many more beds available for the really important surgical cases, and waiting lists could be cut. The cost of such convalescent homes would, I believe, be relatively low. I know that it is all money and that there is no money now, but it is something which we could look at for the future. However, the Health Service is for patients. It is not merely to be measured in terms of bed occupancy or of bed turnover. As I said earlier, the Health Service is people, not just figures.

7.9 p.m.

Lord HAYTER

My Lords, I believe nearly every one of your Lordships will remember that, when Sherlock Holmes was solving the mystery of the Silver Blaze, he was asked whether there was any point to which he would wish to draw attention. He said he wanted to draw attention to the curious incident of the dog in the night time. "But the dog did nothing in the night time", said his questioner. "That was the curious incident", said Sherlock Holmes. I used that as an illustration because it brings me to the community health councils and why they have not made any major comment on the Health Service as it stands today. I felt that, if I reviewed very briefly the changes that have taken place in the community health councils in the last year and a bit, it would at least be a change from the recriminations which have been exchanged in this House during the past three or four hours.

The great thing about the community health councils which I believe was recognised by both sides was that they gave the layman a chance to have his say in relation to the Health Service. "Participation" is the "in" word these days and it was therefore a matter of principle on both sides of the House that stress should be laid on their education and their functions. To the extent that it was possible, the King Edward's Hospital Fund has been trying to do this in the past year or so. It is a very complex and sophisticated world in which these volunteer laymen are beginning to find themselves. I do not say that in any impertinent sense at all because any of us who remember our own feelings when we first joined a management committee or the board of a hospital will remember that it was some considerable time before we felt able to comment sensibly on what we saw going on.

I will not weary your Lordships, but doubtless you will remember that there are 229 community health councils in England and Wales, involving roughly 5,500 people, which is approximately the same number of people who were involved in management committees and governing boards in the old National Health Service. The selection of these people was determined by the Houses of Parliament, and council membership ranges from 18 to 32 in the various regions and areas. Half are elected by local authorities, one third by voluntary organisations, and one sixth by the Regional Health Authorities. Their power is that of questioning and consultation. No hospital can be closed without their approval, They can give evidence to official committees. They can enlist MPs' support and they can use the Press to express themselves. That brings me back to where I started, for at this moment they have not been very vocal.

Community health councils vary enormously in the way they organise themselves. Some do it geographically in their part of the world; some do it by functions, public relations and research; some do it by the consumer angle, the children and the elderly; and some do it by the type of health care, the mentally handicapped and the geriatric. Some decline to split themselves up at all, and they work as a body. It is interesting that this article on the way in which the community health councils arc organised appeared in the Community Health Council News; I say interesting because that is the publication which the King's Fund brings out every two months. It is intended to go to every member of the community health councils. In that news bulletin there are articles on primary medical care, on the Abortion Bill and on Health Service statistics. There was an article on Dr. David Owen's very valuable contribution when he talked recently to a conference of 200 people who belong to community health councils. The newsletter gave publicity on this talk to all the 5,500 members of community health councils. Dr. Owen said in his speech: Community health councils give the National Health Service a public lobby and a public voice. They have got the public lobby; the public voice has yet to make itself heard.

In this newsletter there are also guides on selective reading, and there is a very open correspondence column, in which some things which are said are by no means complimentary. One secretary of a community health council stated: It was not at all appropriate for a newsletter to be devised at this stage as it preempted the proper decisions of the National Council and the Steering Committee. That reference to the Steering Committee brings me to one more point. A Steering Committee has been set up which has been asked to advise as to whether there should be a national council for the community health councils. To cut a long story short—I think it was quite a long story in the deliberations of that Steering Committee—it has now been recommended that there should be formed an association of community health councils, probably at the beginning of 1977 after the next election of members of the community health councils.

How can one judge the usefulness of community health councils to date? It is perhaps too early to do so, partly because they have not had much money with which to devote themselves to some of their worthwhile objectives; they have so many things to learn. The average community health council individual, if visiting his wife in hospital, would find himself—just as you and I did, my Lords, when we first got mixed up with hospital visiting—commenting on the food, the nursing and the building. But if that individual asked himself whether his wife had the right treatment, he might find himself in a very difficult position before being able to answer that correctly. My experience of hospital visiting taught me a long time ago that deficiencies of hospital buildings are not necessarily significant; it is the people who work in the buildings, and the skill and the care which they can devote to their patients, that count far more than that.

For anyone who becomes involved in this way in hospital matters there is the whole gamut of questions dealing with the organisation. We got to discussing what I always call the "dirty grey book" when we were considering the reorganisation of the National Health Service. It was then puzzling for most of us as to how the organisation would work. The advice which we try to instil through this Community Health Council News is that hospital bed counts do not matter much. Medical fashions, such as transplants, do not matter much. It is the communication with the patients in the hospital that matters. In quite a different context we decided recently to give a grant to a surgeon at one of the London teaching hospitals. He is doing what would popularly be known now as a "consumer-based study" to improve the treatment of patients. He says that he is determined to give more attention to the patient than those who think that they know what the patient wants.

Therefore, I sum up the issue of visiting in hospitals by saying that it is not important to watch out for leaking roofs what is important is to try to discover the attitudes of mind of both the people who work in, and are patients in, those hospitals. The touchstone for community health councils in the future is the extent to which they conic to terms with primary care: the extent to which they come to terms with social service, because we have now established that is part of the health problems of this county; the extent to which they come to terms with the problems of local authorities, a very dangerous point, but a most important one; and the nature of the community health councils themselves, because one is beginning to worry as to whether they are truly representative of the community.

Perhaps I should end by making one remark: so far as I am concerned the King Edward Hospital Fund works always within the parameter of the Government of the day and therefore of the National Health Service of the day. To us all the patients are the same; they are indeed the same all over the world. Their sufferings and their needs are the same, and this is all quite irrespective of Party politics. But the difficulty arises when decisions have to be made on how to satisfy those needs. It seems to be common ground between the two Parties that community health councils are one of the key elements in the present situation. We have been very pleased to do what we can in this past year with our money and our personnel, and we shall continue to do so provided we have the confidence and the backing of the Department, which I think we have. What will emerge, if it has not already done so, is an institution which will never satisfy the demands for instant solutions to our health problems, but on the other hand, provides the means of bringing about change by consent. It is an institution worth preserving by, I hope, any Government when they come into power.

7.19 p.m.

Lord COBBOLD

My Lords, almost everything that can be said has been said—much of it several times. However, I should still like to detain the House for a moment or two to make a few observations from my own personal experience. I have the privilege of being chairman of the board of governors of the Middlesex Hospital for 10 years or so and of taking some part in the discussions during the early 1970s about the reorganisation of the National Health Service. There is no advantage in dwelling too much on the past, but the noble Lords, Lord Aberdare and Lord Wells-Pestell, both referred to the reorganisation, and the noble Lord, Lord Cottesloe, said something about the effect of the reorganisations on morale. Therefore I should like to recall one or two of the points which were made on behalf of the teaching hospitals in debates in this House at the time.

The main burden of our argument was the unwisdom of doing away with something which worked fairly well without being fairly certain that you had something better to put in its place. Boards of governors and hospital management committees, or so we argued, both facilitated quick decision and ensured the involvement of lay members with medical, nursing, administrative and auxiliary staff. Instead, it was decided to set up a complicated and costly structure of District, Area and Regional authorities which seemed to us likely to confuse responsibilities and, even more important, to make it impossible for lay members of those bodies to have any intimate involvement with individual hospitals and with their staffs.

My Lords, the only things which really matter, and for which the prime responsibility must rest with the Government of the day, are surely standards of medicine and care of patients. It has seemed to me that in discussion in the media and elsewhere these fundamentals tend to be lost sight of and to be bedevilled by political dogma, arguments about pay and sectional interests generally. Over many years I have seen at first hand the very heavy load falling on hospital doctors and the burden of hours worked, which most of us would regard as highly unsocial. I have admired their dedication and that of nursing and administrative staffs, and like the noble Lord, Lord Cottesloe, I have been equally impressed by the loyalty and devotion of so many who work behind the scenes, often in old-fashioned and unsatisfactory conditions; kitchen and domestic staffs, engineers, carpenters, porters—the list is endless. My Lords, everybody who has had this experience must bitterly regret the present situation. The message from this debate must surely be a hope that everybody concerned, not least Her Majesty's Government, will take a fresh look with determination to get away from the present drift towards confrontation. The appointment of a Royal Commission seemed a step in the right direction, and we have had hopeful news of a meeting this morning.

Much has been said about pay beds, and I add my voice to the many who have urged the reference of this subject to the Royal Commission only because I may have seen it from an angle which is slightly different from that of some earlier speakers. Ten years as chairman of a large teaching hospital certainly persuaded me, on purely practical grounds, that the balance of advantage lay in maintaining the original compromise. Quite apart from the financial contribution, it seemed to me a definite benefit to the National Health Service, and therefore to National Health Service patients, that the best doctors should be able to do some of their private work in the hospitals. It has undoubtedly kept consultants more involved in, and more easily available to, the hospital as a whole. Nor was I conscious, my Lords, in fairly frequent visiting round the wards, of any hostility by National Health Service patients to the existence of private beds. One thing is certain: further deterioration of morale or more acute confrontation would go far towards destroying something of which this country has been rightly proud, the prime concern of which, I repeat, must lie in medical standards and the care of patients.

7.24 p.m.

Lord PANNELL

My Lords, I have noticed this afternoon that undertones have been expressed, particularly by those people who are concerned with the medical profession, about the Minister, the status of the Minister—I should like to refer particularly to what Lord Cottesloe said—and the desirability of getting rid of the Minister. I can only say that everyone must of course wish to maintain the Government's anti-inflation policy, and the principal charge against the Minister is that, with the Minister for Employment, she has maintained that policy. If anybody says that they want a different atmosphere, the way to get it will not be to lead assaults upon the Minister herself. She is close to the Prime Minister she moves in concert with the Cabinet and her view has been a Cabinet view.

I have known every Minister of Health since Nye Bevan, and I do not think that anyone has more devoted herself or himself to the affairs of a Department than has the present Minister. As a matter of fact, her achievements are very considerable indeed. Somebody suggested that she is abrasive. Nobody less than an abrasive Minister would have got a percentage of the GNP to the extent that she has. Let us make this perfectly clear. She came to office at a time when, as Lord Porritt said, morale was at an all-time low, left byte Party opposite. I sat in the House of Commons during that period. How else can the policy of the Government, in their fight against inflation, in their attempt to hold the line on the question of the pay issue, be achieved unless the Minister stands firm?

There seems to be a campaign to discredit the Minister. This can be noticed in the rather vulgar speech which Mr. Norman Fowler made at the Conservative Party Conference. He is the "shadow" spokesman for the other Party. There were references to "Calamity Castle", there were references to abortions, and all that sort of thing—the sort of language that the gentlemanly Party can use to a Minister on our side but which would never be tolerated by that side towards Mrs. Thatcher. One has only to see this throughout the media. When people speak about getting rid of Mrs. Castle, they might just as well speak about getting rid of Dr. Derek Stevenson, because his image on television is pretty awful.

Lord SANDYS

My Lords, I do protest for one moment that the noble Lord should refer to two people who cannot express themselves in this House. It is not normally the practice to refer to officials of bodies, nor Members of another place.

Lord PANNELL

My Lords, that sounds all right coming from a noble Lord who has sat there, I do not know for how long, but who could not have listened to some of the speeches that I have been condemned to listen to this afternoon.

Lord SANDYS

My Lords, once again I protest. I have sat here throughout the afternoon, from twenty minutes to three. There is no word that I have missed.

Lord PANNELL

My Lords, there are some people who sit still in this place without listening, and I can only tell your Lordships that I have listened to two speeches this afternoon which were, in their terms, insulting without there being any protest. I do not want to breach the conventions of this place, but when, in effect, a colleague is attacked—a member of the same Government in which I have myself served as a Minister—I think that it is an elementary duty, at least, to protect that Minister; and I might tell your Lordships that the sort of delicacy by which one refrains from doing that does not appeal to me at all. No convention of this place will hold me back in that way.

Does anybody think that if the Prime Minister intervenes he will "ditch" this Minister? There is Lord Hill, who has served in a Cabinet. He knows that the best way to protect a Minister is to attack her. I can remember an occasion when it was "tipped off" in the newspaper that two Conservative Ministers were to go. I met another colleague, a Conservative Cabinet Minister, and I said, "What idiot ever put that there?", and he said, "They are safe now, Charlie, for another six months"; and they were, because, quite frankly, the Cabinet, the House of Commons, Governments, public men, by their very nature will not stand this sort of attack. So, consequently, the Prime Minister is the custodian of the policy of the Government. And it might be remembered that it is Mr. Foot's policy, too. These two are so linked together on this issue that you could not attack one without unseating the other. In the present state of the Government majority, I can only tell noble Lords opposite that that is not on. Access to the Prime Minister, or his intervention, will not solve the problem. The profession must make peace with the Minister.

I understand we have the separate issue, the private bed issue, which is of immense significance to the consultants. A porter or a domestic can take his or her service elsewhere. I understand that the surgeons, the anaesthetists or the radiologists cannot—it needs a team and equipment. Outside London, without the Health Service, there would be almost no private facilities at all. That is what has brought them here. But do not let us deceive ourselves that there has not been a measure of abuse in this system, of people being put back. Anyone who has moved at a political conference and has heard cases put up knows that it is so.

To come to the point of the Royal Commission, policy has emerged gradually over the years and it has appeared in two Election Manifestoes. That is what has made it a political instead of a technical issue. The Government therefore, seeing their forces behind them, the feelings of the National Union of Public Employees and so on, could hardly refer this issue to a Royal Commission. It was never on. Another thing about Royal Commissions is that they usually take about three years to deliberate. On average—and I once took out these figures—over the last century it has usually taken 19 years to implement whatever they have recommended. There is nothing more frustrating than to sit on a Royal Commission and see this emerge. How much came out of the Donovan Commission on trade unions? Only the Industrial Relations Act 1971, which flew in the face of everything the Royal Commission observed. Let us assume that this came up in two or three years' time. The same arguments would be regurgitated. I would not die in the last ditch over pay beds. I agree for once with the noble Lord, Lord Hill of Luton, that there are plenty more important things on the horizon than this.

On the other hand, it is not an issue to bring down the Government. It applies both ways. Is it so important one way or the other? I understand this is a vital issue. I have been enough of a craftsman in my time defending trade union interests to know that there is a great deal in this of a demarcation dispute. The NHS has been taken for granted by a good many consultants; and this is probably something of a backlash. The consultants have a duty to the National Health Service which has not always been daylight clear to some of us.

It must be remembered that the National Health Service is the largest employer in the country. I heard it said yesterday that it is the largest employer in the world. Under this Minister, the percentage devoted to it has risen in her first year from 4.9 per cent. to 5.4 per cent. Only a very determined Minister could have done that. Anybody who has been in Cabinet knows what that means at a time of stringency. This Minister upheld the Service, defended the Service and extended the Service. She must be judged against that rather than against the prejudices of a few Peers in this House. She has secured something like social justice for the nurses—this was her first job—by increases of 60 per cent. of average earnings. This is a considerable achievement. One sees this, as I have said, as something of an internal struggle in the Service itself.

The noble Lord who spoke first from the Benches opposite was, I thought, a trifle less than fair. He hardly mentioned the question of the junior doctors' salaries; but under this Minister, if we take the figures between 1974 and 1975 (and I have taken the maximum figures for the grade) for health officers, salaries have gone up to £3,294 from £2,538; for senior house officers, to £4,152 from £3,198; for registrars, to £5,109 from £3,879; for senior registrars, the figure has risen from £4,743 to £6,279. Those are the figures: and they got those only last March. The pay policy insists that you cannot get another increase under 12 months.

This is a blatant attempt to breach the Government's pay policy. Members of this House should not underrate what that pay policy is. The Yorkshire coal fields came near my constituency and the prime mover there is Mr. Arthur Scargill. He advanced an idea to breach the pay policy before the NUM. He was defeated. But only this week he has been trying to get the Yorkshire miners to breach it. Let this be breached by the doctors and you will not stop the miners; and you know what they did to a Conservative Government. The line must be held the whole way. My own trade union is presided over by Mr. Scanlon, no friend of the Government pay policy; but we hold the line on this. Millions of workers do so by an act of faith.

With regard to the doctors, we ought to be able to expect some sort of discipline from them. I took out some figures. Generally speaking, the total recurrent cost of educating a medical student over a five year course is about £25,000. That can be a phoney argument, I appreciate; for it can be applied to anyone who gets higher education. But anyone on whom £25,000 is spent by the generality of the public is thus far advantaged in the prestige of his profession. There is no doubt that doctors are in the most prestigious profession in the country. Whoever seeks any advice about what profession to put in a British-born coloured boy who has certain things to overcome, will be told: "Put him in the medical profession; he will not suffer there."

A body that has had this money spent on them and who claim, proudly and rightly, that they are a privileged body have extra responsibility to the public. Not for them the downing of their tools at the snap of a finger by a silly shop steward over a dispute. They are certainly responsible to the public itself. They are the custodians of the public. As one who has had the good fortune during 40 years of his life to be a personal friend of his doctor, I know what this means in the reassurance of family life.

This is an odious sort of business and the noble Lord, Lord Cottesloe, was right when he said that the contagion of unrest that has affected all other professions has affected the junior doctors as well. As was said in another place, there are extremists in that profession also. I noticed that the "uncle" of us all, namely the noble Lord, Lord Goodman, was at No. 10 Downing Street. Knowing what he has done (or not done) to the Trades Union Bill, commonly known as the Press Bill, I still have hopes that he will be able to bring his magic to bear upon the warring parties. He has the utmost confidence of the Prime Minister and of the Secretary of State. One thing he will not have advised is getting rid of the Government, the Prime Minister, or the Secretary of State. He will try to bring people together and there will be that wonderful emollient that we have seen displayed in this House. He will weave a spell over them and I hope that they can come to their senses.

In my adult life I have been a trade unionist and I have heard trade unionists spoken of (even this afternoon) in rather derogatory terms. But the trade union will is, of course, often the will of people organised in an industry. The will of a Government is the reflection of the most mature democracy in the world. In effect, they fight an Election and get returned on a policy, and that is what we are responding to now.

This afternoon I tended to think that the British medical profession were now where American medical profession was when I was in the United States—and somebody has to live among them to know what that medical profession can come to. In America a noble profession has become a filthy trade. I do not look on our medical profession as a filthy trade; I am conscious of too much service; I am conscious of people who have dedicated themselves to the profession. If we take the pay bed issue, I hope it can be settled. I would not die in the last ditch over that. I do not think that it is important enough to bring down a Government; I do not think it is important enough for the consultants to withhold their services. After all, these are the commissioned officers, the crack troops of the medical profession. If they behave badly, they can hardly expect the junior doctors to behave any better. The question of example is important here.

Regarding the doctors themselves, I believe that the Secretary of State having dealt with the nurses, will attempt to deal honestly with the doctors. But they will have to run their period out now to about next April, which may not be too long to last out if one considers the inflationary pressures on all of us at the present time. I want this profession to remain a noble profession. Nobody will solve their problem if they think that they can take on a Minister who is a brave person, a person of great courage and drive, and who has done rather more for the medical profession than anyone has ever achieved before.

7.42 p.m.

Lord LUCAS of CHILWORTH

My Lords, if I may, I should like to bring your Lordships hack into the field of dentistry, although I accent and appreciate that my noble friend Lord Colwyn gave an expert resume of the position in which members of that profession now find themselves. However, there are one or two points I should like to endorse. Only about one in six of the population use the National Health Service in terms of dentistry. The purists would like to see about one in three, because although the remainder may not go to a dentist, it does not necessarily imply their dental health is of a standard not requiring treatment. They are therefore relying entirely upon the general dental practioner, a rather unique person who has the ability to practise in the Service or privately, or both, at his free will. I believe dentists are the only people in this country who are self-employed and yet still enjoy the benefit of superannuation from Her Majesty's Government.

The National Health Service, so far as dentistry is concerned, restricts its service largely to what one might call a "care and maintenance basis"—maintaining oral dental hygiene rather than doing anything else. My noble friend Lord Colwyn says a dentist has complete freedom to prescribe treatment, not having to worry too much as to who is going to pay the bill at the end, but I do not think that is quite fair. The Dental Estimates Board—particularly in some areas of the country—are exceptionally strict about what they call "cosmetic dentistry". They are very strict also on the use of some of the new adaptic materials for fillings, which are rather more expensive in terms of the material and labour involved than the more traditional silicate materials. This is a pity, because although the dentist may wish to use the later materials, he feels perhaps the fee will not be sufficiently rewarding. But if the fees payable took into account the fact that the use of such material would probably enable that patient to attend fewer times for treatment, the saving in the long run would be that much greater.

Each year the Department of Health make an announcement, usually about April, regarding expenditure on the Dental Health Service, and the Dental Rates Study Group meet and fix rates in October, by which time they are usually working on figures some 12 months old. It would be rather more useful to the profession if the Dental Rates Study Group could use forward projection techniques. As we have been told this afternoon, the practice expenses, particularly in the past two years, have risen enormously. This is for rents, rates, materials, machinery and so on. A practitioner tells me that in the past 12 months his practice expenses have risen 65 per cent. over an average of from between 45 per cent. and 50 per cent. in the previous two years. This increase cannot be contained by the existing fee scale. One should attempt in the future to bring rather more sophisticated techniques to bear on this question of fee fixing. From my knowledge of the profession (which is fairly scant and is gained from my wife's participation in the dental service) I do not think that the practitioners are particularly militant or upset at the presen level of fees. They may come again another day when the moment is more opportune.

If the National Health Service is concerned with care and maintenance, it must be more aware of the preventive aspect of dentistry. My noble friends Lady Ruthven and Lord Colwyn referred to this in terms of children's teeth. Fluoride treatments and sealing treatments are not available under the National Health Service. I am advised by my wife, who treats many children in oral hygiene, that innumerable people, from all walks of life, salary scales, and so on are paying for this service. It is prescribed only by dentists, and there are cases where, because of inadequate diet or other factors, this treatment is not desirable or helpful. It is painstaking and difficult. It would be more helpful if this kind of treatment could be brought within the National Health Service. We could then start right at the beginning of a child's life with an aim to improving dental health of all people throughout the entire age group. Then we do not have the problem of tremendously expensive dental and oral treatments in later years.

In conclusion may I ask the Minister this question, of which I have not given notice, and I understand if he is not able to give an answer this evening: Why is it that the proposed new charges for dental treatments appear to favour those who do not go to the dentist frequently and who require more treatment as a result of their laxity? Also, it is probably more expensive treatment in that the more work that has to be carried out, the less the patient is going to be required to pay, whereas the man or woman who goes to the dentist reasonably frequently—perhaps two or three times a year—is to be required to pay more. Surely that is a denial of the right kind of attitude we would wish to encourage in having people go for preventive dentistry rather than curative dentistry.

7.50 p.m.

Baroness MASHAM of ILTON

My Lords. I should like to congratulate the two maiden speakers this afternoon, and to express the hope that the next time the most reverend Primate speaks, he will not have oil poured on troubled waters in front of him. I should also like to thank the noble Lord, Lord Aberdare, for giving your Lordships the chance to discuss this vital matter. With so many eminent doctors taking part in this debate, I think it would be advisable for me to speak from the patients' point of view. It does not seem very long since your Lordships debated the White Paper on the National Health Service. I remember a conversation I had with the noble Baroness, Lady Scrota. Neither of us could find patients mentioned once, but the word "management" was there very many times. A great many of your Lordships remarked on the top heavy management, but pleas in your Lordships' House were not heeded and we are now experiencing what many people working in the Service, or interested associates, prophesied would happen.

Throughout the country many people have remarked that the National Health Service has become first and foremost a Service for the staff who work within it, while the patient takes second place. So long as the deplorable appointments system exists, with little consideration for the patient, inadequate sanitary facilities, the lack of privacy for those who crave it and the heavy and unappetising food, many patients will he attracted to using the private treatment. Apart from a few, most patients are very grateful for the treatment and care they receive from the National Health Service, and basically it is providing a wonderful service. Therefore, a way must be found to overcome the problems that beset it now.

For many years the strains have been showing. People have, sadly, found that nonce is taken of them only when they descend to industrial action. This is deplorable when the patients are at risk. Many staff working in the hospitals and the community feel that more personal direct contact with the civil servants who work for the Department of Health would be useful. The civil servants are so often called "faceless bureaucrats", but when one meets them personally they often become thoughtful and charming human beings. Many doctors feel that they are working in isolation and have become divorced from taking any part in running their hospitals. Morale must not drop lower. The red light has been showing for too long. It is the front-line field workers who really know what is needed, and not those people who sit in their offices, deprived of personal contact.

Travelling round the departments, finding out what the needs are and passing up-to-date information to those who need it must be of mutual advantage. If more of that were done it is likely that there would be a considerable saving in expenditure. I have heard that doctors who prescribe drugs and treatments to patients are often not aware of the costs involved. Because doctors and patients are themselves not paying, nobody seems to question the cost or the real need of some prescribing. I am sure that all your Lordships will have heard of the classic example of patients in hospital being woken up to be given their sleeping tablets. There is in many hospitals a desperate need for more efficient and up-to-date equipment. If the waste in some areas were alleviated, more could be spent on the vital necessities.

Staff morale will not rise unless the priorities are right. It is tragic that the National Health Service in many areas has become a political pawn, open to abuse and not able to attract more full-time medical staff who would give their undivided attention to raising the standards. The aim should be for excellence. So many skilled people have become disillusioned and disheartened that they have found themselves forced to find the freedom and incentive to achieve their aims and meet their challenges in other countries. Doctors, as patients, are highly individual people. They need to be sensitive to the needs of their patients. They have the qualities, and indeed they need the qualities, of leadership to create a loyal team to work with them. To do this they need to have enthusiasm and freedom to achieve self-actualisation.

The thought of "nine to five doctors" makes one shudder. Some years ago I had an internal haemorrhage on a Saturday evening and my life was saved by the medical skill given me through the night. This Monday evening, a consultant friend of ours came to dinner and he said that his junior had been looking at her watch during an operation. He told her that this should not be done. She left the hospital at 5 o'clock. Unless one has full commitment from medical people, there will be disaster after disaster. Patients, be they in need of surgery or psychiatry, should have continuity of care. If the Government intend to remove pay beds from the National Health Service, hospitals are going to lose the service and a much needed sum of approximately £30 million. If Her Majesty's Government want to attract consultants to work full-time for the National Health Service, they will have to make their remuneration comparable with that of their colleagues in other European countries and in the Commonwealth. I should like to ask the Minister whether, at this period of crisis in our country, this is the time to do it.

The Government may have been forced by the unskilled workers in the National Health Service to take this action now, but they must face the fact that nobody else can do the job of a surgeon or physician. If the worst happens and the hospitals close, the surgeons could perform on a kitchen table and the patient could be cared for at home. I do not believe that senior doctors will desert their patients. Most consultants give so much of their time over and above their contracted hours: they teach students and visit patients. If this good will is to go, the Health Service will be in a very much worse state than it is now. There is a desperate need throughout the Service for more humility and devotion from the most senior to the most junior employees. A climate of mutual understanding and of the needs of the patients is called for.

As a member of a community health council in a rural area, I should like to bring to your Lordships' notice a few of the problems involved. Patients in our district, which is in North Yorkshire, who are in need of psychiatric treatment, are not being adequately cared for because there is no full-time consultant in the district. Strange things go on up the Dales, and there is a high rate of intermarriage. Continuity in psychiatric medicine seems important. A few weeks ago, not far from my home, a man hanged himself on a tree in a children's playground.

The rise in the cost of petrol has hit the rural areas particularly hard. Villages are cut off from public transport, and this involves great difficulties over people visiting their relatives in hospital. A technical officer who visits disabled people who are marooned in their homes, told me that his mileage was astronomical but that his superiors, sitting in their offices, were unsympathetic. I hope the Government will take into consideration the special needs of rural areas.

The Westminster Hospital should be of special interest to your Lordships, as this is a hospital which is closely linked with Parliament. Every nurse who has trained and qualified there wears on her belt the Westminster coat of arms, which we share. I was a patient in that hospital a year ago and found splendid nurses working under extremely hard conditions. So much is said of the extras which teaching hospitals are supposed to have, but in the surgical ward, with a very quick turnover of patients, there was only one lavatory and one bath. With so many cross-infections and extremely ill patients, those facilities seemed totally inadequate to the needs of the patients. Nurses and patients were united in their wish for more basic sanitary ware. There was only one hand basin for the ward, which was used by the staff and the patients. One night the drain became blocked. A maintenance worker unblocked it in the early hours of the morning, but the basin remained in a disgusting state until 3.30 in the afternoon. A nurse said that she could not bear it any longer, and she cleaned it out of sheer dedication. Some years ago one would never have experienced such events. Our standards of cleanliness in many hospitals leave a great deal to be desired.

This year, I have been pleased to visit some of the hospitals which have been made demonstration centres in rehabilitation. This seems to have raised morale and interest. I should like to ask the Minister a question which I found myself asking. Will patients who come from areas without these facilities be able to benefit from the expert knowledge and treatment within these centres? I have recently visited West Germany and have seen some excellent new rehabilitation developments. We should benefit greatly if we had such improvements. Am I right in thinking that application can be made to the European Community for allocations for a rehabilitation programme from the European Social Fund? Also is it correct that the demand has to be made on the basis of specific programmes initiated either by Her Majesty's Gov- ernment or by voluntary organisations, in which the Government have an interest? I do not expect an answer tonight, but I should be grateful if the noble Lord, Lord Wells-Pestell, could write to me later with an answer.

There is great difficulty for the social services and the Health Service after being under different authorities. The aims of those services are often so similar, working for the benefit of the same consumer, and yet, because of independent budgets and controls, it appears that there cannot be an easy coming together and a sharing of the pool of resources, which, of necessity, restricts development. I do not think the noble Lord, Lord Aberdare, has quite understood the present problems here. I hope that there will be steady progress in the future after the immediate problems are solved, and that when the country picks up there will be more up-to-date health centres built. Also, health self-care education, as part of the curricula in schools, could help take some pressures off the National Health Service.

Furthermore, I hope that the Government will look again at the new mobility allowance for disabled people. To cut this off at the age of 60 has given these people the impression that it is the first step to euthanasia, and this cannot he helpful in the rehabilitation of this age group. I am sure your Lordships will agree that at 59 there should be some useful years of life left. Everything seems to cost money, and today there must be some very worried, helpless patients in our country. I hope that there are still some people who will give them at least a little TLC—tender loving care —for this can be administered at no extra cost.

8.4 p.m.

Lord AUCKLAND

My Lords, this. debate has so far produced two notable maiden speeches, with contributions from many facets of the National Health Service, both from those who have practised in it and from those who have been concerned with it executively and in voluntary grades. I should like to apologise to my noble friend Lord Aberdare and to the noble Lord, Lord Wells-Pestell, for not being in my place to hear their opening speeches, due to a very long-standing and important business engagement. Also, I should like to assure the noble Lord. Lord Wells-Pestell, that any remarks I make which may be taken as unfavourable to Her Majesty's Government do not reflect upon him, because I believe that noble Lords in all parts of the House will recognise the excellent work which he has done during his tenure of office in dealing with health matters in this House.

Not for the first time, your Lordships' House is debating a matter of great importance at a very suitable time. One of the problems is that from day to day, and possibly even from hour to hour, there are changing developments. I am sure that all sides of your Lordships' House will hope that today's consultations are fruitful, and the very last thing I want to do, or any Member of your Lordships' House who has any experience of the Health Service will want to do, is to say anything which is abrasive enough to prejudice those negotiations. But I am bound to say that in recent years both of the main political Parties have indulged in legislation and in actions which have not always been favourable to the National Health Service.

The reorganisation of the Service has been widely criticised, not least by the medical profession itself. Of course, the reorganisation is now a reality and the onus is upon us, and all who are in public life, to see that it works as well as possible, because those who serve on the Area Health Committees and the community health councils are, I am sure, dedicated people. But I think I may be permitted to say that those who served on house committees—asI did for 12 years or more at two hospitals—and on hospital management committees, also did a very fine job for the National Health Service, and I venture to suggest that in these difficult days their services are very much missed.

It is difficult at this stage of a long debate to throw much light on anything new, but there are still some points which need to be made or reinforced. The noble Baroness, Lady Masham, to whose excellent speech we have just listened, referred to the patients. If there were no patients in our hospitals there would be no doctors, nurses or physiotherapists and, indeed, hospitals would not be needed. Some people may say that it might be good if this Utopian situation were a reality, but this is a completely unreal situation. The fact is that faster cars and other mechanical phenomena will result in more accidents. We still have the scourge of cancer and other diseases which our doctors and nurses have to treat.

Last Monday I had the good fortune to tour one of our leading teaching hospitals in the East End of London—the principal nursing officer of that hospital, whom I have had the pleasure of knowing for some years, has been listening to much of this debate—and talk to several consultants and junior hospital doctors who spoke in a restrained and responsible manner. There is no doubt whatever as to the number of hours a week that most of the registrars work. As part of what is clearly a compromise I do not think that it is a reality to reduce the working hours of a registrar to 80 per week.

The great difficulty is that certain hospitals have a reasonable complement of consultants, registrars and nursing and medical staff, but in the "grey" areas—one might speak of the Potteries, South Wales or North-East England—there are far too many old hospitals which do not necessarily attract nurses and doctors, as do some of our teaching hospitals. Until they visit them, many people think that our teaching hospitals are luxury palaces. The hospital in White chapel which I visited dates back to about 1790 and I saw much of the upgrading which has been carried out. I saw also depressing sights. Indeed, pharmaceutical products are stored in the bowels of the hospital, and these are an obvious fire hazard. As Vice-President of the Royal Society for the Prevention of Accidents this causes me, and others, much concern. This is not the fault of the hospital. The fact is that there is insufficient space in which to store these products.

Nor is it the fault of the present Government, or of the present Minister or previous Minister, my right honourable friend Sir Keith Joseph—at least, not entirely. Over the years Ministers must, of course, take some blame for these conditions, but the fact is that a growing population and the increasing use of these hospitals means that time has caught up with them. For all that, I found complete dedication in this hospital on the part of all the nurses and doctors whom I saw. However, the doctors are very worried. One of the doctors to whom I spoke comes from Australia and he is likely to return to that country. Australia and New Zealand have provided us with some outstanding doctors, but present conditions will make it very difficult to attract them to this country.

It is difficult to justify the action which some of the junior doctors and consultants are taking. It is true that when they enter the profession they know that the working hours will be long and that somebody who is run over by a car at three o'clock in the morning cannot be left lying in the road but must have immediate treatment. Their hours are unsocial, unlike those of your Lordships' House or of those who work in offices, although we in this House have recently been working rather unsocial hours. However, the medical profession have to work unsocial hours in order to save life, and this the general public as a whole do not always realise. Only by visiting both teaching and district hospitals and seeing conditions for oneself, can one realise that as a fact.

If I may turn to the Royal Commission, a number of Royal Commissions have been set up during the 18 years that I have sat in your Lordships' House. As was said by the noble Lord, Lord Pannell, in a somewhat controversial but very interesting speech, many people take a cynical view of Royal Commissions. They can take a very long time to report, and the Royal Commission on the National Health Service will be no exception; there is an enormous spectrum to be covered. I join those who implore the Government to consider the question of pay beds within that spectrum. I believe that this is very important. My family and I have always been National Health Service patients and have received excellent treatment. Indeed, my own general practitioner listened to part of today's debate. So far as he could, he has always given us the best possible treatment. In these circumstances, the National Health Service is in danger of losing some of its finest doctors.

One or two points were made to me by a consultant at a hospital near to where I live. In the interests of time I shall quote only one of them, although this consultant went to a great deal of trouble to give me many facts, and I shall be very pleased to pass them to the noble Lord for study because I believe that they are reasoned points.

He says: I would also add that as a part-time consultant I work on average a minimum of 56 hours a week and on top of that I am on call continuously one week out of three. I think it is true that the vast majority of consultants in this country have come up the hard way. They have not come up through working office hours. Many of them have worked—indeed many of them now work—80, 90 or 100 hours-plus per week. I believe the junior doctors probably have today an easier time than the consultants before them. At the same time, their job is not an easy one and I think they need more understanding from the general public, and from Parliament, than they are getting at this time.

It would be the greatest possible pity if Parliament were to be engaged at this time in a kind of death struggle between the National Health Service and private beds for private patients. In my view, both have a vital part to play and it seems to me that the most important point to consider is this: is the pay bed system as operated at the present time prejudicial to the National Health Service? Is the existence of pay beds depleting nursing and medical staffs for National Health Service patients? If I thought—I believe many noble Lords would endorse this—that there was any serious chance of this happening I would certainly be for phasing out private beds at the earliest possible moment, but from inquiries which I have made of many grades within the medical profession, this is not the case.

During the last 18 years I have taken part in a number of debates on the Health Service. One of the great problems of the Service is that it has been subjected to report after report, but all too little has been beneficial to those who operate therapeutically within the Service. If there is to be a Royal Commission, let it be set up as soon as possible; although I believe obtaining a chairman and members will be no easy task. But let it have sufficient terms of reference to restore our National Health Service to being the envy of the world that it once was—those who operate it are still the envy of the world—and let it soon return to the status which it so thoroughly deserves.

8.25 p.m.

The Lord Bishop of BIRMINGHAM

My Lords, I wish to join with those who have already voiced their congratulations to the most reverend Primate my Brother of York and to the noble Viscount, Lord Kemsley. It is not my intention to dwell on the present dissention within the Health Service, particularly that concerning the junior hospital doctors and the consultants. I only want to express the hope that the junior doctors will very soon get a reasonable deal and that the pay bed issue will be resolved on some basis other than that of politics, because to confuse it with politics seems to me to neglect the real essence of the situation, whatever may be the embarrassment to the present Government.

Apart from this, my concern is the impact of the National Health Service on the ordinary man and woman. Of them, millions already have good reason to be grateful to the National Health Service and particularly to their GPs and to those who have served them well in hospitals. Here, I am in entire accord with the noble Lady, Lady Ruthven of Freeland, in the emphasis she places on where the hospitals belong. They are our hospitals: they do not belong to the National Health Service; they do not belong to those who work in them in whatever capacity. In my judgment we should not be told what to do with our hospitals by any sectional interest within those hospitals. We should, rather, seek to educate them into their role as part-owners with us of this splendid inheritance.

Even so, I think this debate is timely, if only that it provides an opportunity to say. "Thank you" to all those who are so engaged in our hospitals, and to wish them well. They need and deserve our encouragement as well as our thanks. But I believe the time is also needed to get the system more nearly right after the considerable upheaval of the recent re-organisation. From the opinions which I have gathered from quite a large number of people engaged in different ways in the Health Service, they see a great need for readjustment in the structure of the NHS and in the attitudes which the structure creates, both for those within the Service and among the general public for whom that Service exists. I am certainly one of those who thinks that there is one tier too many in the structure. The chain of command is too complicated and too remote, as against the former and still-remembered simplicity of the Regional Hospital Board.

There is a real problem in deciding where responsibility lies, and from my inquiries, and indeed from my own observations, there seems to be an obsession with management structures which tends to limit the ability of the Health Service to respond more adequately to the needs of the people. We need to take note that any large institutional system rapidly assumes its own momentum and then meets its own institutional needs before all others. But surely the first priority of the National Health system is not the system but the patient. In this context, I suggest that the policy of working towards the very large and therefore often remote hospital needs thought on other levels than efficiency and the concentration of expertise and expensive equipment. Those who work in such large institutions sometimes see the disadvantages very clearly. I heard an observation from a psychiatric consultant whose offices have just been moved to a vast new health factory. He remarked that one needed to be in first-class mental health just to find it. I believe that is a serious criticism of what could be the outcome of these vast institutions for those who are taken there, sometimes literally in fear of their lives, in order to be restored—as it is hoped—to better health.

If it is argued that present resources are insufficient—it is undoubtedly true that in some parts of the country they are—it is also important to note that insufficiency of resources is not just related to needs in some objective sense but is complicated by demands for services, and those demands are, of course, affected by what people have been led to expect or what is understood to be available. I believe that this kind of a resources dilemma will become more important as it becomes clearer that we do not live in an automatically expanding economy. So the local community must be organised more and more for local activity. It is just not possible to go on adding ad infinitum to the number of people who are paid as professionals for dealing with other people's problems.

I believe it is almost certainly not healthy to go on endlessly in that direction. After all, the National Health Service is a national health service, and not a national sickness service. If it is concerned with prevention—as I think it ought to be far more than it is—as well as with diagnosis and the treatment of disease, then we need to ask whether our technological skill in doing this is producing an impersonal style of hospital medicine, so that birth and death, the two great events of life, take place more and more as clinical events, and less and less in a family context.

I believe it is essential to recover a value system in hospitals which gives care of patients priority even over the cure of disease. Doctors and nurses and the ancillary professions must get together to work out their ethical values. At present the doctors are too divided on important issues such as, for example, when to prolong life or to let people die. Implicit in the care of people there is surely the need for a reassessment of our own use of high technology medicine in acute hospitals, involving great expense and specialisation. We need to give priority to community services for care in the home, for home helps and district nurses; I know areas where there are certainly not enough of these and where that need cannot as yet be supplied. We must recognise that the sky is not the limit in health care. There is such a thing as enough.

My Lords, this inevitably means there are things which we cannot do, and that there are some people—this is a terribly serious thing to say—whose lives cannot be prolonged except at the expense of others whose health is not being safeguarded. We must face this hard fact and discuss how we can approach these immense problems in the most humane spirit. I have only to mention the treatment of terminal illness, already referred to implicitly. Are we to keep people isolated so that they live longer, or are we to permit them to die in a community context? In our approach to geriatrics—all of us are moving steadily in that direction—we should ask ourselves how much should be expended in warding off the deterioration of old age, and what good is done to them, and for whose good.

Then there is the question of the choice of expending scarce funds on very complex treatment units such as accident centres, for transplantations, and so on; wonderful and attractive things, but how important are they in terms of what is really a National Health Service? It has been suggested to me, by some who have thought long and hard about this aspect of it all, that on careful exploration and reflection it can be shown that their health treatment could be better done; much could be better left undone, and much could be done differently with less resources.

My Lords, I am glad mention has been made of community health councils, because I believe they can have a very significant part to play, although it seems far too soon as yet to judge their efficacy. Some about which I have heard seem to be insufficiently serviced as against those multitudinous hospital committees, full of people making sure they work despite their inability otherwise to do so. But with these community health councils, there can be an involvement of the community in the whole process of health, so as to enable more and more of us to get out of the obsession with illness and sickness in its various forms. The more we think about these things the more we can become open to infection, and I use that word in a non-medical sense.

My Lords, we need to be wary of over-professionalism, although at the same time I believe if the community health councils or any other aspects of the Hospital Service are to work well, then we cannot do without our professionals. Nor must they be handicapped in their professional independence, either within the National Health Service or outside it. May I close with a short quotation from the most experienced of the hospital chaplains in my own diocese. He writes: There is no doubt that many of the general public have the idea, and they have been led to believe, that there are unlimited resources and that every demand can be satisfied. The education of the public in the realities of the situation seems to be of importance, and at the same time people may well have to learn to do more for themselves, for their own physical and spiritual wellbeing. While we must be thankful for the presence of experts in the field of community care, quite clearly they are not coping with all the demands and are never likely to do so. To take away personal responsibility can never be right.

8.36 p.m.

Lord SEGAL

My Lords, I feel sorely tempted to follow the right reverend Prelate the Bishop of Birmingham in his excellent speech, particularly his reflections on the problems that face all of us in our geriatric state, and when he touched on the fringes of euthanasia. But there have been already so many excellent contributions in this debate that, at this late hour, there are only a few points I would venture to touch upon, even at some slight risk of repetition. First, I think we must all deplore the fact that industrial action has been taken by medical men; whether junior hospital doctors or senior consultants. On that issue, there should never be any doubt.

Secondly, I feel it is time to call a halt to sniping at the Minister. This can only confuse the issues and do no good whatever to the doctors' case. Moreover, the present Minister has inherited an appalling legacy from many years past, one which would have bedevilled any Minister trying to cope with existing problems. I dimly recollect having made a maiden speech 11 years ago on this very Subject, the malaise existing then in the National Health Service. That was a convenient diagnosis way back in 1964. Since then, matters have become steadily worse. Today, we are faced with almost a head-on confrontation between the Government and the medical profession.

My Lords, I recall an occasion just a year ago when I was with a Parliamentary delegation in the Caribbean, and the local airline could not maintain its scheduled services. The pilots did not go on strike or work to rule; they merely announced that henceforth they would operate with "lack of enthusiasm", and so the aeroplanes between the islands merely arrived some two or three hours late, and the passengers were thankful if they arrived at all. Today, the supreme act of statesmanship would be to rekindle the enthusiasm of the medical profession. Every young doctor qualifies with some sense of a mission, with a burning enthusiasm to go out into the world, and heal the sick. The aim of any Minister should be to keep that enthusiasm alive through the whole of a doctor's career. It is not primarily a matter of pay, but rather of the climate in which the doctor has to work.

The medical profession, by its very nature, is the most difficult profession in the world for which to legislate. A doctor's relationship is intensely personal towards each individual patient. His diagnosis often has to be tentative and his treatment empirical, related to the particular patient rather than to his particular illness. That is why we flounder so often in trying to assess his salary scales. During an intricate operation, when the patient may be hovering between life and death, and the slip of a scalpel may prove fatal, how can we assess the level of a doctor's salary in terms of the human life on the operating table?

Surely, the best we can attempt to do is to ensure that a doctor is enabled to carry out his duties free from any financial anxieties, and free to concentrate all of his skills on his work. This may well be the ultimate ideal for which to aim, but in the meantime, it seems utterly wrong that today, just in the midst of our present economic crisis, doctors should withdraw their help, in demanding higher scales of pay. They may go slow or work without enthusiasm, but to withhold their labour entirely, is, in my view, quite unforgiveable.

And yet, cannot something be done to dispel the present mood of discontent? I believe the statistics of doctors who emigrate are totally misleading; they are merely the tip of the iceberg. For every doctor who is able to emigrate there may be a dozen or more frustrated, embittered or disillusioned who would willingly emigrate if only they could. It is this feeling of profound dissatisfaction that has eaten into the heart of our National Health Service today. I recall a proverb of my younger days, "You may take a horse to the water but you cannot make him drink".

So where does the power of Parliament come in? Do we appeal to the doctor's patriotism, to his loyalty, to his law-abiding nature, to his respect for the institution of Parliament and to his dedication to his Hippocratic Oath? Of course, we appeal to all of these, but, in the last resort, what sanctions can we impose without endangering innocent human lives? One cannot arrive at a difficult diagnosis by democratic means, nor perform an intricate operation successfully by Act of Parliament. To that extent the role of a legislator is limited, and even the highest court in the country cannot compel. Moreover, in the last resort, every medical practice is a private practice, based on a doctor's private knowledge, experience and understanding of his patient's stresses and anxieties, all worked out in the inner recesses of the doctor's mind. What we can do is to create a climate of co-operation and mutual trust, to enable the doctor's mind to work in an atmosphere of quiet confidence, with his skills unhurried and unharassed.

This does not mean a profession which is pampered or feather-bedded or singled out as another special case, but it does mean a profession keen with enthusiasm, always on its toes in the interests of its patients. Let us never forget that in the bad old days, before the NHS, consultants gave their services to the hospitals entirely free of charge, without any fees at all; junior hospital doctors were glad to work without any salary, merely for their subsistence, and senior registrars were proud and honoured to work full time for pocket money alone. The same was true of our nurses in those bad old days. But those days have now gone for ever. Yet the same spirit of dedication to medicine, and through medicine to the community, still survives in our midst today.

What then, as others have already asked this evening, has gone wrong? Today it is virtually impossible for most consultants to live on their private practice alone. The wealthy patients are no longer there in large enough numbers. Middle-class patients no longer have the means, and have rushed to join the various contributory schemes, such as BUPA or PPP, to opt for the doctor of their own choice. So most consultants today must depend, either wholly full-time, or part-time, on the NHS. And when a doctor achieves eminence in his profession he often finds the strain of whole-time service in the NHS too exacting, and reverts to part-time work to leave himself more free time for medical reading and research. Moreover, in the old pre-NHS days, hospitals had to compete with each other for private benefactions, and to make do with smaller administrative staffs. They had to economise rigidly in order to survive at all. So it became inevitable that the voluntary hospitals could not continue and the State had to come to their rescue.

Standards of medical practice in this country are, I believe, still the highest in the world. Woe betide that we should ever sink to the cut-throat, beggar-my-neighbour standards of medicine in the United States. But how can they be maintained in this country in both the public and private sectors? Surely by each helping the other, and drawing the best out of both. The only justification, in my view, for the separation of the private from the public sector of medicine would be if, by so doing, the standards of both could be improved in the interest of the patients. I cannot believe that it is in the interest of the patients that National Health medicine should be improved and private medicine allowed to go hang. Surely, the Government cannot be indifferent to maintaining the highest possible standards of medicine in the private sector as well as in the public sector. Today we subsidise excellence in so many diverse fields in the private sector, in the Arts, in music, in the theatre. Should not excellence in the healing art, in both the public and the private sector, also stake its claim for Government aid?

What then can we do in the present impasse? I believe that we ought to rescue what was best in the old system and adapt it to the needs of the new. Above all, we ought to revive the enthusiasm of the younger doctors, who knew not the bad old days, and are eager to devote their highest skills to the patients of today. Perhaps the climate of medicine needs a little altering, and highly skilled men should be released from the tedium of endless committee work and be free to devote more of their time to the study of their art and the practice of their skills. Perhaps general practitioners should be released from some of the less essential form filling, of supplementary certificates, long lists of prescriptions, that distract a doctor from his role as a healer. If he were adequately paid, there would be none of these petty claims for extra remuneration.

I believe that medicine today is as glorious a vocation as ever it was. The medical staff of a hospital is the keystone of the arch, and if it is removed the whole edifice is in danger of crumbling. Perhaps one may take comfort in the fact that the consultative document is not yet a final declaration of policy, and its concluding paragraph states that the Secretary of State will still welcome comments from all concerned. Perhaps we may also draw comfort from the fact that the Royal Commission has not yet started its inquiries and that the Prime Minister has personally intervened in the doctors' disputes. But if there is a continued failure to gain the confidence of the medical profession, a failure to revive its lost enthusiasm, then the National Health Service is likely to remain in the doldrums for a long time yet to come.

8.50 p.m.

The Countess of LOUDOUN

My Lords, much of the current controversy in the National Health Service seems to centre round such issues as pay beds and mainly concerns itself with the acute sector. But do your Lordships realise that nearly 50 per cent. of all hospital beds are occupied by mentally ill or mentally handicapped people? In her foreword to the White Paper, Better Services for the Mentally Ill, Mrs. Castle said that mental illness is a major health problem, perhaps the major health problem of our time. More than 24 million working days are lost each year to mental illness; 5 million people a year consult their doctor about a mental health problem.

While money continues to be poured into the more fashionable and more acute specialties, mental health services languish in a state of apathy and low morale brought on by constant neglect, constant under-financing, and a failure to afford mental health services the resources they need to cope with the size of the problem. Persistent under-financing has created conditions that would arouse outrage were they found in general hospitals. Recently I myself heard the Secretary of State for Social Services admit that the neglected areas of the Health Service might well have received more material support had public concern been expressed with comparable vigour to that which emerged in the educational sector. These people are unable to speak for themselves. There is still time to think again. It would be madness for any society to ignore mental health, which cuts across every conceivable social issue.

Since 1974 local authorities have been given greater freedom to establish their own priorities when submitting applications for loan sanctions, but how can Central Government ensure that these authorities are building up those services and providing the neccessary care and after-care? I believe that it should be mandatory on local authorities to provide these services. At the moment, there is an imbalance between the health and the social services. These problems are interrelated and should be considered in the overall context of the National Health Service.

The National Health Service could be crucial in helping patients, many of whom no longer need hospital care but have to remain because no other facilities exist to leave hospital and resettle in the community. But domiciliary and day care social services are already under pressure as a result of cuts in public expenditure, and this would increase the demands on them. May I remind your Lordships that there are 645 children under the age of 15 years in psychiatric hospitals, some being cared for in adult wards.

Much of the development envisaged in the White Paper seems to depend on effective joint planning. Large mental hospitals can be phased out only as specialist district services are built up, and these in turn must rely on adequate support services in terms of day and residential provision. At the moment, it is probably voluntary organisations such as Mind local mental health associations who are doing most to move patients out into the community.

I realise that the financial constraints stop any major developments, but I must suggest to your Lordships that some of the proposals in the White Paper could be implemented now. If wards in mental hospitals were to be split into divisions, each division being a part of the hospital serving one health district, this would be the first step in the relocation of specialist services in the community and would not require additional capital or revenue expenditure. Secondly, provision of a 24-hour crisis intervention service. This is already operating in some areas and can often be the means of avoiding admission to hospital. Thirdly, the provision of in-service training for social workers in contact with the mentally ill. This need not be costly and could contribute to a much more effective and humane use of services. Regional planning now during this period of financial restraint would ensure that any plans could be implemented without delay when resources become more readily available. Hospitals should be taking the lead in jointly funded health and social projects which would enable hospital patients to move into community facilities, perhaps also funded jointly by the health and social services.

The Department of Health and Social Security should consider further the potential sale of surplus hospital land in order to finance further services. There is a need for much more qualified manpower, and care must be taken to make the maximum use of present resources both of manpower and finance. There is no need for further legislation. There is plenty of legislation on mental handicap already on the books. We should also be looking at the possibility of re-housing patients through the Housing Corporation. "Mind" has talked to my noble friend Lord Goodman, and plans are under way for housing in one area of London. The Royal Commission on the National Health Service must reflect the high proportion of beds occupied by the mentally ill and the mentally handicapped. It should have a good representation from the statutory and the voluntary sectors of the Health Service.

May I beg the Government to take the lead in initiating a public education campaign together with local authorities and voluntary bodies. At the moment all the Press talk about are the small numbers of ex-Broadmoor patients who tend to represent one type of patient, the psychopath. This is not representative of the vast majority of mentally ill or mentally handicapped people. There are problems—no one can deny this. Assessment procedures set up by social workers to deal with the elderly mentally ill and children at risk demand co-operative working and good communication systems to be effective. Increased failures to follow up or to communicate seem certain to arise in the present disrupted situation. The lack of adequate consultant psychiatric cover in some areas has been a topic on which the British Association of Social Workers has expressed concern to the BMA. Nevertheless, we have a Health Service second to none, and one to be proud of. I hope that your Lordships will forgive me if I cannot stay until the end of the debate, but I have to catch a train.

8.58 p.m.

Lord BROCK

My Lords, I first wish to comment on the statement of the Secretary of State for Social Services that by the closing of 2,400 pay beds the Service would be acquiring the equivalent of four district hospitals. Such a statement is a totally misleading simplification; it is unacceptable. The whole is always greater than the part, and it is wrong to suggest that the complex organisation and achievements of four large district hospitals can be equalled by many small parts or groups of beds scattered diffusely across the country. Apart from this incorrect presentation, the cost of administration and upkeep of 2,400 beds would be an additional charge on the already overstretched and under-financed National Health Service. At present this is met by charges to private patients variously estimated, as we have heard, at £20 million or £40 million.

I next wish to put forward the evidence that much harm is being done to the National Health Service by the present policies of the Government and the Sectary of State. Essentially the threat is to the freedom of action of doctors. So much has been written and spoken about the steady and progressive deterioration of the NHS that it is scarcely necessary to repeat all the arguments, with most of which your Lordships are familiar, and indeed have heard today. The outstanding feature, one that is so significant and is doing so much harm to the Service, is the flight of doctors from the country. We have heard and continue to hear of many senior consultants, even professors, who have decided to pack up, in addition to many younger doctors who have only recently finished their training. For example, early in October we were told of a distinguished woman professor who was leaving a famous London hospital for a post in the United States and was taking with her 10 of her research team, including three doctors, three science graduates along with some junior and senior technicians.

At about the same time we heard of various other specialists who were leaving, most significantly several radiotherapists, who are in short supply, who take about 10 years to train in a close specialty and whose departure is determined, even precipitated, by the threat to withdraw the ability to use independently the highly complex and expensive apparatus which at present they are permitted to use, not infrequently for no payment to themselves. They see only continuing frustration in Great Britain. This is a serious loss to the country because their skills are scarce and it takes so many years to replace them. Similar examples can he repeated many times.

It is not solely a question of being deprived of the ability to carry out some private practice. In fact, many of those who complain and who, because of frustration and interference with their freedom of action, have decided to emigrate, are engaged in full-time employment with the NHS and have never engaged in private practice. It is the loss of or interference with professional freedom that disturbs them and which they feel is so unacceptable, especially the threat of future loss. On this the profession is firmly united. There could be no better example of that than a letter written to The Times on 29th September by Sir George Pickering, formerly Professor of Medicine at St. Mary's Hospital and Regius Professor of Physics at Oxford.

Sir George said: I worked for three London teaching hospitals, 30 years of that time being as a Professor of Medicine… In my experience, quality of service did not depend on whether the doctor did private practice or not. It depended upon the ability of the doctors, upon the excellence of their training and, above all, on their morale. Morale in turn depended on the character of the doctor or nurse and on whether or not they were satisfied with their conditions of work and enjoyed a measure of professional freedom. ….During the whole of my service I never received fees from private patients and I refused two opportunities to take up private practice, not because I had any objection to it but because I was far too interested in teaching and research and in the patients whom I had to serve as a Professor of Medicine. I just had not got the time….In the past few years there has been a sad decline in the morale of senior doctors employed in the Hospital Service. This is due first to the increasing yoke of bureaucracy imposed by the reorganisation of the Health Service of 1974. Now is added a new threat, that decisions concerning the NHS are based on politics and not on the best interests of the sick. Doctors ask themselves, who wants to work for that kind of Service? Where I young again I certainly would not. I would emigrate to a country where my colleagues and I could try to preserve the professional standards to which I have become accustomed. Sir Herbert Seddon, a distinguished ortho-paedic surgeon, wrote that he was badly shaken by Sir George Pickering's sad letter and especially by the statement that if he were young again he would get out, emigrate.

One noble Lord referred to the fact that this move to emigrate was only the tip of the iceberg and that many people would like to emigrate but had not done so. There is, in fact, a flood of refugees. A recent assessment in the Daily Telegraph mentioned the answers to a questionnaire about leaving Britain and included 99 surgeons. 48 physicians, 45 anaesthetists, 31 radiologists, 35 psychiatrists and 39 gynaecologists; also that the Australian authorities had confirmed that 221 British doctors had applied for assisted passages last year, treble the number applying in 1973. The BMA reported that in the first six months of this year 622 doctors asked its special emigration inquiry department about appointments abroad. This was 76 more than in the whole of 1974. The United States Educational Commission for Foreign Medical Graduates tested 1,800 doctors from Southern England alone at its last examination in London. Even though some of those leaving the country may return, the cumulative effect is very serious and, I repeat, within a few years many of those who have left, if not already consultants, will have reached that status and are a complete and serious loss to the NHS.

Lord WELLS-PESTELL

My Lords, the noble Lord has given some very impressive figures. Will he please now tell your Lordships how many of them took up those options? If he cannot, I can.

Lord BROCK

I am unable to say how many took up the options, my Lords.

Lord WELLS-PESTELL

My Lords, I will tell the House.

Lord SEGAL

My Lords, I apologise for intervening, but is not the real point the fact that they wish to emigrate, whether or not they are able to do so?

Lord BROCK

My Lords, this yearly loss is becoming increasingly serious and represents a bleeding of the trained medical profession in Britain. It means that the supply of doctors, including many highly trained ones who can be replaced with difficulty, if at all, is running down. This is a loss that we cannot afford, just as a patient cannot tolerate a steady and increasing loss of blood, of haemorrhage. We must recognise that this is what is happening as a direct result of the way in which the NHS is governed and functions; and the loss has been accelerated and made worse by both the action and the mistrust of action taken by the Government in proclaiming their intention to phase out private beds in hospitals, and the conviction that this will be a prelude to the introduction of compulsory State service and complete loss of professional freedom. It is the threat to freedom, not the closing of private beds, that is the cause of the trouble.

Why is this grave step being taken? Why, in times already troublous and anxious, are we faced with this extra worry and this extra threat to our well-being? The Labour Party maintains that in two Election Manifestos it has committed itself to doing this. It protests that the promises in the Manifesto to phase out private beds must be implemented. The Labour Party seems unimpressed that the number of voters expressing an opinion on its Manifesto was no more than 40 per cent., and the proportion of voters who supported them was only some 30 per cent. It is not possible to assess how many of these were actually influenced by the content of the Manifestos, even if they read them. The Government loudly declaim that they are bound by their Manifestos and that these are a complete answer to their provocative and destructive action, action which is causing great distress and destruction of morale among the medical profession, constantly and repeatedly declared. It is a terrible criticism of the-action of the Govenment that they have led astray—some might even say corrupted—the doctors by their cruel and insensitive threat to a great profession which ordinarily sets its ethical standards very high. In that, I refer to a matter which has been mentioned very often this afternoon—the temptation to strike action.

This is no new situation. It is one that was presented convincingly and emphatically by Shakespeare over 300 years ago in his play The Merchant of Venice. Surely this is a straight Merchant of Venice situation. The unpleasant character in the play, Shylock, makes much of the bond he holds, just as the Government keep yelping about their wretched Manifesto. "Give me my bond, give me my pound of flesh," is the truculent and malevolent demand even when mercy and compassion are suggested. My deeds upon my head! I crave the law… There is no power in the tongue of man To alter me: I stay here on my bond. The answer to Antonio the Merchant is, "Therefore lay bare your bosom." And this the doctors are expected to do. They are expected to submit like lambs to the slaughter. Have by some surgeon. Shylock, on your charge, To stop his wounds, lest he do bleed to death? Shylock replies, Is it so nominated in the bond? Does the Manifesto say that the life of the NHS must be guarded lest it do bleed to death? Portia replies: It is not so express'd; but what of that? 'Twere good you do so much for charity. This suggestion is brushed aside. I cannot find it: 'tis not in the bond. That is to say, let the doctors go to the devil and the NHS with them. We know only too well the next comment of Portia but it would appear that the Government are not aware of its significance. At the risk of being thought tedious and of telling your Lordships something you know only too well and probably learned at school, I must remind your Lordships of it and the Government of its significance. This bond doth give thee here no jot of blood; The words expressly are ' a pound of flesh ' … The disreputable character in the play realises the position he has placed himself in and tries to withdraw, but without success. I maintain that, in declaring the rights and justification of their Manifesto, the Government are placing themselves in exactly the same position as did our unpleasant character who loudly declared the justice of his bond. It might be excusable if the Government were able to get their pound of flesh without shedding blood—if the excision of pay beds were the sole achievement. But much else will be lost, as is only too well seen by contemplating the present sad state of the NHS. The Government have been told time and again that they are also destroying professional freedom. As they take this pound of flesh, they must be made to realise that they are also taking the lifeblood of the NHS. Even our unpleasant character in the play suddenly realised the full consequences of his action and tried with withdraw.

I am now pointing out to the Government the full consequences of their action, which they do not seem to have grasped or appreciated. I ask them whether they intend to insist on their pound of flesh and the profound and fateful results which will spring from it; that is, the steady loss of the lifeblood of medicine and of the NHS. Although this may in part be checked by the skill, devotion and readiness of the doctors to face this calamitous situation, they can only check the amount of harm which will result, but the amount of harm will still be incalculable. I challenge the Government to think again, deeply, conscientiously and intelligently before they insist on their Manifesto and on their pound of flesh.

9.6 p.m.

The Earl of HALSBURY

My Lords, I ask your Lordships' indulgence for a late intervention, not being on the speakers' list. The reason why my name is not on the speakers' list is that I thought that, in view of my past involvement with this matter, it would be better for me not to make a contribution. However, in the course of listening to your Lordships' debate on this subject, a quite non-controversial analogy has occurred to me in which matters in controversy between the parties or between the Government and the profession have in another context been solved. I feel that it may perhaps be worth reconsideration.

In the field of transport, one can buy a first- or second-class ticket. The first-class passengers do not jump the queue if passengers are queuing up to get on to the station. It is entirely an option of the consumer whether he buys a first- or a second-class ticket. There are no politics of envy or malice about this at all. If one has a short journey and is in good physical health, one probably saves the money and travels second-class—at least, I do. But, if it is a long journey and one has arthritis and one does not like to be cramped, or perhaps if one wishes to use the train journey from London to Edinburgh to catch up on reading and papers and wants to travel only three to a side so that one's papers can be spread out on one's lap, one can travel first-class. There is no class prejudice about it in the social sense. It is simply a buyer's option. Since we have solved this matter satisfactorily and, in the social sense, without tension in the field of transport, is it beyond the wit of man somehow to preserve a feeling of natural justice, which is what people want, so that, having paid, as it were, a contribution to a minimum standard of public health, the consumer can add to it from his own means and at his own wish out of the income left to him after he has paid his taxes? That is all I want to say and I hope it will be accepted in a non-controversial spirit.

9.14 p.m.

Lord SANDYS

My Lords, as the thirtieth speaker in this debate I should like, first, to thank my noble friend Lord Aberdare for introducing this Motion today. Surely to attract such a very large number of speakers at this most appropriate date has been a great personal triumph. The fact that the debate has attracted two maiden speakers is of very great significance—and it is a particular pleasure that the most reverend Primate the Archbishop of York was one of them. In his most notable speech, which lasted only four minutes, we recognised immediately that the House has been exceedingly fortunate that he has been appointed to this very high office, and we thank him for what he said today. My noble friend Lord Kemsley also addressed your Lordships in a most notable speech, which lasted eight minutes. Thus, we have had two Members making maiden speeches with that admirable quality of brevity which I am quite sure can be reflected by many of us; and I shall endeavour to do so.

We have examined in very great depth the question before your Lordships concerning the condition of the National Health Service. Perhaps I may be allowed to begin in the international context and consider the Health Service as one of the National Health Services of the world. This is a very significant moment in world health because that scourge of mankind since the years of the Pharaohs—smallpox—is all but defeated, eliminated, and expunged from human experience. This is indeed a year to mark down in world health. I understand that the World Health Authority believes that its monitoring system throughout the world is in sufficiently good a condition as to expect that after a period of years it will be able to confirm this particularly welcome piece of news for mankind; and the National Health Service should be congratulated for its part in monitoring, in preventive action, in examination, and for all its other work. But do not let us forget the work of Dr. Edward Jenner, the founder of vaccination, who performed that very great service to mankind. In his death in 1823 mankind lost one of its greatest friends in the health field. With that historical recollection—

Lord PLATT

My Lords, Edward Jenner would not have been allowed to carry out his experiment today, because it was done on a boy aged 9, and one cannot now experiment on children.

Lord SANDYS

My Lords, I thank the noble Lord, Lord Platt, for the very helpful intervention.

There is no doubt whatsoever what has been upper-most in the minds of your Lordships this afternoon; that is, the present situation in which the National Health Service finds itself. I believe that the spirit of the debate was reflected in one of the remarks of my noble friend Lady Ruthven of Freeland, who said that she had great faith, and not despair, in the Health Service. She is not here at the moment, since she came to the House earlier suffering from a severe cold. I think it will be obvious to your Lordships that the quality of her speech stemmed from a very deep knowledge of the whole of the health and hospital service.

It is a hard task to attempt to sum up from this side of the House the excellent speeches which have been made. There have been very few speeches which one could regard as being of an abrasive character. Certainly my noble friend Lord Aberdare opened the debate with an extremely healing speech. In other circumstances—and perhaps in another place—it would have been an opportunity to handle the debate in a wholly different manner, but my noble friend entered into the debate from a very different viewpoint, from a spirit of inquiry and con- ciliation. This has been reflected in many speeches, but it is very remarkable that out of 29 speeches there have been only three which have come out on a different side, against pay beds. This issue is not necessarily the most important; nevertheless, it has commanded considerable attention in your Lordships' House for its obvious connotation and link with the medical profession. I think we must take the view this evening—I hope the Government will take the view of the House this evening—that your Lordships feel that the referral of this matter to the Royal Commission would be of very great benefit.

I should like to comment first of all on the question of agency nurses. As your Lordships are aware, there are no fewer than 11,000 in this category. Approximately 8,000 to 9,000 agency nurses are probably working at any one time, of which about 5,000 are working within the National Health Service; and I was glad that the noble Lord, Lord Amulree, stressed the need to retain the maximum number. The agency nurses have behaved with very great dignity throughout this issue of pay, and, although they have accepted a very much lower award, they have continued in their duties and have not, I think, complained over-much. I feel they deserve the Government's very close and sympathetic attention to their predicament.

The morale of the National Health Service was stressed by many noble Lords, and I feel that issue was raised in regard to the question of the Humberside study of reorganisation. But surely, my Lords, if the whole issue is to be placed before the Royal Commission we shall look forward to their impartial judgment on whether or not the various tiers of organisation are necessary.

In regard to finance, much depends on this factor. I think I must begin by mentioning and quoting the comment of the noble Lord, Lord Wells-Pestell, when he said—and I think I took down his words correctly: Doctors accept cuts from a Conservative Government which they would not accept from a Labour Government ". I think that is accurate. If I may comment upon that statement, the fact is that the doctors believed they were acting in the national interest when they accepted this cut, which was imposed upon them by the then Chancellor of the Exchequer, the noble Lord, Lord Barber, when there was a reduction in the health budget to £3,860 million.

My Lords, I think that the nursing profession as a whole owes a very great debt of gratitude to the noble Earl, Lord Halsbury, whom the House was delighted to hear when he made his brief intervention—all too brief, if I may say so—at the very end of the debate. There is no doubt about it. The nursing profession has been hitherto underpaid and perhaps exploited, but the work of the noble Earl's Committee has done a very great deal to redress the situation.

My Lords, I was particularly interested in the most reverend Primate's speech, when he referred to managerial techniques which are at present employed in the National Health Service, and the fact that he queried whether these should be employed as they are employed at the present moment. He was indeed supported in this by his right reverend brother, the right reverend Prelate the Bishop of Birmingham, and I believe that both speeches reflected a philosophical anxiety about a problem which is very nearly insoluble but perhaps not quite insoluble. It is that now, and indeed in the future, only the very large hospitals can attract the important techniques and equipment necessary for the most advanced variety of treatment for diseases.

At the same time, the anxiety of the patient in such circumstances, in an environment which must be wholly strange to the patient, is something which can be only a matter of concern to those who are very much involved in the Health Service. These clearly will be matters for the Royal Commission to concern themselves with; but I think that perhaps the noble Baroness, Lady Gaitskell, placed her finger on something which has been worrying noble Lords. That has been the activities of NUPE, NALGO and COHSE. She said that NUPE, particularly, "has been petty and spiteful". It is a matter of great concern that the National Association of Local Government Officers, three months ago, in September, urged its members to file objections to all planning applications for new local hospitals within their areas. This has added a dimension to the argument which has been wholly unwelcome and unfortunate in the circumstances. Activities which have taken place the past have added greatly to the fuel in the circumstances and have been wholly unnecessary and harmful to the actions of those trying to conciliate between the parties.

The licensing of hospitals was mentioned especially in his maiden speech by my noble friend Lord Kemsley. We agree with him that there is great concern that the licensing system to be adopted by the Secretary of State will be unlikely to reduce waiting lists in National Health Service hospitals. I think that every noble Lord would agree with what he said; that is, that every bed in a private hospital releases one bed or makes necessary one less bed in a National Health Service hospital. The noble Lord, Lord Porritt, made a particularly interesting speech in which he questioned the whole structure of the Health Service and recommended that it should be dismantled and restructured. At this late hour I feel totally unqualified to comment on such a statement, but also I feel that this, too, is a matter most appropriately to be dealt with by the Royal Commission. Nevertheless, the noble Lord ended his speech by expressing his desire for the re-establishment of trust between the Government and the profession.

The speech of the noble Lord, Lord Hunt of Fawley, was particularly welcomed on this side of the House. He, too, mentioned the question of licensing and suggested it would be a stranglehold both on patients and on the profession and should be firmly resisted in every way. I feel that, in present circumstances, the statement which is before the House in the Consultative Document may perhaps be misinterpreted; nevertheless, it is the only interpretation we can place upon it.

My noble friend Lord Colwyn commented in some depth as a professional dentist. I was particularly glad to hear what he said although I did not altogether agree with him. Your Lordships have not had the opportunity to discuss the very large, thick and valuable document entitled, Childrens' Dental Health in England and Wales, 1973. It is a monumental survey carried out in collaboration with the Department of Dental Health at the University of Birmingham and the DHSS. It is, I think, relevant to what my noble friend said because he was concerned with the preventive system of dentistry and also was recommending to your Lordships that an expenditure of £5 million on fluoridation would cut the incidence of dental caries by half. It so happens that I totally disagree with his point of view; nevertheless, I am not a professional dentist.

He stressed that there is an issue here, and I should like to refer to a problem that has occurred in two parts of the United Kingdom; namely, in Kilmarnock in Scotland and Anglesey in Wales. As your Lordships may be aware, in Kilmarnock fluoridation of water supplies was undertaken. Further, it was adopted for a period of years and totally rejected as unsatisfactory. In Anglesey, a much more interesting situation has taken place. In 1955 Anglesey fluoridated half the county; the other half of the county was to act as a control area. In 1964 the control area was abandoned. In 1973 the local authority decided by a majority of 27 votes to 3 to terminate fluoridation. This decision was communicated to the Area Health Authority, but it felt itself unable to act, so approaches were made to their Member of Parliament, the right honourable Cledwyn Hughes and also to the community health council which adopted the same attitude as the local authority. This is an issue, because here is the machinery of consultation in operation, and evidently there is a blockage in the pipeline because the Area Health Authority finds itself unable to act in these circumstances. I should like to ask the noble Lord whether he could look into this matter and write to me at a later stage about it. I do not expect a reply this evening because the matter has a considerable history.

The incidence of dental caries, especially among young people, is a matter for grave concern. The Report to which I alluded was concerned with a sample of no less than 13,000 children in England and Wales aged between 5 and 15. In this particular study their mothers took part and greatly assisted with their knowledge of their children's dental health. On page 85 of the Report, table 10.8 shows that only 5 per cent. of mothers thought that fluoridation of water supplies helped, while regular teeth cleaning and avoidance of sweets was the over- -whelming majority decision, between 65 per cent. and 73 per cent. for different age groups.

I should like to refer to all the speeches, but at this late hour it would be unprofitable to do so. I cannot close my remarks without referring to a particularly important speech by the noble Lord, Lord Hill of Luton. Your Lordships will agree that, from the noble Lord's wide and deep knowledge of the profession, and his long association with all branches of it, the Government should pay particular attention to what he said. He was emphatically against the phasing out of private patients in National Health Service hospitals, and he was at the same time particularly suspicious of the licensing provisions put forward by the Secretary of State. He laid stress on the fact that the wording of the Consultative Document was particularly ambiguous, and he had a point there as the noble Lord, Lord Wells-Pestell, noted at the time. The noble Lord shakes his head. Nevertheless, if he reads Hansard tomorrow, I think he will he inclined to agree with the noble Lord, Lord Hill.

I should like to draw my remarks to a close, after speaking for 20 minutes. I should not like any noble Lord who has spoken and whom I have not mentioned to feel that either I have been absent from the Chamber or not paid particular attention to what has been said, but time precludes a total examination. It would appear that the situation which the medical profession and the Government find themselves in today is one similar to a fable well known to your Lordships—that of Old Man Kangeroo and Yellow Dog Dingo. Old Man Kangeroo and Yellow Dog Dingo chased each other around all day and then under the night sky they turned and faced each other and said simultaneously, "It's your fault!" I think the accusations and counter-accusations may well be resolved in the efforts which we believe are being undertaken at the present moment: that is, the intervention of the Prime Minister and his advisers in a situation which has been fraught with very great difficulty. We hope that these conciliatory activities will bear great fruit.

9.35 p.m.

Lord WELLS-PESTELL

My Lords, I want to resist the temptation to reply in great detail to certain noble Lords, because I did put the position of the Government and, if I may say so, my own position too, quite clearly and quite frankly when I followed the noble Lord, Lord Aberdare. This has been an unusual debate, in the sense that 25 per cent. of the speakers are very distinguished members of the medical profession. I could not help thinking, while sitting here for something just over six hours: "If I am going to be ill in the future, please let it be now!" I am sure I should get first-class treatment without delay.

I think the noble Lord, Lord Aberdare, can take some comfort from the fact that whatever may be the outcome of this debate he has provided an opportunity for people to discharge a reasonable amount of emotion, and the cathartic effect of this debate must be of immeasurable value to a number of noble Lords who have taken part. I hope I shall not be misunderstood when I say that, sitting here, I began to ask myself: "What is your role in the intervening period?" As most people seemed to address their remarks to me, I came to the conclusion that at that particular time I was, so to speak, a passive bucket into which people were being emotionally sick. I think that is a good medical term, so it should meet with approval.

All I want to do now is to answer as quickly as possible some of the questions that have been put to me. I may have missed some of them, although I hope not. The noble Lord, Lord Aberdare, raised the matter of the health care planning teams. We have issued, as he knows, a draft circular. I know that he was exercised in his mind about when we were going to issue a final circular. All I can say to him at the moment is that shortly we shall be issuing to authorities further guidance in the form of a final circular, setting out the steps needed to secure the joint care approach to planning. This will in fact cover the health care planning teams which the noble Lord has in mind.

He also raised the question of the re-examination of the figures for the extra duty allowance. I can only repeat what I said earlier, that my right honourable friend the Secretary of State recognizes the amount of work being done by junior hospital doctors. While there is the difficulty of the pay pause, there is also the matter of £12 million, and the question is, how best can the money be distributed? My right honourable friend has referred the matter to the Office of Manpower Economics which serves the Review Body, and also to the British Medical Association's statistical adviser. I understand that they met yesterday, but so far we have had no reaction at all—it is early days yet—from the British Medical Association as to the outcome of the meeting. But a meeting was arranged for this afternoon to allow the Junior Hospital Doctors' Association an opportunity to present their viewpoint, and to give the Department's officials the evidence on extra duty allowances which they believe should be brought to my right honourable friend's attention. So I think it can be sad that the matter is well and truly under way.

I answered the noble Lord's point about the addition of staff when I replied to the noble Baroness, Lady Robson. The noble Lord, Lord Amulree, raised a number of matters and, if I may, I shall deal with them very quickly. He raised the matter of agency nurses. Health Authorities have made an encouraging start on the task of reducing the numbers of agency nurses in the National Health Service. Although numbers had increased sharply in the six months to March 1975, by the end of September—which, incidentally, was before the reduction in the rate of pay to agency nurses which took effect on 1st October —Authorities had achieved a 25 per cent. reduction; in other words, from 6,000 to 4.500. The noble Lord may be interested to know that some of the agency nurses have rejoined the NHS.

The noble Lord also raised the question of amenity beds. I did not want to interrupt him at the time, but the charge is now £3 a day and up to the end of 1974—obviously, I cannot give him figures for this year—we had in England and Wales 3,326 amenity beds. The only other matter which the noble Lord raised was the hours of work of junior hospital doctors. I think we must get the figures correct. A survey conducted for the doctors' and dentists' review body showed that the average weekly hours of duty worked by junior hospital doctors were 85.6. But a lot of that time was spent on "stand-by" or on call as distinct from working, and there were 42.4 hours on call or "stand-by" compared with 43 to 44 hours on duty.

I should like to join the congratulations which other noble Lords extended to the noble Viscount, Lord Kemsley. Having heard him on this occasion, we hope that he will not be so long in making his next speech and we are sure that his contribution will be just as valuable as it was today. The noble Viscount wondered how 3,000 private beds could make any different to the situation. If I may also answer a number of other noble Lords on this point, there are 4,100-odd private beds in our hospitals today, only 3,000 of which are fully occupied in the course of a year. I ask your Lordships to bear in mind, as I am sure the noble Viscount will, that a bed can be occupied by between 20 and 23 people in the course of a year, the average stay in hospital normally being about 13 days, and that these 3,000 beds are in our hospitals where the staff and doctors are already. You will see that if they passed into the use of the Health Service it might well mean that we could take between 40,000 and 50,000 people off the long queue of those who want to enter hospital for medical reasons, and who have been waiting an interminable time. When I tell your Lordships that the last available figures showed that there were 517,422—over half a million—patients awaiting admission, you will see how important this is.

The noble Lord, Lord Porritt, raised a number of matters, and I hope that he will not think I am being impertinent or patronising when I say that I thought he made a very balanced speech. However, he did not give a very accurate description of the situation when he said that this was the first attempt to nationalise the profession and that there would be unwillingness on the part of this Party to allow private medicine to continue. I gave the reasons why the Government want to separate private medicine from the National Health Service. Among them is one of the matters to which I referred just now when I dealt with the points which were raised by the noble Viscount, Lord Kemsley. There is to be no attempt whatsoever to abolish private practice. Nothing could be further from the truth. Let us not confuse separation with elimination.

We want to separate private practice because we feel that we ought to do so, and we have our reasons which I tried to make perfectly clear to your Lordships. We recognise that we are living in a democracy and that in a democracy there is a right to free choice. We say merely that the National Health Service should be a National Health Service that is separate from the private sector. This point was made by the noble Lord, Lord Hunt of Fawley, although if he does not mind my saying so I thought he was a little unfair. He referred to the possibility of people wanting to insure against the necessity of going into hospital and spoke in such a way that there was a vague suggestion, albeit by implication, that they might be prevented from continuing to insure themselves.

When the noble Lord raised the question of private medicine, the implication was that this was the thin end of the wedge and that the ultimate and logical outcome would be to put an end to it. There is nothing in this suggestion. The noble Lord, Lord Hill of Luton, was quite wrong when he said that one could read this into the Consultative Document and that its language is ambiguous. The language is not ambiguous. Let me say to the noble Lord, whose friendship I enjoy, that the language is ambiguous only if you want to make it so; it could not be clearer. It is not fair to suggest that we shall prevent people from themselves making the choice; nor is it fair to suggest that all of these insurance schemes may eventually be denied to them; nor is it fair to suggest for one moment that we shall put an end to private medicine.

I know that the noble Lord, Lord Hunt of Fawley, and the noble Lord, Lord Hill of Luton, are concerned, as are other noble Lords, about the right which the Secretary of State will have, if we seek and obtain legislation, to say where, when and how many private institutions there shall be. I do not know on what basis this fear arises. There are only about 3,000 private beds in continuous use. Plans are already afoot—your Lordships may not know about them but I have the details here—for schemes to be carried out in different parts of the country, and planning permission has been sought and given to build private hospitals, clinics and nursing homes.

In my speech at the beginning of the debate I referred to a 500-bedded hospital in the Bristol area, but there are several in London. There are many in different parts of the country, in country areas. There is no attempt to try to stop them. We want to control them and stop them spreading suddenly. We know, if noble Lords do not know, that there is plenty of money available to the profession to build these hospitals. We are going to safeguard the interests of the people of this country who want to use the National Health Service, and we want to ensure that nurses and doctors are available.

I feel it was most unfortunate that the noble Lord, Lord Stamp, should have attacked my right honourable friend in the way he did. I hope on reflection he, too, will feel that it was rather unfortunate. Those remarks could only have been made by somebody who does not know her. I have known her for many years. People who work and have worked with her, whether or not they agree with her politically, will tell you that she is the easiest person to work with. The noble Lord has allowed himself to fall a victim of the public image that the less reputable sections of the Press have given her. He could not have made the statement otherwise. She really is a most accommodating person. She has views and she holds them hard if she believes them to be right, but then so do I and so do we all—listen to the doctors this afternoon! There is nothing wrong with holding views strongly if they are sincere. Nothing would be achieved by changing the present Secretary of State. Of course, she would be popular among members of the medical profession, and in particular with the BMA, if she had agreed with everything they wanted. We could all buy popularity that way. The important thing is to adhere to principles that you believe to be right.

I do not want to say anything more with regard to the speech made by the noble Lord, Lord Hill of Luton. I tried to deal with one or two of the points he raised when I referred to what had been said by the noble Lord, Lord Hunt of Fawley. All I want to say is that I hope he will sincerely believe that the Government want separation and not abolition of private practice. I believe there are many people in the Labour Party who certainly would not go along with abolition. We are not so peculiar.

The noble Lord, Lord Colwyn, raised a number of matters. He spoke about the number of beds within the private sector and the number of beds which are in private nursing homes, and said they were much the same. In point of fact, this is not so: there are over 4,000 private beds and we have in private nursing homes for long-term patients something less than 3,000 beds. One has to bear in mind that 85 per cent. of the beds we use for National Health Service patients in private nursing homes are for long-stay patients. It helps the National Health Service, and I am not putting too fine a point on it by saying that it certainly helps the nursing homes concerned.

The noble Lord asked why dental practitioners are not represented, as of right, on Health Authorities. I do not think my reply will be a satisfactory one, but the noble Lord will know that there are a number of small authorities—almost a proliferation—which have responsibilities for making various decisions which involve a whole variety of members of the medical profession. By virtue of their constitution it is not possible to have representation from the dental profession on every one of them. If the noble Lord feels that the dentists are not adequately represented on some of the small authorities then I think this is a matter we could look into, but there is the problem that they are small authorities and none of them, by virtue of size, can have an adequate representation of each section.

My Lords, the other matter raised by the noble Lord was about the £5 million a year for fluoridation. This is a difficult matter. We have gone into this but, again, it comes down to the fact that we are a democracy. Until 1973, this was a matter for individual local authorities. It is now a matter for individual Area Health Authorities. The Department of Health and Social Security have always commended the virtue of fluoridation, but no Government have felt that they have the right to impose it by law; the simple reason is that there is a considerable division of opinion in this country. Until we move closer together, it would be quite wrong to enforce it by law.

My Lords, the noble Lord, Lord Redesdale, questioned the accuracy of my figures on doctors, dentists and various other people receiving increases varying from 30 per cent. to 38 per cent. I do not normally give wrong figures, but I have been at some pains to have this checked. All I can do is to refer the noble Lord to page 44 of the Report. I gather he has it there and, if that is so, he will see that, between April 1974 and April 1975, junior doctors received increases of between £657 per annum and £1,536 per annum, depending, of course, on their grade. If we work that out—we will have to take each grade separately—we find it is about 30 per cent.; if one takes the average of all doctors, the increase was about 35 per cent. If the noble Lord disagrees with me, perhaps he will let me know at some later date.

I wanted to say a word to the noble Lord, Lord Hayter, because we, too, would like to express our gratitude to community health councils. We would accept all that he has said on this matter. They are at the beginning stage, but we are expecting great things of them, which we feel certain will come. All I can say to the noble Lord, Lord Lucas of Chilworth, is that the dentists, we think, but I am sure the noble Lord does not, received quite substantial increases last April. This is a matter for the Review Body.

The noble Lords, Lord Lucas of Chilworth and Lord Colwyn, raised the question of dental examinations. The only comment I want to make is that dental examination has always been, and will continue to be, free of charge to patients. It is true that minor treatment will cost the patient who is liable to charges rather more in the future than in the past, but I would think that the important thing is the fact that one can get examination free. While it remains free, there is really no excuse for people not using the services of their dentists. The noble Baroness, Lady Masham, raised a very obscure point and said I could write to her. If that sounds like a rebuke, it is intended to be.

Baroness MASHAM of ILTON

My Lords, I am used to it.

Lord WELLS-PESTELL

I wish the noble Baroness had given me advance notice that she was going to raise the point. She is my major correspondent, if that sounds all right. I write more to her in the course of a year than I do to anyone else. It is not always easy to deal with the volume of correspondence that I personally have in the Department, while my colleagues at the Department each receive several thousand letters a year to which they have to reply personally. I am always loath to write a letter unnecessarily, and that makes me turn to the noble Lord, Lord Sandys, in the hope that I can persuade him to put down a Question rather than for me to read Hansard and to have to write to him.

I think I have replied to the point raised by the noble Lord, Lord Auckland, who asked whether it is correct to say that pay beds are detrimental to the NHS, He may not be satisfied with my reply, but I think they are, and I would give him the reply that I gave to the noble Viscount, Lord Kemsley. I am sorry that the right reverend Prelate the Bishop of Birmingham is not here, because he said that the matter of pay beds must not be confused by politics, I do not know whether the most reverend Primate the Archbishop of York will tell him to read Hansard, but I feel I must say this—I say it as a churchman, as a lay reader—that the right reverend Prelate must realise that we live by politics. We are governed by politics, and important things cannot be kept out of politics. Our decisions on both sides of the Chamber may be wrong from time to time, but, to be quite frank, if we had left the whole question of the National Health Service out of politics, we should never have had a National Health Service in this country. The Party opposite would not have introduced it. So I want to say to the right reverend Prelate the Bishop of Birmingham that it does involve politics. For us it is a matter of principle, and I would not dream of asking the right reverend Prelate, if he were here, to compromise on his own principles, which would be based on some sort of ethic or Christian teaching; so far as we are concerned these considerations are just as important.

I think the only comment I want to make to the noble Lord, Lord Brock, is with regard to doctors going overseas. I do not want to repeat myself on the pay beds question. It must be very clear to noble Lords how the Government feel about this. My information is that, taking 1974 to 1975 only 64 British consultants and 42 British registrars resigned from the National Health Service in England to emigrate. Although that may seem to noble Lords to be a rather large figure, it does not seem to me to be so when you remember that we have 11,000 consultants and 2,200 senior registrars in post. We derive some comfort from the fact that Sir Cyril Clarke, who I believe is President of the Royal College of Physicians, described the figure as "not a landslide".

I think again it was the noble Baroness, Lady Masham of Ilton, who raised the question of consultant salaries. I do not want to take up a tremendous amount of time on that matter. Consultants in this country receive salaries of between £7,536, which is their minimum, and £10,689, and over and above that 130 of them get a distinction award of over £10,000. There are 5,142 distinction awards, varying from £2,025 at the lowest end of the scale up to £10,689. About two-thirds of consultants are on the maximum of this scale, which is £10,689, and over their working lives about one-half of consultants get a distinction award at some stage during their consultancy. I was not going to mention that, but the matter of consultants' salaries was raised and I thought that it was right and proper that I should do so. I hope that I have succeeded in answering all the questions. If I have not, perhaps noble Lords will let me know at some stage.

10.6 p.m.

Lord ABERDARE

My Lords, I shall say only a word of grateful thanks to all noble Lords who have taken part in what has been a very well informed and most interesting debate to listen to. It has also been an example of how a debate should be conducted. We have had 30 speakers—I except the noble Lord winding-up who has a very formidable task—and until the winding-up we averaged just under 15 minutes for each speech, which is a creditable performance. I should like especially to thank and congratulate on two excellent speeches the two distinguished maiden speakers, the most reverend Primate the Archbishop of York and my noble friend Lord Kemsley. May I also say to the noble Lord that the right reverend Prelate apologised to me because he had to catch the last train home to Birmingham, and that is why he is not here. I thought the noble Lord was rather surprised that he is not here.

I should like to thank the noble Lord for his winding-up and all he has done to give us information in this debate. The gulf between us still seems to be a rather formidable one, and certainly I was not convinced by anything he said about the merits of removing private beds from the National Health Service hospitals. It seems astonishing to me that a Socialist Government, both in the health field and in the field of education, should almost be increasing the private sector, both in the direct grant schools by almost compelling them to go private, and in the case of the hospitals compelling the private sector to replace beds that otherwise would be in National Health Service hospitals. That is the Government's affair. I shall only say that if I were to press this matter of my Motion for Papers, the Papers I should ask the noble Lord to produce would be an agreement between the Government and the medical profession on these outstanding difficulties which I sincerely hope will be sorted out and solved within the next few days. I beg leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.