HEALTH SERVICES BILL

HL Deb 10 November 1976 vol 377 cc335-413

3 p.m.

Lord WELLS-PESTELL

My Lords, I beg to move that the House do now resolve itself again into Committee on this Bill.

Moved, that the House do now resolve itself again into Committee.—(Lord Wells-Pestell.)

On Question, Motion agreed to.

House in Committee accordingly.

[The LORD ABERDARE in the Chair.]

Clause 4 [Functions of Board as regards withdrawal of NHS facilities from private patients]:

Baroness YOUNG moved Amendment No. 25: Page 4, line 21, leave out ("and").

The noble Baroness said: Amendment No. 25 is a paving Amendment for Amendment No. 28, and I should like to speak to both Amendments. Amendment No. 25 is quite simply to leave out the word "and" in order that Amendment No. 28, which reads, "give its reasons", may be added to the matters which the Board ought to do. It seems to me that the easiest way to put this case is to ask the Minister who will reply why the Board is not required to give the reasons for its decisions, rather than to ask that the reasons for its decisions should be given. After all, I think the noble Lord, Lord Wells-Pestell, would agree that almost every organisation, Government Department or Minister, when giving a decision, is nowadays expected to give the reasons for that decision.

After all, under Clause 4(3) the Board must have regard to the principles which have been set out. It must consider representations made to the Secretary of State and by the Secretary of State; it must consider representations by doctors and by patients; and it must consider representations by other people who have a substantial interest in the matter. It is therefore being asked to listen to quite a number of different organisations before reaching a decision. The noble Lord will be aware that a court is always required to give the reasons for its decisions; in the case of a planning inquiry the Secretary of State or the inspector is required to give his reasons for what he concludes; the Ombudsmen, both the Parliamentary Commissioner and the Local Government Commissioner, are required to give their reasons; and even another place is required to give its Reasons for not accepting our Amendments. I therefore hope that it does not seem at all an unreasonable point that the Board should be required to give its reasons, and that is what this Amendment is designed to do. I beg to move.

Lord WELLS-PESTELL

If I have understood the noble Baroness correctly, she is in fact moving Amendment No. 25 as a paving Amendment to No. 28, and I do not know whether the noble Baroness wants me to reply to Amendment No. 28 now or merely to deal with Amendment No. 25.

Baroness YOUNG

I should have thought it would be for the convenience of the Committee to speak to Amendment No. 28, because Amendment No. 25 really makes very little sense on its own.

Lord WELLS-PESTELL

That being the case, may I say that in the Government's view the Amendment is inappropriate for two reasons. I understand that the effect of the Amendment would be to require the Board, as the noble Baroness has said, in formulating proposals for the progressive withdrawal of authorisations of pay beds and private facilities, to give its reasons for its recommendations. In our view, the Board must have regard to the principles set out in subsection (7). In other words, before it makes any recommendations to the Secretary of State it must apply the four criteria and satisfy itself that there is a reasonable demand for private practice in the catchment area of the hospital or hospitals concerned; that sufficient alternative facilities are available to meet that demand; that, if there are not, all reasonable steps are being taken to provide such facilities outside the National Health Service; and if such steps are not being taken, that those concerned have been warned that failure to do so could result in the revocation of the existing authorisations. Secondly, the Board must consider representations from those concerned with, or interested in, any proposals it may make to the Secretary of State.

Should the Board then submit proposals to the Secretary of State, it seems to the Government that there will be no need for it to give reasons for its recommendations. The Board's reasons will, I submit, be apparent; I think of necessity they must be apparent. Where it recommends separation, it will be satisfied that the facilities involved fall within the criteria for separation. Where it does not recommend separation, clearly it will have concluded that the criteria are not satisfied. I think Members of your Lordships' Committee must realise that the criteria are clearly set out in the Bill, so if the Board decides for or against it is because the criteria are being met or are not being met.

Perhaps I may conclude by saying that in carrying out its duty to submit proposals to the Secretary of State the Board is intended to be completely independent. If the Board is going to be asked to give its reasons, the question could easily be asked: Why is it being asked to give its reasons when it is an independent body and its decisions should be accepted? Its reasons for making recommendations are, and will always be, that it is satisfied that it has met the requirements of the Act in respect of the progressive withdrawal of pay beds and other facilities for private patients. Whether or not the noble Baroness agrees with my answer, I hope she will think it is a fair answer, having regard to the responsibilities put on the Board and to the obligations that the Board must fulfil under the Bill.

Baroness ELLIOT of HARWOOD

May I ask the noble Lord this question? Suppose the Board makes a very controversial decision, even though it is within the criteria set out here. After all, we are dealing with (what shall I say?) somewhat argumentative people, in the sense that doctors, members of the health services and all the rest of it are not people who are going to sit down and accept anything without question. Does it mean that the Board announces the decision as a fait accompli without anybody knowing what the reasons are except that there are criteria here? How do the people who want to know why find that out? Do they have to go to the court? What is the machinery for those people who do not understand a decision of the Board if the Board has not got to publicise it in a sense in which it can be understood by the ordinary person who is involved in this particular thing?

Lord WELLS-PESTELL

I appreciate the point which the noble Baroness has raised, but we have to bear in mind that here we have a Board of five members. There is one thing we can be absolutely certain of, and that is that the chairman is independent. He is independent, if I may say so with the greatest respect, of the medical profession, and is completely independent of the other two representatives. If the Board makes a decision, it can make that decision only on a majority viewpoint: it may be three to two, I concede, but it is nevertheless a majority. But the Board will have discussed with the various people concerned what is in fact involved in the withdrawal of pay beds; it will have discussed with the people involved the local situation, the local needs and requirements and what can be provided. We are, I think, dealing with a fairly high-powered board and not a run of the mill committee. It has, so far as I can see, no axe to grind, and will have an independent chairman. In view of the discussions that may take place beforehand, I think that this problem is much more academic than it is likely to be real.

Baroness ELLIOT of HARWOOD

Will the discussions which go on beforehand be public discussions so that people concerned will know what is being discussed? I am concerned that people should, if they want to, accept the Board's decision; but if they do not want to do so, how do they protest? That is an ordinary procedure—I was going to say "freedom of speech"—that we all have if we want to take a different point of view from that of some authority.

Lord SANDYS

We are starting on a very long debate which will last through the afternoon, evening and night and take us into tomorrow morning. I hope, if I may say so, in opening my remarks to the Front Bench opposite, that the somewhat threatening and monitoring manner adopted by the noble Lord, Lord Wells-Pestell, both on Second Reading and on previous Committee discussions will perhaps give way to a more mellow appraisal of this very difficult Bill. On behalf of my noble friends I can also say this. As my noble friend, Lady Young, lives in the Latin Quarter of Oxford, on our joint behalf I would say non perturbatnus. We are totally aware that there is a very substantial discussion ahead of us.

Lord WELLS-PESTELL

May we conduct the proceedings in English?

Lord SANDYS

For centuries it has been the practice of this House to treat a Latin quotation as an acceptable form of discussion. Nevertheless, I will draw that point to a close and come on to the Amendment as such. I hope that, first, I may cool the Government's impatience on the programme and refer to a document which I shall draw on from time to time which is the Royal Commission on Medical Education, the Todd Report (Command Paper 3569). If I may, I will quote one sentence in paragraph 21: The future pattern of medical care will be determined only partly by deliberate decisions. To a great extent it will be the result of developments in medicine itself. I think it is a truism to say how often the unorthodox of yesterday becomes the orthodox of tomorrow. I do not think I need quote an example here, but I should like to refer to a debate on 12th May this year which was introduced on an Unstarred Question by my noble friend Lord Ferrier. It was in regard to the Professions Supplementary to Medicine Act 1960. The noble Lord will recall that he replied to that Unstarred Question and it was a very interesting one. Also, if I may, I refer to his right honourable friend the Minister of State, Dr. David Owen, and what he said in regard to this particular important subject. Dr. Owen in a broadcast on BBC4 early in May said: We are also slightly worried that, for instance, things like backache which can cost the nation over £100 million a year, is a very under-researched problem; but you have to have fundamental research and so I am wanting very much more public debate at this stage. His right honourable friend referred to an issue which was brought up on that debate. I believe it would be much more satisfactory if we considered within the ambit of the National Health Service what might be called the fringe professions. I hope that they will take absolutely no offence at that expression. The unorthodox methods adopted so far as some medical practice is concerned may perhaps endear themselves to the Department of Health in the future, but if we adopt the attitude which is built into the Bill which is before the Committee it will not be possible to have the practice of these particular professions to anything like the same extent as may be possible without the Board's intervention. I refer to other researches and we shall come on to research later, but let us consider this. British developments have been very significant in the medical field and I quote only two of them: waterbeds and airbeds. Both have been invaluable in medical care. If the Government's intention is taken to its logical conclusion, very little opportunity is going to be given for this type of innovation in the National Health Service hospitals, as we understand it, through the use of these innovations in private circumstances. I think that there is an overwhelming case to take a much more open view of this particular situation. I beg to support the Amendment.

Lord O'HAGAN

In order to save time, perhaps I could follow my noble friend and give the noble Lord, Lord Wells-Pestell, the opportunity to answer us together. I should like to know from the noble Lord, speaking on behalf of the Government, how he reconciles the answer he has given so far to my noble friend Lady Young with Clause 10 of the Bill that we are considering. This clause deals with the publication of proposals and the preparation of annual reports by the Secretary of State. It may save the time of the Committee if I read out the first few words of Clause 10 which are: The Secretary of State shall cause every set of proposals submitted to him under section 4 or 5 above"— that is, Clause 4 or 5 of the Bill— and every report submitted to him under section 4(2)(b) above, to be published as soon as practicable after its submission …". There then follows the mechanics of publication. It may be that I have not fully grasped what Clause 10 refers to. The word "proposals" in Clause 10 may be different from the word "proposals" in Clause 4. It may be that there is some subtle distinction which is beyond me. But even if there is a distinction is it not inconsistent that in Clause 4 we should have one type of proposals not to be published and then have Clause 10 the whole of which is devoted to making it possible for proposals to be published?

Clause 10 also deals with the annual reports. If the Government consider it may be inconvenient or impractical to issue a continuous stream of reports dealing with one particular set of circumstances after another, if there is a technical objection to issuing a whole package of proposals one after another—it may be too expensive to do that—would it not be possible as a compromise, if we have the annual report which is to be debated by Parliament, to have what my noble friend is asking for included in the annual report? I should be grateful if the noble Lord could explain the difference between the proposals as defined in Clause 4 and the proposals as defined in Clause 10. Could the noble Lord explain to the Committee why one type of proposal is to be published and the other is not to be published? I support the Amendment.

Lord SLATER

Could we have from the noble Lord who leads for the Opposition some clarification regarding the statement he made? He said that the Committee stage will take a long time. He did not address himself to the Amendment which is before the Committee at the moment. My noble friend replied that the Board will be set up with its independent chairman. I take it that the Board will have plenary powers and the casting vote will depend upon the chairman. Then the noble Lord, Lord O'Hagan, said that he supported his noble friend in what he had to say regarding the Amendment, but the noble Lord, Lord Sandys, never referred to the Amendment.

Lord SANDYS

The noble Lord, Lord Slater, is mistaken because what the Amendment says is obvious. It requires reasons to be given.

Lord SLATER

When the noble Lord sees Hansard tomorrow morning he will read what I have just stated. The statement he made was not as clear as he is trying to make out.

Lord SANDYS

I cannot accept what the noble Lord, Lord Slater says. We are trying to include a number of professions and illustrate them in this particular sense. It is clear that the Amendment requires the Board to give reasons. I am illustrating it.

Baroness MACLEOD of BORVE

I agree with the noble Lord, Lord Sandys. Those who have anything to do with the National Health Service are bound to be worried that this important Board, which would not have much to do with grass roots views, will be able to report to the Secretary of State but give no reasons to anybody else. Apparently nobody at grass roots level is to be told the reasons for the decision of these few men on the Board. The noble Lord said in his answer that the reasons will be apparent. Apparent to whom? Obviously they will be apparent to the Secretary of State but, unless they are asked to give their reasons, they will not be apparent to anybody else.

3.13 p.m.

Lord WELLS-PESTELL

I am sorry that the noble Lord, Lord Sandys, feels that I might become aggressive. I am the most cool of persons in the ordinary way but my comment the other day was made because I felt we were not making sufficient progress. We have already spent several hours on this Bill and we have not dealt with very many Amendments. As we have the rest of the day and the night before us, I hope that we shall keep cool because obviously there is no useful purpose served by behaving in any other way.

Lord SANDYS

Hear, hear!

Lord WELLS-PESTELL

In answer to the noble Baroness, the only point I can make is there is no appeal to the Secretary of State because, rightly or wrongly, we feel that with this type of Board made up as it is the need will not arise. The noble Lord, Lord O'Hagan, raised a matter which is, I concede, of some importance. The Board is answerable to Parliament for its annual report which the Secretary of State must lay before Parliament. That is perfectly clear. I know that it must give reasons for deciding not to recommend any further revocation at each six-monthly interval. That is a safeguard—I would not put it any higher than this—against unreasonable delay in carrying out the policy of separation which is enshrined in the Bill. Under Clause 10, the Secretary of State is required to publish each set of recommendations submitted by the Board. There is no requirement on the Board to give its reasons. I do not think that I have failed to answer any other question, and I do not think that there is anything more that I can say on this matter.

Lord O'HAGAN

On that particular point of the annual report, am I correct in understanding the noble Lord to say that this report will not contain the reasons for the proposals which we are discussing in this Amendment? What will be in the report? Surely, the purpose of the annual report is to inform Parliament, and therefore the public, what the Board are doing and how they are carrying out their duties. I am not trying to split hairs. If the Board is not to be allowed to publish its reasons for what it is doing in the annual report, could the noble Lord explain what is the point of the annual report?

Lord WELLS-PESTELL

Most annual reports cover the activities of the organisation or group during a specified period and the purpose of the annual report is for Parliament to see clearly what the Board has done, what decisions it has made and what has been accomplished. That is very different from giving reasons.

3.17 p.m.

Baroness YOUNG

This Amendment and the reply to it is an extremely good illustration why we are making slow progress. It cannot conceivably be a Party political point to ask a Board to publish its reasons for doing something. We do not have the slightest inkling that the Government even think that it is worth considering this point, let alone that they are going to accept it. If the Amendments had been grouped, we should have made more progress, because it would have been easier for everybody. However, that is water under the bridge.

I found Lord Wells-Pestell's answer unbelievably unsatisfactory. He said that it would be inappropriate for the Board to give its reasons, and he gave two reasons why this was so. First, the Board has to have regard to what is Clause 7 and see whether there are reasonable alternative facilities before the private facilities are phased out, Secondly, it must consider representations from all the interests concerned. The noble Lord went on to say that we are going to have an independent body with an independent chairman, and of course if the criteria are not satisfied they will judge. How will anybody know why they decided that the criteria were satisfactory or unsatisfactory unless there is the evidence available on which they base their decision? It is no answer to say that an annual report will be published. I have read enough annual reports in my life to know perfectly well that unless you have a great deal of information about the background of the situation they are not always helpful. It is extremely easy to write a singularly unhelpful annual report. What is important to people is to know why a decision is arrived at, otherwise they cannot make a sensible judgment. They may say: "It is easy to see why the decision was arrived at because they had explained the reasons." It would be a very odd circumstance to say that the Board ought to give its reasons when nobody else does.

If one quotes similar examples, a judge may be regarded as an independent person, but he is required to give reasons. A planning inspector is required to give reasons. He is expected to be independent. We are not, as the noble Lord suggested, talking about small bodies and boards that have no particular power; we are talking about organisations and boards and individuals who exercise great power and they are expected to give decisions. Not to have to give decisions is putting the clock back to the kind of situation, perhaps in a more trusting world, where people felt they could accept a decision without having the reasons.

It is not my intention to press this Amendment, but I ask the noble Lord to consider it carefully. I think he will agree with me that people would have much more confidence in the Board if they had the published reasons for its findings. I think he may well find that he will get the whole of the Goodman proposals to work better. It is not as if the noble Lord, Lord Goodman, commented on this point in his recommendations, so the Government would not be going back on any pledges in that regard if they put it in. If they considered it further, they would find that it would be useful, but I beg leave to withdraw the Amendment.

Lord WELLS-PESTELL

I want to repeat what I said because there is no point in my taking this matter back to look at it afresh. We have had sufficient time to look at these matters and we have done so carefully. The criteria which govern the actions of the Board are clearly laid down in the Act. We assume that the Board will apply the criteria because it cannot act on any other basis. It can act only on the basis of the views of the people who are going to be affected and the decision which it has to take. There has to be a good deal of good will and give and take on both sides—give and take because the criteria lay down that beds cannot be phased out unless comparable private sector beds are available. At this stage in the proceedings I do not think that I am going to say anything which will please the noble Baroness, because I do not imagine I am going to be able to meet any of her requirements. If she does not agree with the Government's view, the remedy is in her own hands; she can divide your Lordships on any matter.

Baroness YOUNG

I must try to tell the noble Lord, Lord Wells-Pestell, that if he cannot see the point I am making he is considerably more gullible than I should have thought. I should not have thought that he could accept that argument whether it was given to him by his right honourable friend in another place or his advisers. He is assuming that the Board will make a perfect judgment and that we will all be completely satisfied with everything it does although he knows as well as I do that human beings do not work like that. We have debated this matter; I am sorry he does not see the point, but I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

3.24 p.m.

Lord SANDYS moved Amendment No. 26: Page 4, line 26, leave out from ("in") to ("or") in line 27.

The noble Lord said: If Amendment No. 26 is made the subsection will read as follows: any body which is representative of medical practitioners or dental practitioners or of persons employed or concerned with the interests of patients at NHS hospitals … The following Amendment will remove "NHS" and I leave that for the time being. My first point is that the Board is claiming independence. The noble Lord, Lord Wells-Pestell, as well as his right honourable friend referred to this, and I do not think we need go into it at very much greater length. Not only is the chairman referred to as being independent but, if we read the remarks of his right honourable friend, one is given to understand that the Board as well as the chairman is supposed to be independent. Having established an independent Board, it is instructed to adhere to certain principles set out in subsection (8). Then it is told that it is to listen only to representatives of the medical and dental professions in NHS hospitals; it must listen to nobody else. On the previous Amendment I spent some time in referring to fringe professions. I believe it is a mistaken view of the Government to allow the Board to listen only to those professions practising in NHS hospitals. If the Board is to function with any degree of satisfaction to the population as a whole, it is very much better to broaden the scope of its remit and to include everybody. I should have thought that that was self-evident. Certainly it is self-evident to this side of the Committee.

Lord O'HAGAN

Perhaps I could give some informal grouping and follow my noble friend. In so doing, I speak to the next Amendment which hangs with this one. In this clause we are looking at the mechanism which revokes authorisations for the use of NHS accommodation and we are examining the various channels of communication open to people affected by these revocations and the ways in which representations can be made to the Board on their behalf. In Clause 4(3), to which both these Amendments refer, we are dealing with those people who are entitled to make representations, and in (3)(b) (i) (ii) (iii) we have a list. Amendment No. 26 moved by my noble friend and the next Amendment No. 27 seek to make a little wider the list of people who are entitled to make representation. There is a good reason for this.

The Secretary of State in another place when ending his speech on Second Reading said: Let us stop the politicing and get back to the primary task of patient care", and I agree with him. I should have thought that, if we are concerning ourselves with the primary task of patient care, we ought to make sure that all those who are concerned with patient care have a chance to make representation. The Amendment moved by my noble friend and the following Amendment No. 27 make sure that the Board can consider the interests of patients at all NHS hospitals. I believe sickness to be indivisible and that this Bill should be concerned with the primary task of patient care. If our Amendments are accepted, it will make the Bill that little bit better and I hope the Government will look favourably on them.

Baroness STEDMAN

I am grateful to the noble Lord, Lord O'Hagan, for suggesting that we take the two together because they logically follow on one from the other. The effect of Amendment No. 26 would be to remove the reference in lines 26 and 27 on page 4 to "one or other of the national health services" and I do not think this is something on which we need spend much time. We have been advised by the Parliamentary draftsmen that this reference is necessary in order to establish beyond doubt that, when formulating proposals for revocation of authorisation of private facilities in NHS hospitals, the Board is under an obligation to consider representations made to it by representatives of persons other than doctors or dentists employed in the NHS in Scotland as well as those employed in the NHS in England and Wales.

The NHS in Scotland is a legally separate service, as are the services in England and Wales. That is explained in the general interpretation of Clause 23(1). Amendment No. 27 would retain the obligation of the Boards to consider representations from representatives of NHS employees, in addition to those of doctors and dentists. It would have the effect of extending the same right to make representations to the Board of persons concerned with the interests of patients in private as well as in NHS hospitals. We also believe that is unnecessary, because it is unlikely that the Board would refuse to accept representations from bodies such as BUPA or the Nuffield Nursing Homes Trust, which may be regarded as being broadly representative of patients in private hospitals, under the terms of Clause 4(3)(b)(iii). That reads: … any other person having a substantial interest in the proposals;". As such bodies would be covered by this provision, there is clearly no practical need to mention any of them specifically.

We think there is a presentational argument for making specific reference in Clause 4(3)(b)(ii) to the persons concerned with the interests of NHS patients, because the Board's primary functions under this Bill are to separate the private practice from the NHS and to ensure that such exceptions as are allowed to that policy do not operate to the disadvantage of the NHS patients.

Baroness YOUNG

I am grateful to the noble Baroness for that explanation and I can see that she has taken great care over it; but the fact remains that she says that the Board's primary responsibility is to make quite sure that the NHS and the private patients are separated and that the NHS patients shall not suffer. I should have thought it would he equally important to ensure that all patients should not suffer, and the object of Amendment No. 27 is that the interests of all patients should be considered—or rather that representations may be made by them—and not simply the patients at NHS hospitals. I appreciate what she has said on the drafting point, but on the second Amendment it seems to me there is a clear distinction. I should have thought that their interests, although partly covered by representations from bodies such as BUPA, are not precisely the same in every instance. I cannot see why their interests should not be considered under Clause 4(3)(b)(ii).

Baroness STEDMAN

We think they are covered under Clause 4(3)(b)(iii): Any other person having a substantial interest in the proposals;", which would cover persons in the pay beds and in private nursing homes.

Lord O'HAGAN

In that case, why is it that it says "any other person" as opposed to "any body"? There is a difference in terminology. In sub-paragraph (ii) it is "any body", which I presume means an organisation, whereas sub-paragraph (iii) talks about "any other person". Is the noble Baroness saying that BUPA is a person?

Baroness STEDMAN

No, but I think "body" is used in sub-paragraph (ii) as meaning a representative body of medical practitioners, dental practitioners and people of that kind, rather than organisations or people who are individually involved in providing private nursing facilities.

Baroness YOUNG

Again, I am bound to say that I do not think this is a matter of great political difference between us; but if the noble Baroness says that that clause is meant to include representations from private patients as well as from NHS patients, I cannot see why it would do any harm to say so. However, the noble Lord, Lord Wells-Pestell, has told us that he is not going to consider anything at all, so even if we are asking the noble Baroness to consider something which the Government say they think is covered but about which there is obviously some doubt, perhaps there is no point in continuing. However, I should just like to hear why the noble Baroness feels that she cannot say in writing what she says she thinks the clause means.

Baroness STEDMAN

Because we think it is all covered within the clause as it is drafted at the moment, and we are advised by Parliamentary draftsmen that this clause does cover the points that have been made.

Lord SANDYS

I must confess I am not totally convinced. The noble Baroness has advanced arguments and my noble friend has replied; but perhaps it would be for the benefit of the Committee if I asked leave at this stage to withdraw the Amendment.

Amendment, by leave, withdrawn.

Baroness YOUNG moved Amendment No. 29: Page 4, line 38, after ("the") insert ("grant or").

The noble Baroness said: My Lords, I beg to move this Amendment. It is consequential to No. 17.

On Question, Motion agreed to.

3.35 p.m.

Lord SANDYS moved Amendment No. 30: Page 4, line 39, after ("section") insert ("1(1) or").

The noble Lord said: I think this would be a convenient moment to mention a letter, which is probably known to your Lordships as it has been mentioned earlier—that is, the Nodder letter, written by Mr. T. Nodder on 27th February, 1976. Your Lordships will be aware that this Amendment tries to ensure that the Board must separate proposals for in-patients as well as for out-patients, and the Nodder letter refers to consultation. This is a point which we may have, or should have, mentioned earlier because it has a bearing on the drafting of this particular part of Clause 4: At this stage authorities are not required to comment on the actual location of the pay-beds from which authorisations would be withdrawn or on the distribution or location of those that will remain. These are matters which the Secretary of State recognises should be the subject of fuller consultation during the passage of the Bill and, if necessary, in the period immediately following Royal Assent.

As drafted, we believe the Bill to be not at all satisfactory. A waiting list has been referred to and, of course, there are many operations of a non-urgent nature such as hernias, prostates, ophthalmic work and so on. I would ask your Lordships to turn to Clause 5(4) because if we turn to the next clause we see that the Secretary of State in particular circumstances is allowed to make adjustment of the accommodation, but that is only on a very short-term basis, when a number of wards or individual beds are closed. In Clause 4(5), if one plods through one hundred words at the beginning and then follows with the further ninety words in paragraph (b), it will give effect to what I have said. Those are restrictions, of course, on the powers of the Secretary of State under Sections 1 and 2 of the 1968 Act. But it is quite fundamental in our thinking that there should be flexibility.

The only flexibility the Government have thought fit to include is if there are circumstances which reduce the number of beds in a hospital—that is, the number of authorised beds after the first thousand beds have been withdrawn. The number, of course, is 3,444. Should there be a fire, for example, the Secretary of State is allowed to adjust the numbers, otherwise there is no question of adjustment. We believe that the in-patient services should be adjustable and there should be powers enabling the Secretary of State in particular circumstances to make those adjustments. It would be very much to the benefit of the Bill if he were allowed to do so.

Lord WELLS-PESTELL

At present the Bill requires the Board, in formulating proposals for the revocation of authorisation at any National Health Service hospital of facilities for private non-resident patients, to have regard to the different purposes and specialties for which accommodation or services are provided. The effect of the Amendment would be to require the Board, when making proposals for revoking authorisations of pay beds, to apply similar principles and consider revocation according to the different purposes and specialties for which pay beds were currently made available. Clause 4(4) as it stands allows the Board to make separate proposals in respect of the different purposes for which private out-patient and day patient facilities are available.

Under subsection (5) the Board is required to make its first proposals for revoking authorisations in respect of consulting rooms separately from those in respect of diagnostic facilities. It may also make proposals separately if it thinks fit in respect of separate specialties even though the actual authorisation is customarily given in respect of the accommodation and services provided at a hospital, or group of hospitals, as a whole. Clause 4 as it stands will allow an authorisation to be revoked in part or in whole if the Board so proposes.

The grounds for considering revocation by specialty so far as in-patient facilities are concerned—that is, pay beds—are not particularly convincing. Pay beds are not allocated to particular specialties—I repeat that: Pay beds are not allocated to particular specialties. If the Board were to attempt to recommend withdrawal of pay bed authorisations from one specialty but not from another, a considerable amount of confusion would be bound to result, particularly where a private patient in one specialty required attention from a doctor in another specialty from which facilities for private practice had been withdrawn.

With out-patients, it is quite common for a private patient seen in private consulting rooms outside the National Health Service to be referred to one particular department of a National Health Service hospital, either as a private patient or as a National Health Service patient, whether for consultation or for diagnostic services. An in-patient in a National Health Service hospital is admitted either as a National Health Service patient or to an authorised pay bed as a private patient. If the person is admitted as a private patient, he will remain in that category during the course of his treatment, although he may be treated by a number of doctors from different departments of the hospital. Thus where the Board has not recommended the withdrawal of authorisations, it makes sense that the pay beds should be available for use by all specialties in that hospital. In the case of a hospital devoted to a single specialty—and I have in mind a maternity hospital—the Board will have regard to the availability of alternative facilities for the same specialty in the private sector.

Where a hospital includes some department offering treatment of a specialised nature using specialised equipment and skills, Clause 8 will allow occasional private patients to be treated there by any doctor in the hospital—even after the withdrawal of authorisations—subject to the fulfilment of specified conditions. To have authorised pay beds in a hospital in which private patients could be treated by part-time consultants in one specialty but not in another would, I suggest, be a source of friction among consultants, additional to the friction between staff who believe in private practice in the National Health Service and those who do not. I think it would be wrong to add to the problem to which private practice in National Health Service hospitals already gives rise. Consequently, the Government do not feel that they can accept the Amendment.

Lord SANDYS

My Lords, I warned the Government that in resisting an Amendment of this sort, which offers a degree of flexibility, they were making a rod for their own backs in future. There is nothing more valuable than to have a degree of opportunity to vary the terms and circumstances. It is the situation in the Hospital Service today, I think, and I am certain the noble Lord will agree, that those in authority would like to be able to adjust circumstances where possible to suit their particular circumstances. Flexibility in legislation is one thing that can always he introduced if the Government are so willing. We believe it is desirable. I am not going to press this Amendment. The Government have shown themselves rock-faced about it, but we shall refer to this particular problem at a later stage. I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

Baroness YOUNG moved Amendment No. 32: Page 5, line 4, leave out ("may") and insert ("shall").

The noble Baroness said: Amendment No. 32 is concerned with Clause 4(4)(a) in which we are concerned about what will happen if there is suddenly the need to find temporary accommodation. My Amendment is simply concerned to leave out the word "may" in line 4 at the top of page 5 and to substitute the word "shall". It seems to me very important that in this case it should not be simply a permissive function of the Board, but that the Board must have regard in these circumstances for the proposals in respect of different specialties for the different purposes as they are set out in this clause. Therefore, I hope that the Government will consider favourably this Amendment, although I am bound to say it is rather a forlorn hope in view of what has been said. I believe that if the Bill is to work at all satisfactorily it is very important that we should strengthen the Board's ability to deal with all of the different varieties of case with which it may have to deal, and that the Board "shall" be obliged to deal with them rather than "may" deal with them in certain circumstances. I beg to move.

Baroness ELLIOT of HARWOOD

I should like to support this Amendment. It reminds me very much of the other Bill we are discussing at the moment, getting local authorities to supply alternative housing for agricultural workers under the Rent (Agriculture) Bill. Having been in local government for a very long time, I think one has to put obligations on people. If it is necessary for the person concerned for his health, his domicile or whatever it might be, there should be some urgency and perhaps more insistent words should be put in Bills of this kind. In view of the fact that the Board is going to be very authoritative, as the noble Lord explained when I was asking a question on another Amendment, I think there should be the authority for it to be told with some vigour that it is essential that unfortunate patients should be found other accommodation. It is only fair to the patients, and it is a word which might be very useful in this connection.

Lord AMULREE

I, too, should like to support this Amendment. It has always seemed to me that permissive legislation is a bad thing to encourage. If some things are permissive, good people do what they should. But had people have no reason to do anything. If something is worth doing at all, it should be made obligatory and, therefore, the word "shall" should be used in place of the word "may".

Lord WELLS-PESTELL

As the Government do not accept this Amendment one could give an answer in a very few words. But I know that a very few words will not satisfy noble Lords opposite, and probably would not satisfy me if I were in their position, as I should want a much longer explanation. I come back to the composition of the Board and to what we believe will be its quality. Members of your Lordships' Committee must ask whether, when one is dealing with a Board of that calibre, and when the conditions are laid down very clearly and precisely, even though some noble Lords may not like them, one ought to hamstring and tie a body like that, and whether a matter of this kind should be left to its discretion, which is what we have so far as possible tried to do.

The effect of the Amendment would be to oblige the Board, in putting forward proposals for withdrawal of authorisations of NHS accommodation and services for private out-patients, to put forward separate proposals for different purposes and specialties for which the authorised facilities are available. The Bill as drafted enables the Board to do this where it thinks appropriate, but does not oblige it to do so, though it does require it to distinguish in its first proposals between consulting suites and specialist diagnostic back-up facilities. Although authorisations of private out-patient services are seldom, if ever, related to particular purposes and specialties, in practice it will be possible to propose the immediate withdrawal of some facilities, while maintaining others for a longer period. For instance, the private sector may not have the ability, nor for reasons of safety may it be desirable for it to seek, to provide radiotherapy services outside the NHS. The desirability of the NHS continuing to allow private patients access to such a facility, however, need not prevent the Board from recommending the withdrawal of other facilities for private out-patients. What is practicable and desirable will, of course, vary from one hospital to another and from one part of the country to another.

In these circumstances, it seems right to the Government that the Board should he under a duty, when considering what recommendations it should make in respect of a particular hospital or group of hospitals, to apply the principles of Clause 4(7) separately in respect of each purpose or speciality for which private out-patient or day patient facilities at that hospital are being used. Clause 4(4)(a) so provides. But in the Government's view it would be wrong, with the exception of consulting rooms (Clause 4(5)), to oblige the Board to make separate recommendations to the Secretary of State in respect of each of these purposes and specialties. There should be discretion for the Board in how it deals with these matters. Clause 4(4)(b) provides such discretion. In other words, we nail our flag to the mast that it must be left to the discretion of the Board, and in the long run that is a much better way of working.

Lord HARMAR-NICHOLLS

I am not surprised that the noble Lord said that, if he were on this side of the Committee, he would not accept the answer he was going to give.

Lord WELLS-PESTELL

I did not say that. If the noble Lord is going to quote me, let him quote me accurately. What I said was that I could well understand that noble Lords opposite would not feel happy with it, and nor would I if I were in their position, but I am not of their Party.

Lord HARMAR-NICHOLLS

I do not think there is much difference between what the noble Lord has just said and what I paraphrased him as saying. This is rather like somebody telling a joke, when people laugh before the punch-line conies because they know what it will be. The noble Lord knew that the answer which he was going to give on this Amendment would be inconsistent with the argument he used on Amendment No. 29, because he then made it very clear that he thought it was in the best interests of administering this legislation—if it ever becomes law—to give the Board clear instructions on what it is to do. He said that we must not give the Board any freedom, and everything must be laid down.

In this Amendment, my noble friends are asking for the kind of flexibility which the noble Lord resisted on the previous Amendment. We are saying that we should make it perfectly clear that it shall do this thing which is desirable, not that it may do it. Let us give the Board clear instructions as to what it is supposed to do. The noble Lord cannot expect to get away with it. I know that it is not his argument. He is working to a brief, and I have a great deal of sympathy for noble Lords on the Front Bench opposite in view of the kind of briefs they are having to put up with. But the noble Lord cannot say, on the one hand, that clear instructions must be given, with no flexibility; and then, on the other hand, that flexibility must be retained, because the Board will have the ability and knowledge to allow it to use flexibility properly. I believe that the inconsistency in the noble Lord's opposition to this Amendment shows the weakness.

Nobody is suggesting for one minute that the Board will not have the knowledge and the ability to use its discretion. But there are certain matters covered in this Bill on which the instructions should be clear, and on which flexibility should not be allowed, and this is a case where the Board should accept as one of its obligations the duty to carry out this task. The noble Lord cannot say on Amendment No. 29 that he does not want flexibility, and then say on Amendment No. 31 that he does want it. My noble friend is absolutely right. If the Board is to carry out the instructions laid down in this Bill they must be clear, and this is one of those points where they should be clear.

Lord WELLS-PESTELL

The noble Lord must bear in mind that it will depend on what is the function of the Board in any given direction. At some stage or other, every one of us has to do certain things because society requires it of us, but in other matters we can use our own discretion. In the same way, there are certain things which the Board must do, and these are clearly laid down. But one cannot say that everything the Board does must be settled for it in advance. In carrying out its functions the Board must be allowed discretion in certain areas and, in our view, this is an area where it ought to have discretion. But we concede that there are other areas where the duty must he very clearly spelled out.

Baroness YOUNG

We have had a very useful discussion on this Amendment, which has been of more value than a simple debate in this House. As my noble friend Lord Sandys pointed out, this is one of the Amendments which was tied in Standing Committee in another place. It was never debated on the Floor of the House because it was guillotined. This is the first debate that we have had on the Amendment on the Floor of either House of Parliament, and as the Government have already guillotined the Amendments that we might conceivably send back to them it is almost certainly the only time that it will be debated. Therefore noble Lords in Committee should realise that a very real responsibility rests upon them, because this is a Government measure which, so far as I can see, is hardly going to be discussed by Parliament. Indeed, if your Lordships' House were to be abolished the measure would not be discussed by Parliament at all, so at least the fact that we can debate this important matter is something to he said for us, even by our critics.

As my noble friend Lord Harmar-Nicholls has pointed out, there is a degree of inconsistency in the Government's view. We are asking that the Board must make separate proposals both for in-patient as well as for out-patient services. It does not seem to me to be a highly controversial point but, as the noble Lord has said, the calibre of the Board is such that the people on it will be so good and so perfect that we must not question their reasons or ask for those reasons; and in this particular case we must give them great latitude.

Tomorrow we shall read with great interest in Hansard what the noble Lord has said on this Amendment and on Amendments Nos. 30 and 31, all of which are related to the same subject. It has been a rather complicated argument to follow and I shall read it with great care, because it may be a matter to which we shall wish to return at a later stage. In the meantime, I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

Baroness YOUNG moved Amendment No. 33: Page 5, line 6, after ("the") insert ("grant or").

The noble Baroness said: I beg to move this Amendment which is consequential upon Amendment No. 17.

On Question, Amendment agreed to.

Baroness YOUNG moved Amendment No. 34: Page 5, line 21, after second ("the") insert ("grant or").

The noble Baroness said: I beg to move this Amendment which is also consequential upon Amendment No. 17.

On Question, Amendment agreed to

4.3 p.m.

Baroness YOUNG moved Amendment No. 35: Page 5, leave out lines 29 to 33.

The noble Baroness said: This is a somewhat complicated matter with a rather long history and I hope that the Committee will bear with me while I go through it. Subsection (5) is concerned with outpatients. Once I had understood the clue to this, which is that Section 1(1) of the 1968 Act deals with in-patients and Section 2(1) with out-patients, one has it quite clearly. The issue before the Committee is the phasing out of private out-patient facilities.

When the Bill was first drafted I believe that it was the intention of the Government that the Board should be under an obligation to report within the first six months on the phasing out of consulting rooms—that is subsection (5)(a)—and also on other services which are named there: radiotherapy, diagnostic pathology and diagnostic radiology, together with the other matters included in paragraph (b). The consulting rooms were to be phased out within six months, but there was no time limit on the phasing out of the other out-patient services, on the grounds, quite rightly I think, that they are extremely expensive to produce and that it is unlikely that similar facilities could be produced within the very short time scale allowed under the Bill—certainly not within six months or even within a year.

One of the practical difficulties which follows from the Bill is that the private facilities will have to be provided with considerable rapidity if there is to be a true possibility for consultants to have private patients and private facilities. At the Committee stage in another place the Government introduced an Amendment which recommended that other out-patient facilities should also be phased out within a certain period of time, except radiotherapy. The consequence of all this is that the consulting rooms will now be phased out within the initial period of six months. The diagnostic pathology and diagnostic radiology services, including scanning, ultrasonics and methods involving the use of radio-isotopes will, under subsection (6), be phased out within 18 months. The only service which still has no time limit upon it is radiotherapy.

It is very difficult to know why there was this sudden change of heart during the Committee proceedings in another place. Because the matter was guillotined, Government Amendments are carried automatically so it has never again been discussed on the Floor of the House of Commons. This is most likely to be the only part of Parliament where we shall hear from the Government the reasons why they decided to do this.

May I ask the Government to think very carefully about whether they are implementing the spirit of Goodman. We have heard time without number that it is the intention of the Government to support private facilities and private medical practice; but if this argument is to have any meaning at all the facilities must be there. One of the most difficult things to produce will be not only the hospital beds but the equipment, which is so expensive. Clearly there was a change of heart on the part of the Government regarding the original undertakings, and my Amendment would simply put back the Bill to what it was when it began. It seems to me that if this was the original intention of the Government they must have had a good reason for doing it and I hope that they will now consider that it is time to put back the Bill to what it was at the beginning. I beg to move.

4.8 p.m.

Lord WELLS-PESTELL

As the noble Baroness has pointed out, lines 29 to 33 were added to subsection (6) as the result of a Government Amendment at Report stage in another place. The Amendment was designed to ensure that the Board submits proposals dealing with diagnostic out-patient facilities for private patients within a period of 12 months from the initial period. The effect of this Amendment would be to return to the former position whereby the Board's commitment to submitting proposals in this field was open-ended. The Government gave very careful thought to this problem and concluded that such a situation was unacceptable.

The Bill sets a timetable for the Board's reports. In our view, pay beds are clearly the first priority. The second is the report on common waiting lists, to which we also attach considerable importance. The third is facilities for private out-patient consultation. Diagnostic out-patient facilities come next. We realise that it will take time to equip and staff premises for use as pathological laboratories or radiology clinics and that it would be unrealistic to expect the Board to report as with a view to recommending revocations of authorisation of these facilities within too short a time. The question is how much time is sensible? One could argue six months, or a year, or 18 months or, as suggested in this Amendment, no set period of time. Six months, we feel, is too short bearing in mind the priorities which have been described and the initial pressure of work on the Board. On the other hand, we recognise the need for progress and if no target is set for a first review of these facilities we run the risk that the private sector may see no need to make alternative provision.

Taking these considerations into account we conclude that a requirement to submit its first report 12 months after the end of the initial period—that is, spring 1978, and we are in 1976 now—was fair to the private sector, fair to the Board and would not delay progress towards complete separation of private practice from the National Health Service which the Government are determined to bring about, as your Lordships know, within a reasonable time. In short, all this part of subsection (6) seeks to do is to set a deadline within which the Board is required to submit its first report on the revocation of diagnostic facilities for private out-patients other than radiotherapy. A deadline, moreover, which allows 18 months from Royal Assent is not, I submit, an unreasonable period. Even then it does not follow that the Board will recommend the phasing out of all such facilities in 18 months' time. We shall take note of the situation. It merely requires the Board to look specifically at those facilities within 18 months of Royal Assent and to submit recommendations in accordance with the same principles as it will apply to pay beds, and consultation suites on which it is required to submit its first report within six months of Royal Assent.

By proposing this Amendment, noble Lords opposite no doubt are seeking to delay the process of phasing out, and we understand this. Their Amendment will not necessarily achieve their aim, since it would still be open to the Board to look at out-patient facilities whenever it chooses, depending on how it gets on with its tasks, and I am sure your Lordships realize there is no reason why this should not be sooner rather than later. On balance, the Government feel that it is preferable to set a target date for the Board's first report on these matters, but, as I have explained, having regard both to the Board's task and to the time needed by the private sector to provide alternative facilities, and bearing in mind that the responsibility will be on the private sector to provide alternative facilities, we feel that the time that we are prepared to give is not unreasonable.

Lord O'HAGAN

On a previous Amendment, the noble Lord said that, if the proposals we were putting forward from these Benches were carried, a considerable amount of confusion would be bound to result. I can only say to him that, having tried as hard as I could and having listened most carefully, a considerable amount of confusion has resulted in my mind and perhaps I may not be the stupidest member of the Committee. Perhaps I am, but I hope the noble Lord will now be able to confirm that by answering my simple question.

How can the noble Lord argue in this Amendment that the Government must tell the Board what to do, when in answer to my noble friend Lord Harmar-Nicholls a few minutes ago he said that the Board must be allowed to do whatever it wants to do? In answer to my noble friend Lord Harmar-Nicholls, when we were dealing with the Amendment to insert "shall" instead of "may", the noble Lord, speaking for the Government, said that the Board must have flexibility. This Amendment moved by my noble friend Lady Young would increase flexibility, yet in these circumstances the Government say, "Oh no, we can't have flexibility; we don't like flexibility". Can the noble Lord explain this inconsistency? That is the first of my simple questions. Perhaps I may complete the short list before the noble Lord answers.

The other question I want to put to the noble Lord is this. The Government say that—and I do not want to blaspheme—the doctrine of immaculate conception applies to the Bill in that it is a perfect expression of the Goodman compromise; that it is flawless; that no Amendments are needed; no Amendments will be accepted, and even where there are printing errors the noble Lord does not admit that there is a mistake. This is what the noble Lord says. Yet the Government in another place have come forward with an Amendment which is embodied in the words which now appear at the end of this subsection that my noble friend has moved to leave out. How can the Government say, when resisting our Amendments, that the Bill is perfect and any alterations to it will upset the Goodman proposals, when they themselves use the argument the other way and say, if they wish to make alterations to the Bill, minor or major, that they do not alter the balance of the Goodman proposals?

Lord HARMAR-NICHOLLS

It may help the noble Lord and also save time if I rise now. May I repeat what I said on the 8th November when we were dealing with Amendment No. 18. I support absolutely what my noble friend has just said about inconsistency, and if one is realistic about it, 12 months is not long enough. I think it is unwise to put in any figure at all; to leave it at the discretion of the Board is the right way to do it, but if we are going to put in any figure at all then 12 months is certainly not enough; when you are doing this sort of thing 12 months does not add up to two minutes—everybody knows that.

The noble Baroness, Lady Stedman, will remember that I dragged her into the argument on 8th November. She was a constituent of mine and she was one of the leading local government leaders in the constituency that I had the honour to represent. She knows that on matters much less intricate than this she, on her planning committees, could not give answers under two or three years; not because they were lax, not because they were lazy, but because of the difficulty of getting together all the people who had to be consulted. Because of holidays and all the other things that go into the working of bureaucracy, 12 months is no time at all.

As the noble Lord has just explained, in any case this is No. 3 in order of priority. If they have to give whatever time there is to the other two matters which are put ahead of this in the list of priorities, then to put in the period of 12 months is really ludicrous. It would be much wiser to leave it to the Board, as my noble friend said, and for it to decide on its own timetable. The first thoughts of the Government were right. This is a case where their second thoughts were wrong. I wonder who it was who felt that they were being much too realistic in their approach. They are not often realistic, if I may say so, but in their original version at least they faced up to the sort of world in which we live, where posts are delayed, where one cannot get through on the telephone, where officials are being changed. If the period of 12 months is left in—and I repeat what I said on the 8th November—this will result in a slipshod decision because the time does not allow the Board to get the details it wants. Or it will result in some official being left to make the decision and this wise Board that the noble Lord has told us about not being able to use its accumulated wisdom to help us at all. It will be either slipshod or it will be decided by one or two people who are not representative of the point of view that the noble Lord has assured us about. In my view, the Amendment is more sensible, but if it is that because of some pressures that we do not know about they have to put some period into the Bill, then 12 months is not enough. It must be two or three times that length of period if we want the job to be well done.

Lord WELLS-PESTELL

The noble Lord shook me when he said that he wanted to speak and he thought that what he said might help me. I only hope that he is never against me, because if that is an indication of his help, well, some of us could do without enemies with some of the friends that we have! I should like to answer the noble Lord, Lord O'Hagan, and I say this very sincerely. The noble Lord laughingly said of himself that he is the stupidest Member of your Lordships House. He is far from that, and I can say for both sides of the Committee that we regard him as one of the ablest Members of this House. There is no question about that. I wish he would cross the Floor, as I think he will do one of these days.

Several noble Lords

Oh!

Lord CARRINGTON

Noble Lords opposite certainly need it!

Lord WELLS-PESTELL

My Lords, we could all do with extra ability.

Lord O'HAGAN

Was that a general indication?

Lord WELLS-PESTELL

Oh no!—do not embarrass us. There really is not any inconsistency at all. I do not want to go over the same ground again. In every board, every committee, every organisation, in anything that is organised, there must be spheres in which they have to take a definite line and make definite decisions. As in private life, there must also be areas in which one must be left to one's own discretion. This applies to the Board. The Board must have discretion in certain things. The Government have determined what those areas are, and have determined also the areas in which they shall make a decision along certain lines.

I do not want to go again over the whole question of the Goodman proposals. I do not want to have to repeat this often. I think it was the noble Lord, Lord Platt, who referred to the Gospel according to Saint Arnold—perhaps it was the noble Lord, Lord Hill of Luton; I am not sure—but we do not want to go over it again. We say that this was an agreement and we have honourably discharged our responsibility by putting that into the Bill. But our having done that does not mean to say that the Government have not the right to frame the rest of the Bill in the way that they think is right. When the noble Lord, Lord O'Hagan, complains that we have done this but we have also done other things, it is true that we have. This is embodied in the agreement. The other matters are subjects which the Government feel are desirable in respect of other matters outside the Goodman proposals. I think the noble Lord, Lord Harmar-Nicholls, kept on talking about the 12-month period. I should not have thought I was indistinct in this Chamber, but on a number of occasions I said that the period was 18 months, and not 12 months.

Lord HARMAR-NICHOLLS

It happens to be 12 months that is written into the Bill we are discussing. One knows that there are six months on top of that, but it is the 12 months in the Bill that I want to be extended.

Lord PLATT

As the Government are so clear on what they are going to lay down and what they are not going to lay down, would the noble Lord, Lord Wells-Pestell, tell us what decisions are to be made by the Royal Commission on the National Health Service? Is that Commission to have nothing to do at all?—because as far as I can see, all the decisions will be made for them.

Viscount LONG

We seem to be having a good debate on this Amendment. I have come to the conclusion that as the afternoon goes on, one is going in the end to wonder what this Board is going to be able to do or not do. Equally, I am getting worried whether the Board will like this Bill or the responsibility handed to it by the Government. The Board is responsible for making sure that the pay beds are phased out, that the private facilities are phased out; but in the long run, so far as I can see, the Board will be held responsible for making sure—and I stand to be corrected—that the hospital still makes money. If you are going to have part of this equipment taken out, then surely I am right in saying that the private sector had to pay a fee to a National Health hospital, and that money will not be there when this happens. So the Amendment of my noble friend is quite right and quite in order. We should watch the matter and protect the Board from some of its difficulties which will be produced by the Bill.

Lord HILL of LUTON

I do not want to continue the argument, but there is one point of confusion in my mind with which, perhaps, the noble Lord, Lord Wells-Pestell, will deal. Let us take the 12-month period and the specialty of radiography as an example. If, at the end of 12 months, it is seen that alternative private facilities for radiology are not available, what does the Board then propose? The Bill says, "the Board shall bring forward proposals". If it is accepted that these National Health Service hospital facilities are not to be denied unless and until alternative facilities are available, how can the Board then produce proposals? Presumably the Board does nothing until that condition is achieved. This is not a debating point; it is a serious point. What does the word "proposals" mean when in fact the circumstances are such that under this Bill nothing is to be done to deny those facilities to private patients?

Lord WELLS-PESTELL

My understanding of the situation is that there will be a responsibility on the Board within a specified time to see what alternative facilities are available in the private sector. If in a particular area or areas those facilities are not available, then the facilities in those spheres which are clearly set out will be available in National Health Service hospitals for the private sector.

Lord HILL of LUTON

That I understand; but the Board in such circumstances "shall produce proposals" governing exactly the set of circumstances to which the noble Lord, Lord Wells-Pestell, referred. But what can it possibly propose? I understand the word "proposals" in this context to mean positive proposals relating to those circumstances. If the Act is observed, nothing will be done. What can "proposals" mean when it contemplates circumstances in which nothing will be done?

Lord STONE

I can vouch for the fact that these conditions do exist today in the private sector, both for radiology and pathology. These conditions have been there ever since 1948. They are in practice at this moment, and they exist. I can see no reason why they should not in point of fact even do better as and when they may or may not be phased out of the National Health Service.

Lord WELLS-PESTELL

May I just answer the noble Lord, Lord Hill of Luton, because I understand his point—at least, I think I do. The use of the word "proposals" will mean two things. One will be the proposals for the alternative facilities within the private sector, and where the private sector cannot produce these, the proposal will be that the private sector shall continue to use those specialties within the National Health Service. That is how I understand it.

Lord HILL of LUTON

I hope that is the interpretation. If, as the noble Lord, Lord Wells-Pestell, says, a proposal can be a decision not to revoke the facilities to private patients in such circumstances, I must say it is rather an odd phrase to use—"requiring the Board to produce proposals", when in fact it contemplates a set of circumstances in which there will be no proposals.

Lord WELLS-PESTELL

If I am wrong, then I will write to the noble Lord, Lord Hill of Luton, and perhaps he will allow me to send a copy of the letter to the noble Baroness.

4.29 p.m.

Lord HARMAR-NICHOLLS

I am sorry to come back on that, and I admit that I am looking at this as a layman. I do not think I can accept the interpretation given by the noble Lord, Lord Wells-Pestell (although that is what he himself genuinely felt) in the context of the Bill, unless it is written into the Bill at some other point. I do not think I can accept that it means what the noble Lord himself has said he thinks it means. The word "proposal" can only mean, if not the withdrawal the threat of withdrawal. There is no reason at all why that phrase should be in, unless it carries that meaning with it—in the absence of the explanation of the meaning being as the noble Lord has put it embodied somewhere else in the Bill. I must confess I had not thought of the point until the noble Lord, Lord Hill, made it.

My worry about this was for other reasons. I believe the point brought out by the noble Lord, Lord Hill, and the noble Lord's answer, make it even more essential that this Amendment should be accepted. If we remove these words from the Bill the Board will be in the same position as the noble Lord has described. If these words are not there, the Board will be able to implement what is obviously the intention in the way the noble Lord has described it. But as long as these words remain in the Bill, at the end of the day it comes to the Law Lords to interpret the meaning. The noble Lord may remember that I got a Private Member's Bill through on the meaning of a word which affected very many people very much indeed.

I venture to suggest to the noble Lord, in all humility, that in the context of this Bill this word "proposal" as it stands does carry with it a connotation that this service will be withdrawn, and will not remain as the noble Lord explained. I would venture to suggest that it may be a good thing to accept this Amendment so that the noble Lord can look at the matter and get advice as to whether or not my layman's interpretation is wide of the mark. If he can produce greater evidence than just his own opinion to show that the meaning of this word is different, then we can accept it. I do not know whether my noble friend had it in mind to withdraw this Amendment, but in the light of the point brought out by the noble Lord, Lord Hill, I would hope that my noble friend would think very hard before withdrawing it. If we vote and we are able to get sufficient support, we shall know that the Government will have to look at it again, whereas if it is not taken out there is less likelihood of that happening.

Lord SANDYS

I very much agree with my noble friend Lord Harmar-Nicholls; he has many arguments on his side. I should like, also as a layman, to address my remarks not only to the Government but also to the noble Lord, Lord Stone, who I think is addressing the House in Committee for the first or second time. He, of course, is a general practitioner. Despite the fact that he agrees with the Government, perhaps cautiously, as a layman, I might address these remarks to him as well.

The Royal Commission to which I previously referred, the Todd Commission on Medical Education, which sat in days when the situation was perhaps a little less frenetic, between 1965 and 1968, in their Command Paper 3569, addressed themselves to this particular problem. I think it is an advantage to listen to a Royal Commission which considered the subject with care and close attention. I will make a brief reference to Chapter 10, paragraph 515: A number of Consultant teachers will probably wish to continue some private practice. The problem which this raises, both in ensuring that such teachers are available where and when they are needed for teaching and that they have access to the facilities needed to treat private patients at an acceptable modern standard, have given rise to proposals that Consultant teachers' service should be 'geographically full-time'; i.e. that they should be enabled to see and treat private patients at the teaching hospital. The point is that the Government's Bill as drafted turns the Todd Commission's recommendation on its head. The Commission goes on later in that chapter to stress this particular point. I believe that so far as medical education is concerned the Board are being asked to do quite the wrong thing.

Lord PLATT

As an ex-member of that particular Commission, I entirely agree with what the noble Lord has just said.

Baroness YOUNG

The purpose of the Amendment we have put down is, of course, to restore the Bill to what it was when it was first introduced in another place. It is important that we have had this very full debate here, and I am most grateful to those noble Lords who have taken part because, of course, this was a Government Amendment introduced on Report and guillotined in another place; it is yet another example of an Amendment which has never been discussed on the Floor of the House in another place and therefore never discussed by Parliament at all except for the proceedings in your Lordships' House. I think it is important for us to note, in the course of this Committee stage, how many of these points there are.

The first point I tried to make to the Government was to ask the noble Lord why they had changed their mind and altered the decisions of the Board in this way. I have not yet heard the noble Lord, Lord Wells-Pestell, give an answer to that question, which is, after all, the crucial one. They obviously had second thoughts. They moved their Amendment, they guillotined it, and we have it now in the Bill which has come to your Lordships' House. It would be helpful if the noble Lord felt able to answer the question in Committee, because it is clearly the first one that is going to be asked. As my noble friend Lord O'Hagan quite rightly said, the reply of the noble Lord is another inconsistency.

In this particular case the Board is being required to act in a certain way in regard to out-patient facilities. The time-scale suggested—if one looks at subsection (6) one sees that it is 12 months following the initial period—means that these particular facilities must be phased out, as I understand it, 18 months after the Bill becomes law. As my noble friend Lord Harmar-Nicholls quite rightly said, it takes a very long time to establish another hospital and to put into it suitable facilities. The noble Lord, Lord Hill, quite properly asked the question, what is the Board to propose? As I understand the answer, if there were not any other facilities the Board would not necessarily propose that they would be phased out. But, of course, that is not what the Bill says; that is the noble Lord's interpretation of what the Government hope the Board will say. It is precisely this kind of point that the medical profession is most anxious about.

I would refer the Government to the words of the noble Lord, Lord Goodman, at Second Reading (cols. 1500/1): There are other changes which are much of the same sort and they are changes which the doctors seek because they want a clarification of the position and a reassurance that what they are told the Bill means is in fact what the Bill means. I would urge the Government to give it to them in every single case."—[Official Report, 21/10/76.] Here, I should have thought, was an exact case in point. It is the kind of issue on which clearly the Government consider this was part of the original Goodman agreement. Going back to the actual text of the agreement, I quote: The Board shall not necessarily retain existing private facilities for the purpose of specialised operations, treatments and investigations where the National Health Service is prepared to make such accommodation and equipment reasonably available on an occasional basis for individual requirements in specified circumstances and at an appropriate charge. The Bill would propose to allow health authorities to provide and charge for such specialised services for patients provided that they can satisfy the Secretary of State that there will be no disadvantage to NHS patients, and that such patients—whatever their country of origin—are admitted on the same basis of medical priority as an NHS patient. It seems to me that what the Government originally wrote into the Bill meets the Goodman point. What the Government have now put into the Bill on Report does not. There is now a doubt about it, even though the noble Lord has said that that is not how it would be interpreted. The Bill has tightened up the timetable. It has put a firm timetable on expensive and difficult equipment and services. It is one thing to provide a consulting room within six months—after all, presumably anybody could turn over his dining room for a consulting room if that were what was required—but nobody can produce within a short period of time (and eighteen months is a short period of time) these alternative facilities. I feel that this is an Amendment I cannot withdraw, and therefore r wish to ask the Committee to decide upon it.

4.41 p.m.

On Question, Whether the said Amendment (No. 35) shall be agreed to?

Their Lordships divided: Contents, 153; Not-Contents, 68.

CONTENTS
Airedale, L.	Emmet of Amberley, B.	Molson, L.
Alport, L.	Erskine of Rerrick, L.	Monck, V.
Amherst, E.	Exeter, M.	Monson, L.
Amory, V.	Faithfull, B.	Montgomery of Alamein, V.
Ampthill, L.	Ferrers, E.	Mottistone, L.
Amulree, L.	Ferrier, L.	Mowbray and Stourton, L. [Teller.]
Atholl, D.	Fraser of Kilmorack, L.
Auckland, L.	Gage, V.	Newall, L.
Balerno, L.	Garner, L.	Northchurch, B.
Balfour of Inchrye, L.	George-Brown, L.	Northesk, E.
Banks, L.	Gisborough, L.	O'Hagan, L.
Barnby, L.	Goschen, V.	O'Neill of the Maine, L.
Belstead, L.	Gray, L.	Onslow, E.
Berkeley, B.	Greenway, L.	Platt, L.
Birdwood, L.	Grey, E.	Rankeillour, L.
Blake, L.	Gridley, L.	Rea, L.
Blakenham, V.	Grimston of Westbury, L.	Reading, M.
Boothby, L.	Hampton, L.	Redesdale, L.
Boyd of Merton, V.	Harcourt, V.	Rochdale, V.
Bradford, E.	Harmar-Nicholls, L.	Rochester, L.
Broadbridge, L.	Harvington, L.	Ruthven of Freeland, Ly.
Brock, L.	Hawke, L.	Sackville, L.
Brooke of Cumnor, L.	Henley, L.	St. Aldwyn, E.
Brooke of Ystradfellte, B.	Hertford, M.	St. Davids, V.
Byers, L.	Hill of Luton, L.	St. Just, L.
Caccia, L.	Hornsby-Smith, B.	Saint Oswald, L.
Cairns, E.	Howe, E.	Sandford, L.
Caithness, E.	Hunt, L.	Sandys, L.
Campbell of Croy, L.	Hunt of Fawley, L.	Savile, L.
Carr of Hadley, L.	Hylton-Foster, B.	Selkirk, E.
Carrington, L.	Ilchester, E.	Sharples, B.
Chesham, L.	Inglewood, L.	Somers, L.
Clancarty, E.	Jessel, L.	Spens, L.
Clifford of Chudleigh, L.	Kemsley, V.	Stamp, L.
Clitheroe, L.	Kinloss, Ly.	Stokes, L.
Clwyd, L.	Kinnaird, L.	Strathcarron, L.
Cobham, V.	Kintore, E.	Strathclyde, L.
Coleriane, L.	Lauderdale, E.	Strathspey, L.
Cottesloe, L.	Leicester, Bp.	Swansea, L.
Craigavon, V.	Lloyd, L.	Terrington, L.
Crawshaw, L.	Lloyd of Kilgerran, L.	Tranmire, L.
Cullen of Ashbourne, L.	Long, V.	Vickers, B.
Daventry, V.	Lonsdale, E.	Vivian, L.
Denham, L. [Teller.]	Lyell, L.	Wade, L.
Digby, L.	Macleod of Borve, B.	Ward of North Tyneside, B.
Drumalbyn, L.	Macpherson of Drumochter, L.	Waverley, V.
Dulverton, L.	Malmesbury, E.	Westbury, L.
Dundee, E.	Mancroft, L.	Windlesham, L.
Ebbisham, L.	Margadale, L.	Winstanley, L.
Eccles, V.	Marley, L.	Wolverton, L.
Elles, B.	Merrivale, L.	Young, B.
Elliot of Harwood, B.

NOT-CONTENTS
Ardwick, L.	Davies of Leek, L.	Kirkhill, L.
Arwyn, L.	Davies of Penrhys, L.	Leatherland, L.
Aylestone, L.	Donaldson of Kingsbridge, L.	Lee of Asheridge, B.
Birk, B.	Douglas of Barloch, L.	Lee of Newton, L.
Blyton, L.	Douglass of Cleveland, L.	Llewelyn-Davies of Hastoe, B.
Bowden, L.	Elwyn-Jones, L. (L. Chancellor.)	Lloyd of Hampstead, L.
Brimelow, L.	Fisher of Rednal, B.	Lovell-Davies, L.
Brockway, L.	Geddes of Epsom, L.	McCluskey, L.
Bruce of Donington, L.	Gordon-Walker, L.	Maelor, L.
Buckinghamshire, E.	Greenwood of Rossendale, L.	Milford, L.
Burntwood, L.	Harris of Greenwich, L.	Murray of Gravesend, L.
Burton of Coventry, B.	Henderson, L.	Northfield, L.
Caradon, L.	Houghton of Sowerby, L.	Oram, L. [Teller.]
Castle, L.	Hughes, L.	Pannell, L.
Champion, L.	Jacques, L. [Teller.]	Peart, L. (L. Privy Seal.)
Collison, L.	Kaldor, L.	Peddie, L.
Crowther-Hunt, L.	Kilbracken, L.	Ponsonby of Shulbrede, L.

Raglan, L.	Stedman, B.	Wells-Pestell, L.
Ritchie-Calder, L.	Stewart of Alvechurch, B.	Williamson, L.
Sainsbury, L.	Stone, L.	Wilson of Radcliffe, L.
Shackleton, L.	Strabolgi, L.	Winterbottom, L.
Shinwell, L.	Summerskill, B.	Wootton of Abinger, B.
Slater, L.	Taylor of Mansfield, L.

Resolved in the affirmative, and Amendment agreed to accordingly.

4.49 p.m.

Baroness YOUNG moved Amendment No. 36: Page 5, line 36, after ("be") insert ("granted or").

The noble Baroness said: I beg to move. This Amendment is consequential.

On Question, Amendment agreed to.

Baroness YOUNG moved Amendment No. 37: Page 5, line 38, after (' necessary") insert ("grants or").

The noble Baroness said: I beg to move.

On Question, Amendment agreed to.

Baroness YOUNG moved Amendment No. 38: Page 5, line 44, leave out ("remain") and insert ("be").

The noble Baroness said: It may be helpful to the Committee if I move Amendment No. 38 and speak at the same time to Amendments Nos. 39, 41, 42 and 43, all of which are consequential to Amendment No. 38. Once again we are hack on this important series of Amendments which meet the point made by the noble Lord, Lord Goodman, on Second Reading. I have already quoted Lord Goodman once and I hope that the Committee will forgive me if I quote him again, but this series of Amendments is in fact designed to meet the point that he made at column 1500 at Second Reading on the 21st October when he said: The Bill contains a provision that that accommodation shall be reasonably suitable."— that is, alternative private facilities. The noble Lord continued: The doctors say that it does not necessarily mean 'reasonable' in terms of quality: it means reasonable, perhaps, in terms of geographical position or in terms of size but it may not mean reasonable in terms of being good enough, clean enough, light enough, in the right position. My own interpretation of 'reasonable', which I think would be supported by better lawyers than I am, is that the word must mean' reasonable in every sense'. In my view it is not necessary to underline it but at the same time it would cost nothing to underline it."—[Official Report, 2410/76; col. 1500.]

His argument went on to say that it would be to the advantage of the Bill if such Amendments were made because that would reassure the doctors, and he urged the Government to give in on these matters.

Amendment No. 38 would change the word "remain" to "be". This may be regarded in a sense as a semantic point, but "be" has a slightly different connotation from "remain", which has the unfortunate habit of suggesting that it might not remain something and therefore becomes one of those words which are regarded as part of the ratchet effect when legislation comes in which cannot be altered because of the complexities of altering it. This Amendment is in a sense a paving Amendment for the others which follow. The important ones are Amendments Nos. 41, 42 and 43 which are designed to strengthen, by including other words, the needs that the Board must consider when saying that the alternative facilities are good and reasonable enough for the private practice of medicine.

In a sense, Clause 4(8) contains the key to the whole Bill because it sets out the principles of the Board and therefore it is extremely important to get the principles right. I appreciate—I do not intend to quote again the exact Goodman Agreement—that the words in the Bill are in many respects very similar to the words in the Goodman Agreement. Nevertheless, it will seem that where the Bill talks about facilities, it is necessary to explain that they should be at a satisfactory standard; that where the Bill talks about facilities that are available, they should be facilities accessible to patients and to practitioners of their choice; and that where the Bill talks about hospitals, they need to be available at reasonable cost. There are many ways in which the facilities would simply not be reasonably provided unless these three criteria are met.

The words in Amendment No. 41 "facilities at a satisfactory standard" are taken from Clause 8(2), in which it will be seen that the Government use these very words to strengthen what it is they are saying in the clause. I hope therefore that the Government will see these Amendments as being designed to reassure the medical profession and patient that when the Bill comes into operation, if it does, it will be fairly operated. As Lord Goodman said on Second Reading, and as all of those who took part said, the essence of the Bill is that people will believe that it is possible to work it: the essence of it must be trust that the alternative facilities are available, and if that trust is not there then not only will things be difficult for private patients but all patients will suffer, which would be a very serious matter.

Again, these Amendments will no doubt not be debated in the other place because of the guillotine prodecure and therefore it would be helpful if those who feel that the Bill should be strengthened in this way would say so. As I say, this will probably be the only opportunity for either House to consider them in detail: they will almost certainly not be debated in the other place because they will be guillotined. As they are Amendments which Lord Goodman would have moved had he been here—we very much regret his illness—and as he would have wished them to be included in the Bill, I hope that the Minister will consider them favourably.

Lord WELLS-PESTELL

If I understood the noble Baroness correctly, she was speaking at the same time to Amendments Nos. 39, 41, 42 and 43, and I will do the same. As I tried to assure her and noble Lords when we last discussed this matter, I have been through this series of Amendments very carefully and I should say at this stage, having taken legal advice in respect of Nos. 38 and 39, that I must, on that advice, resist them. The effect of No. 38 would be to change the emphasis—the noble Baroness made this point—and the character of the first principle to which the Board is to have regard in formulating proposals for the progressive revocation and authorisation of pay beds and facilities for private outpatients. Under this principle, as it stands in the Bill, authorisations at any particular hospital are to remain only while there is a reasonable demand for accommodation or facilities for private practice in the area. The Amendment would mean that authorisations would be made while there was a demand for accommodation and facilities. The substitution of the word "be" for "remain" would, I understand, remove the guiding principle that when a reasonable demand or any demand ceased to exist in the area, the accommodation should no longer remain in operation.

We feel—although I believe that the noble Baroness is against me on this—that this meets the spirit of the proposals of 15th December, where the first criterion is, … that for the retention of beds or facilities for private practice in NHS hospitals there should be reasonable demand for private medicine in the areas of the country served by those particular hospitals". Passing on to Amendment No. 39, again, this is an Amendment upon which I have taken legal advice. Again, I must say that, on that advice, I must resist it. The effect on this Amendment, though innocuous at first sight would be to change the emphasis and the character of the first principle. Under this, authorisations can only be given in certain circumstances. As your Lordships know, the object of the Bill is to separate practice from National Health Service hospitals in a way that allows reasonable time to those who wish to he treated privately or to give private treatment to make suitable alternative arrangements outside the National Health Service hospitals.

Amendment No. 41, to which the noble Baroness made specific reference may in a sense be rather more important. So far as this Amendment is concerned, I am aware of the concern of the medical and dental professions, and in particular of the Royal Colleges, that the Health Services Board should be required to take into account the standard of alternative facilities in the private sector, when considering its proposals for progressive revocation of authorisations of pay beds and other facilities for private practice in National Health Service hospitals.

As my right honourable friend the former Minister of State made clear in Standing Committee, the Government, in the December proposals, accepted that, in phasing out pay beds and facilities, the Board could have regard to the intention of the Government to allow occasional admissions of patients, privately, to specialised NHS facilities if these particular services could not reasonably be provided to a satisfactory standard in the private sector, provided—and this was the point made by my right honourable friend—that this would not disadvantage the National Health Service patients. This means that there is no question of the private sector being driven to duplicate—possibly in an unsatisfactory way—every sophisticated feature of the National Health Service.

Secondly in determining the programme for phasing out. both the Secretary of State—I am speaking now in relation to the 1,000 pay beds—and the Board are obliged to look at the provision which is reasonably available in the private sector. This will inevitably involve a reasonable degree of matching up the nature of what is provided by the pay beds or other facilities at present as compared with the nature of what the private sector can already, or will in future be able to, provide. On the other hand, the Government have never said that they intend pay beds to remain until it can be guaranteed that private practice will be everywhere available, as fully and completely as it might be while pay beds and private facilities remain authorised in the National Health Service hospitals.

The Government are allowing time for a measure of development and improvement of private sector facilities, and the process of matching up will take reasonable account of the character of the private sector provision, and therefore of the kinds of medical practice which could satisfactorily be carried out in it. The private sector is subject to control by registration under the Nursing Homes Act 1975, and if it is shown that this control does not sufficiently maintain standards, I am prepared to consider, in consultation with the profession, what improvements there might be. Primarily, it is for the professional people who work in private hospitals and nursing homes to maintain proper professional standards.

In addition, there is the safeguard that the Board is required to consider representations before making its proposals for phasing out. That was also the reason why we should have liked the professions to join in discussions leading to an agreed schedule, so that the views of the professions at local level could have been taken fully into account. This was the subject of a meeting that the noble Lord, Lord Goodman, had with the Secretary of State on 18th October last.

I do not think that there is much more that I need add in relation to Amendment No. 42, except to say that it is unlikely that private sector facilities would be established in places inaccessible to the private practitioners and patients who would use them. Nevertheless private sector facilities will not always be located so conveniently for all patients and practitioners as the pay beds that they replace. That we acknowledge and the practitioners themselves must realise. It has always been recognised that private facilities would not necessarily be re-provided on exactly the same scale or in exactly the same locations. Indeed, there are those who would urge that many pay beds are even now not located in the best possible positions and that consultants have to travel some distance.

With regard to Amendment No. 43, it is—if I may put it like this—no part of the Board's function to concern itself with the charges made by private nursing homes or by consultants in the private sector. At the same time, there is no reason to believe that private nursing homes in general are likely to charge excessively whether charges are considered in relation to costs or in relation to charges that would be necessary for pay beds in National Health Service hospitals. It has been the policy of successive Governments since the inception of the Health Service that patients who decide to seek private treatment rather than to avail themselves of National Health Service services should pay the full cost whether they are treated within or outside National Health Service hospitals.

I hope that the noble Baroness will acknowledge that, even if I have been rather sketchy in some respects, I have tried to deal with the five Amendments to which she has spoken. For reasons that I have given—in two cases, we have taken legal advice and have been told that, so far as Amendments Nos. 38 and 39 are concerned, we cannot accept them for legal reasons and, in the other three cases, we feel that the Bill provides adequate safeguards—we cannot accept the Amendments.

5.10 p.m.

Lord HILL of LUTON

I should like to refer to Amendment No. 41. Am I right in understanding from the noble Lord that there will be discussions with the profession, as I think he said, with a view to the possible amendment in substance in the direction proposed in Amendment No. 41? This is really a matter of crucial importance from the angle of the public. Today, private accommodation within National Health Service hospitals may for the most part be regarded as of high standard and good quality, though there are variations. Those people who, for good reasons or otherwise, say that they prefer to obtain their service privately—and the reason is usually that they prefer for themselves or their families the privacy which private accommodation affords—need reassurance that in fact the private facilities will not be phased out until accommodation of a satisfactory kind is available.

I would urge upon the noble Lord to make absolutely explicit what he means by the words he has used, and to say whether he contemplates in certain circumstances the acceptance of some such words as these. I should have thought that it would be unacceptable to very many people that there should be the withdrawal of the good facilities that exist, throwing those people, particularly those large numbers who have insured against this provision, back to accommodation which is unsatisfactory or less satisfactory than was available in the private beds hospitals.

As the noble Lord spoke, I was reminded of Aneurin Bevan's phrase when he himself voluntarily offered to the profession that private practice could be conducted within National Health Service hospitals in order to bring them within the Service. He said that he wanted to avoid the development of a rash of nursing homes. Well, this Bill will have that effect. For heaven's sake! let us be certain that those external private facilities in existence, or contemplated, provide a satisfactory service, as satisfactory as is now obtained within the walls of the National Health Service hospitals.

Lord WINSTANLEY

I should like to add my support to the words of the noble Lord, Lord Hill of Luton, and others regarding Amendment No. 41 which I regard as crucial. The noble Lord, Lord Hill of Luton, has perhaps put his finger on the real point. I know that while your Lordships are in Committee we should not be forever referring to history and perhaps dragging in Nye Bevan again. But it is a fact, as he made utterly clear in his Second Reading speech, that in those days, when he originally allowed for private practice within National Health Service hospitals, he did that for two reasons. The first was to keep the specialists in the hospitals—a phrase which he used over and over again—rather than have them disappearing into isolation in outlying nursing homes. The second reason, as the noble Lord, Lord Hill of Luton, said, was in order to prevent, or not spark off, the spread of a rash of nursing homes which he suggested would he substandard. So it is utterly clear that he then was very concerned about standards of medical treatment, wherever that medical treatment was—be it private, be it public, or wherever. He was concerned overall about the medical standards being provided for patients, whether they were State patients or private patients.

I believe that by resisting this Amendment, which merely requires that those other facilities should be at a satisfactory standard, the noble Lord, Lord Wells-Pestell, is putting the clock back and is beginning to say, "Well, so long as we get this separation of private practice from State practice, so long as we start the phasing out of private practice we are not really concerned about what happens to the standards in the private sector". I say at once that I personally am much more concerned about the standards in the National Health Service than I am about any other standards. But I do not think that we here, or anybody who is concerned about public health, should close our eyes to a possible deterioration in standards of medical practice anywhere. So I hope that the noble Lord will think again and will perhaps answer more specifically the question put to him by the noble Lord, Lord Hill of Luton, about his intentions with regard to further discussions and possibly further Amendments later. I feel that in reality he is concerned himself about the standards in the private sector and he would not wish us to think otherwise. But his resisting the Amendment tempts one to think that perhaps he has withdrawn a little from that position.

Lord PLATT

I should like to make a comment on what the noble Lord, Lord Winstanley, has just said. Once again he has led us into the danger of confusing standards of medical practice—which were words that he used several times—and standards of facilities. I suggest to the Committee, for the third or fourth time, that these are two different things; at least they can be two different things. Nursing homes can be inspected and it can be said, "Oh yes, they are clean and they are using the right kind of apparatus and so on". But who are the people who are to work there, and who is to monitor their work? This is one of the greatest advantages of having the two in the same hospital, instead of separating them. It will be found that those members of the profession who are after the gold first and foremost will go to the plushy nursing homes, and some of the others will say, "I am not going to join this racket. I will just stick to the Health Service beds." So the two things would be divided to the great deterioration of standards for patients on both sides.

Lord SANDYS

In regard to Amendment No. 38 I was not altogether surprised to hear the noble Lord, Lord Wells-Pestell, suggest that for technical reasons it was necessary to resist the Amendment on the grounds given. I believe that these two words are very important here. So far as the Government are concerned if the word "remain" stays in the Bill it will ensure what we may term a ratchet effect; that is, a degree of rigidity and an impossibility of reversal at a later date. I am trying to think of illustrations as we go through the Bill. I am not intending to prolong the proceedings in this way, but believe that these very bare bones of clauses need illustration.

It so happens that medical practice changes with the years and what was considered satisfactory on 1st July 1948, when the Health Service came into being, is in some cases no longer current medical practice in the strictest sense. Let me give an example. There is to my knowledge in the National Health Service a number of instances where the Service uses spas or the waters of particular territories for the use of National Health Service patients. In this case I am thinking of a spa which I know in Worcestershire, at Droitwich, where for a very long time patients have derived benefit from the brine waters. Since 1948, up until comparatively recently—that is within the last 18 months or so—a very large number of private treatments have taken place within the National Health Service every year. To the best of my knowledge, the figure is approximately 50,000 treatments. Because medical practice is changing and because it is suggested that the same treatment could be given by other means, this particular feature is liable to be deleted from the National Health Service treatment. If the word "remain" stays in the Bill, no longer would this particular situation obtain.

So far as medical practice changes, the fads and peculiarities of medical practice alter. Sometimes, within a decade some treatments are phased out and then, after a trial period and the adoption of a new drug, they are phased in again, after dissatisfaction. What the noble Lord, Lord Wells-Pestell, said was—and I quote his words—that private facilities would not be reprovided in the same locations. If this occurred in a particular case concerning Droitwich Spa or any other spa, or any other treatment, the difficulty would arise. I believe that to build a rigidity into the Bill by ensuring that the Board follows the instructions set out in subsection (8) would be unsatisfactory.

My noble friend Lady Young reminded the Committee that this Amendment would be subject to, or is liable to be subject to, guillotine in another place. I think the Committee should also be reminded that in Standing Committee in the House of Commons. Amendments Nos. 41, 42 and 43 were subject to a tied vote in all three cases. On Report, in the case of Amendments Nos. 41 and 42 neither of them was reached; and so once again the situation obtains that your Lordships are examining a position of great importance which another place will not have an opportunity to investigate further. For those reasons, I believe that Amendment No. 38 should be upheld.

Lord WELLS-PESTELL

May I take up the last few words of the noble Lord, Lord Sandys, who says that Amendment No. 38 must be upheld. I think the Committee must appreciate that legal advice has been taken on this subject; and in respect of Amendments Nos. 38 and 39, as I said to your Lordships, the Government have been advised that in relation to what they want to do in the Bill the Amendment would be unacceptable. It is for your Lordships to make up your minds as to whether it is felt the Amendments are desirable or whether, the Government having taken the advice that they have, that should be sufficient for everybody concerned.

Baroness YOUNG

I am sorry to interrupt the noble Lord, but it is a rather important point that he is making. He says that the Government have taken legal advice and that therefore they cannot accept the Amendments. Does the legal advice apply to whether or not this is the correct interpretation of the Goodman agreement, or does it mean that if the Amendment was carried there would be a position produced which was contradictory to something in existing law, and therefore would be a legal absurdity?

Lord WELLS-PESTELL

I am most grateful to the noble Baroness. I understand that it was looked at in the light of the Goodman proposals and that the judgment was based on that. I should like to try to reply to the noble Lord, Lord Hill. I wonder whether I made myself perfectly clear. When I said what I did I was referring to the phasing out of the 1,000 beds. I referred to the Schedule, and the Schedule refers to the 1,000 beds. The Department invited comment on that, but no comment was forthcoming. When I said that we should welcome discussions with members of the profession, I had in mind that in connection with the phasing out now of the 1,000 beds it will become the responsibility of the area health authorities to advise on which beds in their area are right and proper to be phased out, and we should assume that discussions would take place between the area health authorities which would have that responsibility and the medical personnel involved. If have misled the noble Lord, I am sorry, but it is to this that I was referring.

Lord HILL of LUTON

I have no doubt it was owing to my own stupidity, but I had hoped that for one moment we could escape from this automatic rejection of every Amendment in order to secure that at least the alternative accommodation which would justify the abolition of private facilities within the National Health hospitals could be required to he of a satisfactory kind, of a satisfactory quality. If the Government reject these words there is no safeguard against a determined drive to exclude private practice from National Health Service hospitals without the slightest care being taken to ensure that the alternative available to the public is of the same quality. In an earlier phase of this Committee stage the noble Lord said that there was nothing in this Bill that was aimed at the destruction of private practice; he stood firmly and solemnly for the continuance of private practice. If he will not accept words to ensure that the alternative provision is of a satisfactory kind, he is giving the whole game away: that this is the beginning of a drive to abolish private practice, starting with the abolition of National Health Service private facilities within hospitals without taking the trouble to make sure that what is available as an alternative is of a satisfactory standard.

Lord WELLS-PESTELL

What the noble Lord is suggesting, if I may say so, is that attention will not be paid to the provision of accommodation and facilities of a reasonable and satisfactory standard. I said that this will be taken into account because in phasing things out the Board have to look at the facilities available.

Lord HILL of LUTON

"Reasonably available".

Lord WELLS-PESTELL

Yes; and they will presumably have discussions with the medical profession as to whether they are or are not. But the noble Lord, Lord Hill, must bear in mind that the whole purpose of this Bill is to separate eventually private practice from the National Health Service; and what he is in fact saying is that deep down in him there is a fear that the private sector is not going to "make it". Very often from some of the things that noble Lords opposite have said when they have expressed anxiety, it is clear that in the back of their minds they also have this fear. There is no evidence at all that this will be so. When one realises, as we in Government realise, the amount of money that is being poured into the private sector at the moment and the plans that there are for building and equipment, I do not see what they have to worry about at all.

Lord HILL of LUTON

I really am not concerned with private practice "not making it". What I am concerned with is the fact that the words "reasonably available" do not cover the quality of the alternative provision. The phrase "reasonably available" means something quite different. It is the rejection of Amendment No. 41, which requires that the alternative facilities should be of a satisfactory standard, which passes my comprehension, after all the noble Lord has said about the desirability of maintaining private practice in the future.

Lord WINSTANLEY

Perhaps I could press the noble Lord a little further at this particular point. I am sorry to do so again; but, after all, paragraph (b) on page 6 does qualify the other accommodation. It refers to it; it describes it. All that is required by Amendment No. 41 is the insertion of these words" at a satisfactory standard". What is said at the moment? At the moment it says that the facilities for the private practice of medicine have to be sufficient. The words are, if sufficient accommodation and facilities … are … available …". That relates to size and the ability to cope with numbers. First we have that description, that they must be "sufficient"; secondly, the Bill goes on to say they must be "reasonably available". In a lengthy discussion on Monday the noble Lord defined the words "reasonably available" as meaning "accessible". I accept that. So now we know that they must be "sufficient", that is, big enough; and they must be "accessible", one must have the opportunity to get to them. Why cannot we add "and they must be at a satisfactory standard" as well?

Baroness YOUNG

I think that we have had a very serious and important debate. I think that we have all listened with close attention to what was said by the noble Lords, Lord Hill and Lord Winstanley, who are both professionals and practising and aware of the needs of the medical profession. In preparation for the Committee's proceedings on this Bill I read the very interesting article by the noble Lord, Lord Taylor, setting out the whole of the background of the National Health Service. One particular quotation struck me as particularly important. He said: On the one hand, medicine of the highest quality must be delivered to all members of the community; on the other hand, those who actually make the delivery must remain free professional men and women if they are to provide the high quality needed. In those two sentences, it seems to me, he summed up the balance required.

What this debate has been about is achieving the balance. I am bound to say, having listened with care to the noble Lord, Lord Wells-Pestell, that I remain deeply concerned that in fact we are not going to achieve that balance. I shall read with great care in Hansard tomorrow what he has said about this and what "reasonably" means. But he has not really allayed the fears of the noble Lords, Lord Hill and Lord Winstanley, because it is much more than just a question of providing facilities; it is a question of providing facilities at a satisfactory standard.

For the life of me, I cannot see why the noble Lord cannot accept that Amendment because Clause 8 of the Bill, at the top of page 10, reads: In this subsection 'privately available' means available at a satisfactory standard otherwise than at an NHS hospital. If he can use those words in Clause 8, I cannot see why he cannot use the words in Clause 4, particularly when it would meet genuine fears. This is not an idle debating point. We are not even debating the whole of the future of the National Health Service. We are trying to ensure that the doctors, having made an agreement that the private beds will be phased out—and I would remind the noble Lord that the basis of the Goodman agreement and the acceptance of it was that the consultants would withdraw their working to contract which they were doing at that particular time—have done so on firm understandings. At every point the noble Lord has reminded us that the Government are sticking to the Goodman agreement. Now they are saying that they are going to interpret it in only one particular way. They are not prepared to write into this clause something that they are prepared to write into Clause 8.

The noble Lord in fact said that we are worried that the private facilities may be worse than the NHS facilities. Whether we are worried about that or not, everybody should be worried that we should be setting up second-class facilities for anybody anywhere—when part of the Goodman agreement was that facilities should be available at a satisfactory standard and, presumably, they were intended to be accessible to patients and the practitioners of their choice and, presumably to be available at a reasonable cost. I think that we are entitled to have this written into the Bill.

To comment on the question of charges, the noble Lord said that it was no business of his what charges are made for private facilities. But there is a relevance to this. The fact is that if charges for private use facilities in hospitals are pitched at such a level, they cease to be alternative facilities available to people. It is easy, as any runner of a monopoly knows, to price anybody out of the market when one does not want to use his facilities. I am not suggesting that that is the Government's intention, but it would do no possible harm to state it in the Bill by saying that it must be at a reasonable cost. That is all that is being asked. We all understand the work of inflation and that charges must go up; but it is not unreasonable to put it into the Bill that it should be at a reasonable cost. Therefore I feel that Amendments Nos. 41, 42 and 43 are of the greatest importance and I shall not feel able to withdraw them.

So far as Amendment No. 38 is concerned, I am not sure that I have yet understood the legal difficulty there. It is because I am not clear what is the legal difficulty, and because I myself would like to take advice on the matter, that I beg leave to withdraw Amendment No. 38 on the understanding that, having taken further advice, I may come back to it on Report. I have linked my remarks to Amendments Nos. 41, 42 and 43. I should inform the Committee that I do not feel able to withdraw those.

Lord WELLS-PESTELL

Will the noble Baroness allow me to say that I gave reasons for the legal difficulty in Amendments numbers 38 and 39, which she will probably see when reading Hansard tommorrow.

Amendment, by leave, withdrawn.

Baroness YOUNG moved Amendment No. 41: Page 6, line 8, after ("facilities") insert ("at a satisfactory standard").

The noble Baroness said: I have already indicated that this is not an Amendment that I feel able to withdraw. I should like to test the feeling of the Committee on this matter. I beg to move.

5.38 p.m.

On Question, Whether the said Amendment (No. 41) shall be agreed to?

Their Lordships divided: Contents, 147; Not-Contents, 63.

CONTENTS
Allen of Abbeydale, L.	Brock, L.	Drumalbyn, L.
Alport, L.	Brooke of Cumnor, L.	Dundee, E.
Amherst, E.	Brooke of Ystradfellte, B.	Eccles, V.
Amherst of Hackney, L.	Byers, L.	Elles, B.
Amory, V.	Cairns, E.	Elliot of Harwood, B.
Ampthill, L.	Caithness, E.	Elton, L.
Amulree, L.	Campbell of Croy, L.	Ely, Bp.
Auckland, L.	Carlisle, Bp.	Emmet of Amberley, B.
Balerno, L.	Carr of Hadley, L.	Exeter, M.
Balfour of Inchrye, L.	Carrington, L.	Faithfull, B.
Banks, L.	Clitheroe, L.	Falmouth, V.
Barnby, L.	Crawshaw, L.	Ferrers, E.
Beaumont of Whitley, L.	Cross, V.	Ferrier, L.
Belstead, L.	Cullen of Ashbourne, L.	Fraser of Kilmorack, L.
Berkeley, B.	Daventry, V.	Gainford, L.
Blakenham, V.	de Clifford, L.	Garner, L.
Boyd of Merton, V.	Denham, L. [Teller.]	George-Brown, L.
Bradford, E.	Digby, L.	Gisborough, L.
Glenkinglas, L.	Macleod of Borve, B.	St. Aldwyn, E.
Goschen, V.	Macpherson of Drumochter, L.	St. Just, L.
Grafton, D.	Malmesbury, E.	Salisbury, Bp.
Gray, L.	Mancroft, L.	Sandys, L.
Greenway, L.	Mansfield, E.	Savile, L.
Grey, E.	Margadale, L.	Seear, B.
Gridley, L.	Marley, L.	Selkirk, E.
Hailsham of Saint Marylebone, L.	Melville, V.	Sharples, B.
Hampton, L.	Merrivale, L.	Simon, V.
Hanworth, V.	Meston, L.	Somers, L.
Harcourt, V.	Monck, V.	Spens, L.
Harmar-Nicholls, L.	Montgomery of Alamein, V.	Stamp, L.
Harvington, L.	Mottistone, L.	Stokes, L.
Hawke, L.	Mowbray and Stourton, L. [Teller.]	Strang, L.
Hill of Luton, L.		Strathcarron, L.
Hornsby-Smith, B.	Northchurch, B.	Strathclyde, L.
Hunt, L.	Northesk, E.	Strathspey, L.
Hunt of Fawley, L.	O'Hagan, L.	Swansea, L.
Hylton-Foster, B.	Onslow, E.	Terrington, L.
Ilchester, E.	Orr-Ewing, L.	Teynham, L.
Inglewood, L.	Pender, L.	Thorneycroft, L.
Kemsley, V.	Peterborough, Bp.	Tranmire, L.
Kinnaird, L.	Platt, L.	Vickers, B.
Kintore, E.	Rankeillour, L.	Vivian, L.
Lauderdale, E.	Reading, M.	Ward of North Tyneside, B.
Lloyd of Kilgerran, L.	Reay, L.	Wardington, L.
London, Bp.	Redesdale, L.	Waverley, V.
Long, V.	Robson of Kiddington, B.	Westbury, L.
Lucas of Chilworth, L.	Rochdale, V.	Winstanley, L.
Luke, L.	Rochester, L.	Wolverton, L.
Lyell, L.	Ruthven of Freeland, Ly.	Young, B.
NOT-CONTENTS
Ardwick, L.	Greenwood of Rossendale, L.	Peart, L. (L. Privy Seal.)
Arwyn, L.	Harris of Greenwich, L.	Peddie, L.
Beswick, L.	Henderson, L.	Raglan, L.
Birk, B.	Houghton of Sowerby, L.	Ritchie-Calder, L.
Blyton, L.	Hughes, L.	Sainsbury, L.
Brimelow, L.	Jacques, L.	Shackleton, L.
Brockway, L.	Kaldor, L.	Shinwell, L.
Bruce of Donington, L.	Kilbracken, L.	Slater, L.
Caradon, L.	Kirkhill, L.	Soper, L.
Castle, L.	Leatherland, L.	Stedman, B. [Teller.]
Champion, L.	Lee of Asheridge, B.	Stewart of Alvechurch, B.
Darling of Hillsborough, L.	Lee of Newton, L.	Stone, L.
Davies of Leek, L.	Llewelyn-Davies of Hastoe, B.	Stow Hill, L.
Davies of Penrhys, L.	Lloyd of Hampstead, L.	Strabolgi, L. [Teller.]
Donaldson of Kingsbridge, L.	McCluskey, L.	Taylor of Mansfield, L.
Douglas of Barloch, L.	Maelor, L.	Walston, L.
Douglass of Cleveland, L.	Milford, L.	Wells-Pestell, L.
Elwyn-Jones, L. (L. Chancellor.)	Murray of Gravesend, L.	Wilson, of Radcliffe, L.
Fisher of Rednal, B.	Northfield, L.	Winterbottom, L.
Geddes of Epsom, L.	Oram, L.	Wootton of Abinger, B.
Gordon-Walker, L.	Pannell, L.	Wynne-Jones, L.

Resolved in the affirmative, and Amendment agreed to accordingly.

5.47 p.m.

Baroness YOUNG moved Amendment No. 42: Page 6, line 9, leave out ("available") and insert ("accessible to patients and the practitioners of their choice").

The noble Baroness said: I beg to move this Amendment.

On Question, Whether the said Amendment (No. 42) shall be agreed to?

Their Lordships divided: Contents, 133: Not-Contents, 57.

CONTENTS
Allen of Abbeydale, L.	Ferrers, E.	Monck, V.
Alport, L.	Ferrier, L.	Monson, L.
Amherst of Hackney, L.	Fraser of Kilmorack. L.	Mottistone, L.
Amory, V.	Gainford, L.	Mowbray and Stourton, L. [Teller.]
Amulree, L.	Garner, L.
Auckland, L.	George-Brown, L.	Northchurch, B.
Balerno, L.	Goschen, V.	Northesk, E.
Balfour of Inchrye. L.	Grafton, D.	O'Hagan, L.
Banks, L.	Gray, L.	Onslow, E.
Barnby, L.	Greenway, L.	Pender, L.
Beaumont of Whitley, L.	Grey, E.	Peterborough, Bp.
Belstead, L.	Gridley, L.	Platt, L.
Berkeley, B.	Hailsham of Saint Marylebone, L.	Rankeillour, L.
Blakenham, V.	Hampton, L.	Reading, M.
Boyd of Merton, V.	Hanworth, V.	Reay, L.
Bradford, E.	Harcourt, V.	Redesdale, L.
Brock, L.	Harmar-Nicholls, L.	Robson of Kiddington, B.
Brooke of Cumnor. L.	Harvington, L.	Rochdale, V.
Brooke of Ystradfellte, B.	Hawke, L.	Rochester, L.
Caithness, E.	Hill of Luton, L.	Ruthven of Freeland, Ly.
Campbell of Croy, L.	Hornsby-Smith, B.	St. Aldwyn, E.
Carr of Hadley, L.	Hunt of Fawley, L.	St. Just, L.
Carrington, L.	Hylton-Foster, B.	Sandys, L.
Chelwood, L.	Ilchester, E.	Savile, L.
Clifford of Chudleigh, L.	Inglewood, L.	Selkirk, E.
Clitheroe, L.	Kemsley, V.	Simon, V.
Cork and Orrery, E.	Kinnaird, L.	Somers, L.
Crawshaw, E.	Kintore, E.	Spens, L.
Cross, V.	Lauderdale, E.	Stamp, L.
Cullen of Ashbourne, L.	Lloyd of Kilgerran, L.	Strang, L.
Daventry, V.	London, Bp.	Strathcarron, L.
de Clifford, L.	Long, V.	Strathclyde, L.
Denham, L. [Teller,]	Lonsdale, E.	Strathspey, L.
Digby, L.	Lucas of Chilworth, L.	Swansea, L.
Drumalbyn, L.	Luke, L.	Terrington, L.
Dundee, E.	Lyell, L.	Thorneycroft, L.
Eccles, V.	Macleod of Borve, B.	Tranmire, L.
Elles, B.	Macpherson of Drumochter, L.	Vickers, B.
Elliot of Harwood, B.	Malmesbury, E.	Vivian, L.
Elton, L.	Mancroft, L.	Waverley, V.
Ely, Bp.	Mansfield, E.	Westbury, L.
Emmet of Amberley. B.	Margadale, L.	Windlesham, L.
Exeter, M.	Marley, L.	Winstanley, L.
Faithfull, B.	Melville, V.	Young, B.
Falmouth, V.	Merrivale, L.

NOT-CONTENTS
Ardwick, L.	Harris of Greenwich, L.	Phillips, B.
Arwyn, L.	Henderson, L.	Raglan, L.
Beswick, L.	Houghton of Sowerby, L.	Ritchie-Calder, L.
Birk, B.	Jacques, L.	Sainsbury, L.
Blyton, L.	Kaldor, L.	Shackleton, L.
Brimelow, L.	Kilbracken, L.	Shinwell, L.
Brockway, L.	Kirkhill, L.	Slater, L.
Bruce of Donington, L.	Leatherland, L.	Soper, L.
Caradon, L.	Lee of Asheridge, B.	Stedman, B.
Castle, L.	Lee of Newton, L.	Stewart of Alvechurch, B.
Champion, L.	Llewelyn-Davies of Hastoe, B.	Stone, L.
Darling of Hillsborough, L.	Lloyd of Hampstead, L.	Stow Hill, L.
Davies of Leek, L.	Maelor, L.	Strabolgi, L. [Teller.]
Davies of Penrhys, L.	Murray of Gravesend, L.	Taylor of Mansfield, L.
Donaldson of Kingsbridge, L.	Northfield, L.	Wells-Pestell, L.
Douglass of Cleveland, L.	Oram, L.	Wilson of Radcliffe, L.
Elwyn-Jones, L. (L. Chancellor.)	Pannell, L.	Winterbottom, L.[Teller.]
Gordon-Walker, L.	Peart, L. (L. Privy Seal)	Wootton of Abinger, B.
Greenwood of Rossendale, L.	Peddie, L.	Wynne-Jones, L.

Resolved in the affirmative, and Amendment agreed to accordingly.

5.56 p.m.

Baroness YOUNG moved Amendment No. 43: Page 6, line 10, after ("hospitals)") insert ("and available at reasonable cost").

The noble Baroness said: We have already discussed this Amendment when we were discussing Amendment No. 38 and I moved all these Amendments together. I must say that I found the Division on Amendment No. 42 quite extraordinary and I think this is a feeling shared by the entire Committee. At the beginning of these Committee proceedings I indicated that we on this side of the Committee were taking this Bill very seriously. As the Committee will be aware, there were 52 tied Amendments in the Committee stage in another place; they were guillotined on Report and but for these Committee proceedings a great many matters would not be discussed by Parliament at all; they are certainly not being discussed in another place. I have done my best to order our affairs on this side as well as I can. The Government have declined to group any Amendments which would have made the procedure easier from their point of view and I am at a loss to understand why they declined to do so, because it is in their interest to get the Bill through, not particularly our interest. However, we have done our best and grouped the Amendments as well as possible in order to help the discussion. When I move a consequential Amendment and have to have a second Division I find it all the more extraordinary. It is wasting the time of the Committee when we have a number of Amendments before us.

Several noble Lords

Hear, hear!

Lord WELLS-PESTELL

It may he that I am at fault, but I think noble Lords had better look at the Amendment before saying "Hear, hear!". Amendment No. 41 dealt with satisfactory standards; Amendment No. 42 dealt with accessibility to patients and practitioners of their choice and I cannot see that that is consequential on the other. The next Amendment which the noble Baroness has just moved deals with these facilities being available at reasonable cost. They are three quite distinct things and I cannot see how anybody can argue that three quite separate matters are consequential.

Baroness YOUNG

As the noble Lord, Lord Wells-Pestell, knows perfectly well, the three points were raised by the noble Lord, Lord Goodman, when we discussed them at Second Reading, and the noble Lord, Lord Goodman, believed that Amendments ought to be made to the Bill. These Amendments made these three points. They are to one particular sub-section of a clause and I spoke to them together. I think this is a rather useless semantic point about their not being consequential and simply takes up the time of the Committee.

On Question, Amendment agreed to.

6 p.m.

Lord SANDYS moved Amendment No. 45:

Page 6, line 12, at end insert— ("() that no authorisation of any such accommodation or services under those provisions should be revoked so long as their use in that connection contributes to the education or training of medical or dental practitioners or of persons employed in one or other of the national health services or concerned with the interests of patients at hospitals;").

The noble Lord said: On the following three Amendments we may find ourselves to some extent in the same difficulty because of grouping or the lack of it. I think it will be of some advantage if I speak to Amendments Nos. 45, 46 and 47 because they all deal with the same point. I will in fact address myself initially to Amendment No. 45, and speak on the other two. Phasing out would most emphatically damage education and training. I have already referred to the Royal Commission on Medical Education. The noble Lord, Lord Platt, who served on the Todd Commission, was one of the members of that very eminent body. He supported me in my conclusion that the Bill now before us flies in the face of what the Todd Commission agreed and set out in their Report, in particular in Chapter 10. I think it would be of some advantage if I reduced the number of quotations. Your Lordships may feel I have dealt insufficiently with this very important document, but I will draw upon it again if need be, if the noble Baroness wishes me to bring out certain points later.

I should like to say, first, that the drafting of Clause 4(8) in paragraphs (b), (c) and (d) is obscure and, speaking on behalf of my noble friends on this side of the Committee, we find the language unacceptable. We have addressed ourselves to this problem and have redrafted those parts of Clause 4 which we believe needed redrafting. I should like to draw your Lordships' attention, for instance, to subsection (8)(c), where we consider the English to be most unsatisfactory. It contains a use of the impersonal passive which makes nonsense. Perhaps I might read it aloud so as to make clear to the Committee what I am endeavouring to show: (c)that the continued authorisation of any such accommodation or services under those provisions for use in that connection should depend on there having been or being taken all reasonable steps to provide, otherwise than at NHS hospitals, sufficient reasonable accommodation and facilities for the private practice of medicine and dentistry to meet the reasonable demand for them in the area or areas served by the hospital or hospitals in question;". The phrase: … there having been or being taken all reasonable steps to provide, otherwise than … is an extraordinary use of English. If one attempts to read the clause as a whole, I believe there is an obscurity of language, and I constantly refer to the problem which is set out in the Renton Committee Report. May I be permitted to omit the reference in that Report? I will read it if any noble Lord wishes me to do so.

I turn now to Clause 4(8)(d). In that comparatively long subsection we have what seems to be equal nonsense, because the language is of a similar nature. I believe that one of our chief tasks in this Chamber is to remove obscurity of language, to make the obscure clear and to make the lengthy and platitudinous interesting and brief, if we can. Here the Government are presenting us with a group of paragraphs containing what I can only describe as nonsense. It may be only linguistic nonsense or perhaps "nonsense on stilts"—which is a higher form of nonsense—but, at least, in addressing ourselves to these three Amendments, we are endeavouring to get the language right as a start.

I would refer to the basic issue of education and training. It is fundamental, and there will be a major gap if the subsections to which I have referred are passed by the Committee. The Todd Commission referred to education and training in Chapter 10 of their Report, and I will not quote from that again as I have already quoted twice from that chapter this afternoon. However, I should like to say that there are two issues I believe your Lordships should consider. One is the question of examinations—and very important it is—for those doctors and practitioners who come to these shores from abroad, and the examinations which are undertaken by those who qualify who are resident in this country. One of the principal points is that of the 10,000 who come from overseas to practise within the National Health Service—I think the noble Baroness will agree that the number is approximately 10,000; it is 9,000 odd—there will be a very substantial number who are not willing to undertake certain tests.

There is a basic test, which is normally applicable here, but I want to address myself to the basic issue of the conjoint examination. The conjoint examination—I hope that noble Lords with medical knowledge will correct me if I am wrong—must be sat by doctors in the United Kingdom, but it need not be passed by those coming from overseas who wish to practise in this country. That is unfair and unreasonable from two points of view. One concerns those very highly-qualified doctors from overseas who have a very high standard indeed in their own territory and who choose to sit the examination and qualify. They are, of course, under no illusions whatever about the fact that many of their fellow countrymen who are not so well qualified are under no obligation to sit that examination. That is one side of the story only. There are other matters to which I could refer, but they are matters to which other members of this Committee who are much better qualified would be able to address themselves. I believe these matters concerning education and training are very serious ones and we should not pass them by. Therefore, I beg to move Amendment No. 45.

Lord PLATT

May I just intervene, since the noble Lord, Lord Sandys, has invited those of us with medical knowledge to do so? One does not have to sit the conjoint examination to qualify in medicine. It is one of the possible qualifying medical examinations. A university degree in medicine is equally good.

Baroness STEDMAN

I do not think the effect of this Amendment would be quite as far-reaching in the actual training of doctors as the noble Lord opposite would have us believe. For many years it has been the manpower policy of successive Administrations to reduce the numbers of contracts for small numbers of sessions in our teaching hospitals, in line with the recommendation of the Royal Commission on Medical Education. For some time, therefore, all the new consultants' posts have been approved as whole-time, or maximum part-time, except in special circumstances. I recognise that the withdrawal of the private practice facilities from NHS hospitals may result in some consultants being less readily available, but I also think it is important not to exaggerate the extent of this problem by suggesting that the education of medical students, junior doctors and other hospital staff will be adversely affected.

This will not be a new development. Many consultants already make use of private nursing homes and hospitals some distance away from their National Health Service hospitals, and by no means all of the NHS hospitals have the facilities for private patients, and those members of their consultant staff who practise privately often have to travel.

Furthermore, I would remind noble Lords opposite that we are here considering a very small proportion of total health service facilities, pay beds being two per cent. of available acute beds, which in any event have never been used as intensively as ordinary NHS beds. The volume of clinical experience that private patients contribute is consequently of a much more marginal value, save perhaps in the case of some of our more specialised units. But this kind of experience need not be lost, because Clause 8 provides for the occasional admissions of private patients who need highly specialised treatments. The same provision will also ensure that the contribution to training resulting from the admission of aliens who come to this country specifically for treatment and who suffer from diseases or complications rarely seen in this country need not be lost by reason of phasing out.

I believe the Opposition want to perpetuate the present arrangements under which a consultant is free to admit to a pay bed any patient, whether a native of this country or from overseas, who is prepared to pay for any treatment, irrespective of the length of the waiting list, if in his judgment research funds or medical education would benefit. While the Government accept that it is not unreasonable that consultants with highly specialised skills should not be denied that opportunity of building an international reputation, provided that the treatment they offer to overseas patients is no different from that given to NHS patients, we think it wrong that in places where there are long waiting lists consultants should be free to use NHS facilities to take in patients, particularly from overseas, for non-serious operations in order to enhance revenue for research. That is not the way to finance research. The purpose of this Amendment seems to us to be destructive of the principle that the National Health Service is first and foremost for the people of this country.

We are rightly proud of our tradition of making these facilities available to patients from overseas who have the misfortune to be taken ill while in this country. We are equally proud of the tradition of allowing patients to come here for highly specialised facilities not readily available in their own countries, and the Health Services Bill will not affect these arrangements. I repeat, however, that the Government are not prepared to allow consultants to sell routine NHS services to overseas patients, or, for that matter, to British patients, who are prepared to pay a premium in order to jump the queue, so as to increase the flow of revenue to research funds at the expense of the majority of the citizens of this country who, through the taxes they pay, provide these facilities for the use of the community as a whole.

Lord O'HAGAN

I wonder whether I may raise one point with the noble Baroness on this Amendment. She may wish to refer to it after consultation on a subsequent Amendment. She has referred continually to "citizens of this country" and she implied that the citizens of this country were the people who were to be considered, primarily, and that no others were to have equal consideration. I ask whether, in the drafting of this Bill, the Department responsible for it took account of our accession to the EEC, because under the Treaty of Rome we are obliged to give to all nationals of EEC countries on a reciprocal basis treatment equal to that we afford to our own nationals. May I ask whether, on reconsideration, she will not wish to withdraw some of her comments about people from outside this country, because if her statement were taken at its face value it would be in breach at least of the spirit of the Treaty. When the Government are making statements of this sort, could she say whether they have considered their obligations under the Treaty of Rome?

Baroness STEDMAN

I am concerned at this point with the pay beds. Whether they are citizens of this country or citizens of Europe or wherever they come from, if they want the facilities and wish to pay for them, those are the facilities with which I am concerned. Our medical obligations, I may say, are honoured under the Treaty of Rome. We are able to offer the NHS facilities. When it comes to pay beds, we said that we were "proud of our tradition of making these facilities available to patients from overseas". We are equally proud of our tradition of allowing patients to come here into our pay beds for highly specialised facilities which other countries cannot offer. However, we have to remember that our Health Service is paid for by the taxes of the people from this country. We cannot allow people to use their cheque books to jump the queue over medical needs or over the needs of the people paying their taxes for the ordinary Health Service treatment. We cannot allow pay beds to continue to be used as a means of jumping the queue.

Lord O'HAGAN

I was not trying to intervene on the point of cheque books or not cheque books or on queue jumping or not queue jumping. What I was seeking to try to obtain from the Government was a statement that when looking at this Bill they would take into account our obligations under the Treaty. The answer of the noble Baroness has confirmed my suspicion that they have not, because she cannot say in the same breath, "We have looked at this matter" and then say, "It is all very well to talk about patients from overseas jumping the queue" and so on. I will not persist now, but at some later stage would the Government give the Committee a firm assurance that when they are talking about foreigners, the Government and the Department responsible for the preparation of this Bill have hoisted in the fact that this Government could be taken to court in Luxembourg if they were to pass legislation which discriminated against our fellow nationals of the Community and gave them a less favourable position under our national law than the position awarded to our own nationals?

The Government may wish to do something that discriminates against people from Saudi Arabia—if they arc foolish enough to wish to do so. What I am asking for is an assurance from the Government that they realise that if they are doing something in this Bill which puts someone from Germany or France in a less favourable position than our own citizens, then they are in breach of the Treaty obligations.

Baroness STEDMAN

I have taken further advice on this. The National Health Service is provided for the people of Great Britain, but nothing in this Bill affects our EEC obligations.

Lord HARVINGTON

I thought I heard the noble Lord, Lord Sandys, make a rather drastic accusation about the English of this clause. I waited anxiously for the noble Baroness to address herself to this question. Unless she feels satisfied that the noble Lord, Lord Sandys, is completely wrong, perhaps she would say that she would prevail upon those cloudy people, the Parliamentary draftsmen, to have another look and see whether they could not make it clear. As far as I understand it, she has ignored that part of the noble Lord's comments.

Baroness STEDMAN

I am sorry if I was discourteous, but I think that the noble Lord, Lord Sandys, has had as much experience as I have of coping with Parliamentary draftsmen. They say that it must be put in this rather archaic way in which it is put—

Lord HARVINGTON

Unclear!

Baroness STEDMAN

Unclear if you like. Far be it from ordinary mortals to argue with them. This is the way in which we have been advised by the Parliamentary draftsmen that it should be put.

Baroness YOUNG

We shall be returning to this point on a later Amendment. I have the deepest sympathy with the noble Baroness, Lady Stedman, and with the noble Lord, Lord Wells-Pestell, but the noble Lord ought to take this up with his colleagues in the Government, because the drafting of parts of this Bill is totally incomprehensible. I suspect that what the Government have done is to take the Goodman agreement, which was a document and not a piece of legislation, and simply write parts of it into the Bill. As I said, we shall be returning to this point, but it hardly helps either the medical profession or organisations such as BUPA, who will have to interpret the Bill, if it is written in this obscure language which can be understood only when the Government have chosen to give us an explanation, and when we have seen it in Hansard.

6.20 p.m.

Lord SANDYS

The noble Baroness, Lady Stedman, used a number of emotive phrases and, to a degree, her remarks failed to recognise that we have plenty of time ahead of us—perhaps another 12hours—to consider the body of this Bill. I believe that there are some real points which I am about to raise, because, although the noble Baroness commented on the volume of clinical experience, the essence of this matter has yet to be discussed. I do not know whether the Hospital Activity Analysis is in the noble Baroness's brief, but if it is I think she will agree that it would be worth while advising the Committee what the hospital activity is. The noble Baroness disagrees?

Baroness STEDMAN

No. It is not part of my brief.

Lord SANDYS

It happens to be part of my interest in this case. I have a quotation from the Minister of State, Dr. Owen, in Standing Committee, and I think it would be valuable for the Committee to have the figures and to appreciate he balance between NHS patients and private patients. The Minister of State said, at column 409 of the Official Report for Standing Committee D: I will quote some figures taken from the Hospital Activity Analysis. In neurology there were 24,000 NHS patients and 700 private patients; in neuro-surgery 26,000 NHS and 600 private: in cardiology 25,000 NHS and 500 private; in radiotherapy 43,000 NHS and 970 private, and in thoracic surgery 26,000 NHS and 600 private. There are plenty of NHS patients receiving complex treatments, and the absence of private patients would not seem likely to affect significantly the amount of clinical material, particularly when one has regard to the effects of Clause 8 admissions. He ended his comment by saying: I think there has been gross exaggeration of the consequences. I totally deny that. There has not been gross exaggeration.

My noble friend Lady Young and I consulted the medical profession, and what we heard was extremely interesting. We discussed the point at some length not only with a general practitioner, but also with a consultant, and the proposition was put to us that if a substantial number of beds disappear—and we know of the initial phase of 1,000 beds, followed in due course by 3,444 beds, if the Government have their way—there will be a substantial loss of clinical experience. Clinical experience, as expressed in the analysis, shows that the vast majority are NHS patients, but the point which the consultants make is that a very small number of cases from abroad frequently bring heart conditions, as well as conditions of the lungs and of the blood, which are quite unknown in this country and they form a very valuable basis for training and examination. For instance, a heart patient from Bradford is most unlikely to have the same condition as a heart patient from Perugia. The point made by the consultants is valid.

As we said at length on Second Reading, private patients from abroad bring not only funds but physical conditions which are not only unknown, but will not be within the experience of the young doctors and consultants of tomorrow. This is a serious point which is worthy of consideration. As I understand it—and, again, I am more than ready to give way to any medical noble Lord who wishes to intervene in specialty training, after roughly two and a half years in general surgery, a young doctor will very often move on to a registrar's job, and it is normal practice in the National Health Service for a registrar to be asked to take over a number of patients. But when a certain situation arises the top man, the consultant, is asked to examine a case in greater detail, and I believe it would be a great disservice to the medical profession, particularly to those members of it who are going in for higher qualifications in both the Hospital Service and the general practitioner service, if we allowed the Government to get away with it. The Government may say that, because there are 43,000 NHS cases, there is an enormous weight of clinical experience. But I am talking not about the weight of numbers, but about the weight of conditions.

Lord STONE

Surely that argument would apply to both sides of the profession, to the public side and to the private side. One can use the same argument about the number in private practice and about the much larger experience of the public hospitals.

Lord HUNT of FAWLEY

I should like to support these Amendments. Many of my colleagues are worried about how this Bill will affect their teaching of medical students, and postgraduates and interfere with their medical research. Several of them have told me—one did so this morning—that they would seriously think of resigning from the National Health Service if that happened. That really would hurt the National Health Service and their patients. These Amendments would help to discourage doctors from doing that, and I hope that your Lordships will agree.

Lord SANDYS

I am most grateful to the noble Lord, Lord Hunt of Fawley, for his support. He is a qualified consultant, and on this side of the Committee we have few enough of them. The noble Lord, Lord Winstanley, is apparently unable to be here at the moment. I believe that the noble Lord, Lord Stone, is wrong and I beg to disagree with him. He is a qualified general practitioner and I am a layman. But I believe that a variety of clinical experience is available within the National Health Service, for the good reasons which I have given.

Lord STONE

But the noble Lord compared 26,000 with about 800.

Lord SANDYS

My point is that among those 800 there were some very unusual conditions, very often from overseas. They are conditions induced by the climate of the country from which those patients came, or by some other cause. If there are fewer beds in hospitals, there will automatically be a much greater throughput, and the biggest block of all will be in the outflow through convalescence, because of the number of convalescent homes which are liable to be closed. Therefore a number of acute patients are likely to stay in hospital quite a long time. This is a particular difficulty because the whole weight of current medical practice is, especially in acute hospitals, to ensure that there is a considerable throughput and that after serious operations patients are quite rapidly impelled to leave those hospitals and go into convalescent circumstances. It seems that there will be a blockage in acute hospitals on this account, and I do not believe that the noble Baroness will be able to produce figures which will be able to convince this side of the Committee that this is not so.

Baroness STEDMAN

No, I cannot produce figures. But what I did say was that the pay beds account for only a small proportion of those people who are treated, and, despite the figures which the noble Lord gave, the great majority of people who go into pay beds go in as maternity cases, for varicose veins, hernias and other conditions, and the highly specialised ones will still retain the right of having pay beds. They will still be able to use the NHS facilities until there are alternative facilities for them.

The hospital for Tropical Diseases will still take patients from abroad with those diseases of which we do not have much experience in this country, but about which our doctors need to know in their training. Those kind of specialised hospitals will not be deprived of having these patients, nor of the doctors getting training in them. There is a vast reservoir of clinical experience in our NHS and teaching hospitals for doctors' training. There is obviously a great divide between us. We do not believe that the position is as serious as the noble Lord, Lord Sandys, would accept. We do not think we are doing anything to the detriment of doctors' training in the future.

Lord AUCKLAND

These conditions seem to apply to London. We all accept that the Hospital for Tropical Diseases in London will not be affected by the Bill. But there are various regional hospitals, such as the Edinburgh Royal Infirmary and a number of specialist hospitals in the North of England, which are likely to be adversely affected, and where these relatively rare diseases are treated. Have the Government given any thought to the hospitals outside the London area, particularly at a time where more people are leaving London for these areas and where there is an increased amount of training of medical students, registrars and others in those hospitals outside London?

Baroness STEDMAN

Where a hospital has built up a particular speciality, which is not available to private patients outside in private nursing homes, then they still will he treated in that hospital for that speciality. We are not taking anything away from hospitals outside London.

Lord SANDYS

I believe we have had an interesting, though not satisfactory, debate. In the first place I drew your Lordships' attention to the drafting of this part of the Bill. I was grateful to the noble Viscount, Lord Hambleden, who reminded the Committee that the noble Baroness had said nothing about it. My noble friend Lady Young has sympathised with the Government on the problem of drafting. But at the same time we are in some difficulty, and I hope that the noble Baroness w ill be able to draw the Parliamentary Counsel's attention to this matter. If she is unwilling to do that on this Amendment, perhaps she will do so on the next one. Nevertheless, it would be for the convenience of the Committee if at this stage I withdrew the Amendment and returned to it at a later stage.

Amendment, by leave, withdrawn.

6.35 p.m.

Lord SANDYS moved Amendment No. 46:

Page 6, line 12, at end insert— ("() that no authorisation of any such accommodation or services under those provisions should be revoked so long as their use in that connection contributes (whether financially or otherwise) to medical or dental research;").

The noble Lord said: Amendment No. 46 was subject to a tied vote in Standing Committee in the House of Commons. This will be a somewhat wearisome and repetitive phrase which we shall repeat at regular intervals. But it is of great significance, for once again the situation will apply that your Lordships' Committee is considering an Amendment which is unlikely to be viewed again in another place. This Amendment is concerned with authorisations and their relationship to medical or dental research. There have been cases in the past, and mention has been made in the newspapers, of obstruction from planning committees for political reasons: the obstruction of authorisation for the constructing of hospitals or nursing homes, using administrative reasons as a cover. I believe that from the body of our knowledge in this field we can cite cases, but I will not do so because it may be provocative at this stage, unless the noble Baroness wishes me to.

It appears that to leave the Bill without this Amendment would be unsatisfactory for the future of medical and dental research. This is a field which I believe my noble friend Lord Auckland referred to as being of great importance. My noble friend Lord Colwyn is a qualified dentist in this field and has in the past contributed to debates on the dental situation. Medical research as conducted in this country at present is perhaps one of those fields in which this country excels. This also applies to dental research. But it can perhaps be said—certainly over the past 50 or 60 years, and long before that indeed; for, after all, Dr. Jenner was a citizen of this country and a resident of Cheltenham—that medical research owes much to particular innovations in both treatment and practice which have been evolved in the United Kingdom. It is self-evident I believe that this situation would suffer, and I beg leave to move the Amendment.

Baroness STEDMAN

Again I would be repetitive if I gave the same answer as to the last Amendment. But really the same kind of circumstances apply in this case as in the other. I think that the noble Lord opposite is getting unduly worried about the kind of experience that our doctors and dentists will use as a result of the revocation, because Clause 8, when we reach it, provides for the occasional admissions of private patients who need the highly specialised treatments. The same provision will also ensure that the contribution to training, resulting from the admission of the aliens to whom we referred on the previous Amendment, also comes in. This was raised, as the noble Lord said, in the Standing Committee. No doubt he has seen the letter which my right honourable friend Mr. Ennals sent to his right honourable friend Mr. Jenkin. If not, may I quote from it where he said: Following David Owens's undertaking during our debate in Standing Committee, I am writing to let you know the final outcome of our enquiries of area health authorities, teaching and boards of governors about the money transferred to research for fees received by whole-time consultants with honorary contracts for treatment given to them by private patients. The full returns confirm the impression we formed on the basis of the replies we received from some authorities by the beginning of August, that the annual amount transferred is relatively small, probably no more than £250,000 from all types of treatment. This compares with a contribution to medical research from trust funds of about £3½ million a year, and total central expenditure on medical research of over £40 million. So far as we can tell, and accepting hospital authorities' own assessment of the proportion of private patients whose needs were highly specialised and who it is presumed would have been eligible for admission under Clause 8 arrangements, the national reduction in the amount transferred to research funds when all pay beds have been phased out is unlikely much to exceed £50,000 a year. Even allowing for the possibility of over-reporting by some authorities of the type of case that may in future be eligible for a Clause 8 admission and for some possible under-reporting of the amounts currently available, the reduction would still be a very small proportion of the total research budget. These figures from the returns confirm…that the problem is not large and the way to deal with any consequences that emerge as phasing out of pay beds proceeds is through our current methods of funding research which are flexible. This shows that the Government are alive to the fact that research projects come and go, that money sometimes dries up before a project is finished and that there are funds available to it. The Government would be anxious to see that all the necessary research was still carried on.

Lord O'HAGAN

if the Government are concerned that the revocation of authorisations will, to however insubstantial an extent, affect research, and if it is a point which the Government take seriously, is it the intention of the Government that the Board will be able to take it into account in its deliberations? If the Board is able to take this point into account, as I hope it will, how will the Board be informed about the reduction of research facilities in particular areas or in groups of hospitals? What is the mechanism whereby the Board will be able to grasp the consequences of its research revocations and how will it take them into account in its activities?

Baroness STEDMAN

My understanding is that this would not be one of the responsibilities of the Board. There would have to be consultation on each individual research project as it came up. If it needed help, presumably it would have to go through its Area Health Authority and Regional Health Authority up to the Department. The final decision on how and if it could be helped would rest with the Department.

Lord O'HAGAN

If I may intervene again, does this mean that the Committee is to understand that if research becomes prejudiced through the revocation of authorisations there will be a departmental mechanism for ensuring that whatever shortfall there is will be considered and will be borne by the Department on the Vote that it gets from the other place for its normal work? Or will this come under one of the research councils? How will the money that is lost be made up?

Baroness STEDMAN

Each case would have to be considered on its merits. If the Government felt that there was no other way of funding a project which needed to be carried out, then they would find ways and means to fund it; but there is no assurance of this, if a project has died out, without an application being made to the Department and the Department considering the merits or demerits of the case put to them.

Lord PLATT

I think that is a terrible answer. A great deal of research is carried out by registrars during their term of training. Half-way through their training they may get a bright idea for which they want support from funds. How many layers did the noble Baroness say that they would have to penetrate? I was not quite sure, but the registrar would probably have retired before he received his answer.

Baroness YOUNG

Again I sympathise with the noble Baroness opposite who has been put into an extremely difficult position by having to speak at relatively short notice on these very complicated matters. However, my noble friend Lord O'Hagan has rightly drawn the Committee's attention to the fact that a great many problems are involved and I do not believe that the Government have faced up to them. If in our financial straits the noble Baroness and her colleagues can just write off £250,000 as being absolutely nothing, they have a most extraordinary conception of the world in which we are living. Money for research is of prime importance to all patients, both in the National Health Service and outside. If one looks at the great achievements in British medical science and research, surely nobody in this Committee would want to deny any funds that could be obtained from this source for such a worthwhile cause. We are told that we do not need to bother about this and that the Government will find the money from somewhere else. I am not suggesting that the noble Baroness is intending to mislead the Committee, but when the Government have told us on innumerable occasions that there is no more money for almost every project which is raised it is stretching our credulity to think that we can possibly accept such an argument.

There is a much more fundamental argument. I do not understand why the Government cannot accept these Amendments. If the Board look at the question and find that the phasing out of the beds will not interfere in any way with training or research, it can phase them out accordingly. I cannot see why the Board cannot have the responsibility for taking this matter into account. Above all, training and research arc going to apply throughout the whole of the health services, whether to private patients or to National Health Service patients. Surely nobody can want less good training for doctors or less good medical research into all of the terrible problems which still confront us.

Baroness ELLTOT of HARWOOD

I have listened with great interest to the debate and to the reply of the noble Baroness, and I am in agreement with the noble Lord, Lord Platt. If any research project has to go through the Department of Health and Social Security from bottom to top before any money is given to it, the registrar or young doctor who has had some bright idea and wants to get on with that piece of research will, as the noble Lord has said, have left by the time he receives permission to go ahead with it. This research might or might not lead to anything; one does not know. However, for that application to have to go all the way through this hierarchy right up to the Minister of Health seems to me to be absolutely crazy.

I understood that if a great doctor or surgeon in a hospital had under him somebody who he thought had a bright idea into which he ought to do some research, he could go ahead and get help from research funds: but if it has to drag through the machinery of the DHSS before anything can be done about it then the money, which we all know is in very short supply, will have been used up. Surely this is a very retrograde step.

The Bill is supposed to be forward-looking and very helpful, but every time we have a discussion it seems to me that we are going backwards more and more and doing things which we stopped doing when the National Health Service was first introduced in 1948. We are going to have to go back and do many things which were done away with then. For instance, we are again going to have the masses of private nursing homes and hospitals which existed before the National Health Service began. Now they will all have to be revived because of this foolish idea about separating the National Health Service from the private sector. Research is going to be hit very badly.

I find it very depressing to hear what the noble Baroness had to say, although no doubt she had to say what she was told to say. I dislike being told what to say and I prefer to challenge the people who do the drafting. There seems to be some kind of "sacred cow" about the draftsmanship of Bills. I have known Ministers who have torn drafts to pieces, produced far better ones themselves and paid absolutely no attention to the drafting. Quite honestly, what the noble Lord, Lord Sandys, read out just does not make any sense at all, and I only hope that the noble Lord and the noble Baroness will go for the draftsmen when this is over and will make them produce something which is easier to read and better to understand.

Lord SANDYS

I entirely agree with every word spoken by my noble friend Lady Elliot of Harwood and also by my noble friend Lord O'Hagan. We are in a very difficult situation here because at this particular stage, with this group of Amendments and with this complexity of language, it would seem inadvisable to divide the Committee on the issue. Nevertheless, I can assure the Government, and warn them at the same time, that we shall be returning to this particular part of the Bill on Report. I beg leave to withdraw the Amendment.

Amendment, by leave, withdrawn.

Lord STRABOLGI

This may be a convenient moment to halt the Committee stage for an hour in order to take other Business. I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.