§ 3.19 p.m.
§ Lord WELLS-PESTELL
My Lords, I shall not pretend that the measure to 1480 which I am asking your Lordships to give a Second Reading is not a controversial one. It deals with an issue on which sincerely held opinions have been deeply divided for a long time, and we on this side of the House recognise that there is a very deep divide between the Government and the Opposition and that it may well be that there is little, if any, meeting point between us.
But the issue is whether today it is socially acceptable to set aside in National Health Service hospitals accommodation and facilities to enable consultants to treat their private patients. When the National Health Service was established in 1948, the late Aneurin Bevan accepted as a means of securing the wholehearted co-operation of consultants in the new service that the practice of the former voluntary hospitals of setting aside a few beds for patients who wished to receive and pay for private treatment should, for the time being, continue in the National Health Service; that was the new National Health Service. Although he made it clear in his book In Place of Fear that he had not contemplated that it would continue indefinitely, the arrangement has in fact continued for the best part of 30 years. In that time demand for private treatment has diminished with the development of a comprehensive National Health Service. Increasingly, however, in recent years the co-existence in the same hospital of a small private sector and public provision of essential medical services has come to be regarded by many patients, and by a large number of people who work in our hospitals, as socially divisive, a source of serious grievance, dissension and, I regret to say, in some places, as your Lordships know, confrontation.
The root of the dissension and confrontation is the widely held belief that it is morally indefensible that those who can afford the high cost of private treatment or the cost of insuring against it, say with BUPA or one of the other provident associations, should be able to arrange for non-urgent hospital treatment sooner in the National Health Service than if, like the majority of patients, they had to rely solely on the National Health Service. In short, it is a widely held belief that the continued existence of pay beds has conferred, at the expense of the majority, an unacceptable 1481 degree of privilege on those who can afford to pay a premium for jumping the queue.
In the Government's judgment, access to a service that is financed by the community as a whole should not be influenced by any consideration other than the relative urgency of the individual patient's need for treatment. No one, my Lords, would dream of denying immediate access to the Health Service if life was endangered. Society as a whole recognises that where it is a question of life and death immediate access should be afforded regardless of a patient's means or financial circumstances, and all our arrangements for emergency services are directed to that end. In fact, 42 per cent. of all admissions to National Health Service hospitals are classed as emergencies.
Difficulty begins only where one is considering essential but non-urgent admissions. It is, I am afraid, a fact of life that demand for health care is infinite, and that ascertained need for treatment exceeds the capacity of available resources to meet that need immediately. In a perfect world no doubt, where resources would be unlimited, there would be no need for waiting lists, no need for queues. In the real world in which we live we have got to face the fact, whether we like it or not, that some rationing of health care is unavoidable.
One issue which this Bill seeks to resolve is how such rationing should be effected; whether a priority should be assessed in terms of clinical and social needs, or in terms of the individual's ability to buy a higher priority than his clinical condition really warrants. In the Government's view there can be only one answer in National Health Service hospitals: priority must he assessed on clinical and social need alone. The Government are satisfied that so long as it is possible for a patient to receive treatment privately in a National Health Service hospital, it will be difficult to ensure that that will happen, or to satisfy the public at large that ability to pay a private fee does not in some way influence the speed of admission.
The National Health Service exists to provide a comprehensive health service for all citizens, irrespective of their means. It is not, therefore, in business to meet the special needs of private patients. The 1482 fact that it has continued to set aside some of its resources for the benefit of private patients is regarded by many of the most ardent supporters of the Health Service as morally objectionable, socially unjust, and a potential source of abuse.
That view is shared by the Government, and that is why my Party laid the policy of separation before the electorate in the successive General Elections in 1974; a policy which the electorate endorsed twice. I need not remind your Lordships that the policy was strongly opposed by the medical and dental professions, and equally strongly supported by the representatives of Health Service staffs. No one, however, could accuse the Government of acting precipitately in this matter. For nine months after my Party was returned to power we tried in the Owen Working Party to discuss future arrangements for private practice with representatives of consultants. And what happened? We were told that they had no mandate to discuss private practice, but we continued to try.
I will not weary your Lordships by recounting the events which led up to the publication in August last year of a Consultative Document or of the discussions between the then Secretary of State and representatives of the professions—discussions in which the noble Lord, Lord Goodman, acted as an intermediary. I do not see the noble Lord in your Lordships' House and perhaps it might well be considered a piece of impertinence on my part to say how indebted the Government, and I think probably everybody in your Lordships' House, are to him for the part he played in what we have come to call the "Goodman proposals".
I do not think that it is going too far to say that the Goodman proposals marked a dividing line between a period of increasing dissension and confrontation in the National Health Service and a period of calmer counsels. I would not pretend that the Goodman proposals offer the perfect solution. I am sure that the noble Lord would be the first to admit that. They are essentially a compromise formula that recognises the deep division of view between, at one extreme, those who see advantage in the continued existence of private medical practice in the National Health Service and, at the other, those 1483 Who—quite frankly, like myself—see it as morally objectionable. They offer a formula for giving effect to the Government's commitment to separate private practice from the National Health Service, while at the same time providing for those who believe in private practice reasonable opportunity for making suitable alternative provision outside the National Health Service. They allow for the immediate phasing out of 1,000 pay beds, which I ask your Lordships to bear in mind are very little used, and thereafter for the pace of the phasing out of the remainder to be determined by a Health Services Board who will be quite independent of the Secretary of State. They lay down four basic principles for the guidance of the Board and provide for private patients to have access to National Health Service facilities for highly specialised treatment on an occasional basis and, a point to which the professions attached great importance, they provide for private practice to be guaranteed by legislation.
As I said earlier, the Government undertook, if these proposals were acceptable to the professions, to give effect to them in early legislation. The British Medical Association thereupon held a ballot of its consultant members and approximately 12,200 consultants in England, Wales and Scotland received the ballot papers. The ballot put to the consultants a rather severe dichotomy: Would you rather accept the proposals of 15th December 1975 as a basis for legislation or resign from the National Health Service? Out of 12,200 consultants, the British Medical Association received 7,039 replies; 63 per cent. of the 7,039 consultants were prepared to accept that the Goodman proposals should be incorporated in legislation. That means that of the 12,200 consultants, only 21 per cent., 2,604, were opposed to the Goodman proposals but, as I say, as a result of the ballot based on the Goodman proposals industrial action was halted and this Bill was prepared.
The Health Service Bill was introduced in another place on 12th April of this year. Since that date there have been almost continuous discussions of its provisions both within and outside Parliament. My right honourable friend, the Secretary of State for Social Services has had several meetings with representatives of the medical 1484 and dental professions. The Chief Medical Officer has had discussions with representatives of the Joint Consultants' Committee, the Department has consulted the Independent Hospitals Group on numerous occasions. There was continuous consultation up to 30th September with the National Health Service health authorities about the best distribution between individual Area Health Authorities and preserved Boards of Governors of the 1,000 pay beds whose authorisations are to be withdrawn within six months of the Royal Assent.
Simultaneously, from 18th May to 3rd August, through 29 sittings the Standing Committee in another place was scrutinising this Bill, not just clause by clause. I think the noble Baroness would agree with me if I said, word by word, line by line. There were something like 500 Amendments considered. They spent upwards of 70 hours discussing this matter. I only say this because I believe, my Lords, there can be few Bills so meticulously, so thoroughly and, let me be quite frank about it, so constructively considered. A number of highly important changes were made, with the Government's agreement, both during the Committee's consideration and also, as a result of it, at Report stage. So careful and intent was the examination of the Bill by the Committee that the Government yielded to the strong persuasion of honourable Members of the Opposition to grant two days for Report.
My Lords, there can be no doubt that this Bill has derived immense benefit from both the customary Parliamentary scrutiny and from the enormous amount of consultation with interested bodies outside. The Government wholeheartedly acknowledge that errors and weaknesses have been identified and have been eradicated. One of the major improvements, I would suggest, was the addition at Report of the provisions which will include the Health Services Board and its Committees among the bodies in respect of which the Health Service Commissioners are empowered to conduct investigations. So the Health Services Board will be subject to the authority of the Health Services Commission should the need arise.
The Board will, I think, gain in stature. Not only will it be fully independent, as 1485 the proposals brought forward under the aegis of the noble Lord, Lord Goodman, envisaged; it will also be openly required to maintain the high standard of administration required of bodies subject to the Health Services Commissioners. Moreover, the Board will, when acting in its quasi-judicial capacity under Part III of the Bill, also be under the supervision of the Council on Tribunals. Noble Lords, may therefore, be assured that both the administrative and the judicial integrity of the Board will at all times be subject to supervision.
Your Lordships may wish me to recapitulate the main provisions of the Bill. I do not propose, because of the time, to go into them in great detail. I know sufficient about your Lordships to know that many of you will have studied them in very great detail. The Bill as it now stands consists of four Parts (containing 24 clauses) with five Schedules. Part I and Schedule 1 deal with the constitution, status and method of appointment of the Health Services Board and its Scottish and Welsh Committees: they contain the important provisions which delineate the Board's relationship with Parliament, with the Crown (in particular with the Secretary of State), with the Health Service Commissioners and with the Council on Tribunals.
Part II begins with the declaration that consultants cannot be compelled by regulation to hold wholetime contracts, which would imply the loss of the right to practise privately. It goes on, in Clause 3, taken with Schedule 2, to require the Secretary of State to remove within six months of Royal Assent, the authorisation of 1,000 pay beds, distributed between the Area Health Authorities of England, Wales and Scotland in the manner set out in Schedule 2. Clauses 4 and 5 describe the way in which the Board must carry out its function to make proposals (which the Secretary of State must implement) for the revocation of authorisations previously given for pay beds and private out-patient facilities. Clause 6 lays an additional duty on the Board, to make recommendations to the Secretary of State for the best method of achieving Common waiting lists for NHS and pay bed patients requiring admission to NHS hospitals. The provisions of Clauses 7 and 8 are concerned with the new system under which patients who require highly 1486 specialised treatment which is not available at all, or accessible to them, in the private sector can be admitted, as private patients, to NHS hospitals on an occasional basis, and in carefully specified circumstances. The rights of general practitioners and others to preserve and make new arrangements with the Secretary of State to treat their private patients in health centres is also dealt with in Clause 9.
Part III contains the provisions for the setting up of a new system of control of some forms of hospital building in the private sector. The Board will have to operate that system. Developers of large acute private hospitals—that is hospitals providing over 100 beds if in London or with over 75 beds if outside London—will need to apply for authorisations from the Board before local planning authorities will consider an application from them for planning permission. These authorisations will be granted unless the Board is satisfied that the development in question would cause detriment to the National Health Service. Other acute private hospital developments will have to be notified to the Board (your Lordships will find that in Clause 14) but the Board will have no powers of control over these. The reason for the inclusion in the Bill of the notification procedure is that the Board must at all times—and it seems to me to be perfectly reasonably and will be acceptable to many of your Lordships—have adequate accurate information about all private sector developments of a kind likely to be relevant to the consideration of whether pay beds in a given area could be phased out. The four principles on which the Board must base its recommendations about phasing out pay beds include the existence or not of adequate alternative facilities in the private sector. I think most noble Lords will consider this to be of supreme importance.
Clause 19 makes a link between the Bill and existing nursing homes legislation under which at present private nursing homes and hospitals are registered by health authorities and are supervised for the quality and standards of the facilities, accommodation and staffing. The clause amends the nursing homes legislation, so that an additional ground for refusing orcancelling registration would be, in the case of a new development of the kind requiring an authorisation from the Board, the contravention by a 1487 developer of the requirement in Clause 12 to obtain an authorisation before building a private hospital. These Amendments also raise the penalty for carrying on a private nursing home or hospital without being registered from a maximum fine of £50 (which has been in existence at that level since 1936) to a maximum of £400 on summary conviction or an unlimited fine on indictment.
My Lords, I think it must be clear now, I hope beyond doubt, what are the aims of the Government in bringing forward the Health Services Bill. The care with which the independence, the rectitude and the balance of the Health Services Board have been attended to, cannot but lead to the evolution of a rational, just and methodical approach to the task of phasing out pay beds from National Health Service hospitals. There will be nothing hasty and nothing arbitrary in the way in which this is done. Similarly, in the testing and delicate field of considering applications for authorisation for the building of large acute hospitals in the private sector, the obvious standing and integrity of the Board must have its effect on the way in which these decisions are made.
In other places, there have been misrepresentations of the Government's intentions. I believe that some of these have been quite deliberate because the Bill itself is explicit, and the Government have explained time and again the reasons for the provisions of Part III. The Bill cannot and does not empower Ministers to squash, squeeze or hustle private practice out of existence; that is, out of the private sector itself—out of the National Health Service, yes.
Since the first announcements of the Government's policy, during the spring and summer of 1975, and increasingly since the publication of the Bill, the Department has kept itself as informed as possible about actual and planned increases in the amount of hospital provision in the private sector. I want to say something about that because I think it will surprise a good many of your Lordships. We know, for example, that between the spring of 1975, when the Government's policy was first announced, and the expected end of the "initial period", that is May 1977, about 300 new 1488 beds for acute treatment in the private sector will have become available in London alone. This will bring the total number of private sector beds for acute treatment in London to approximately 2,000, almost half of the total number of such beds in the whole of Great Britain. In addition, we are aware of a number of well-advanced plans for further expansion of the number of acute facilities in the country. All we say is that for obvious reasons if it is a hospital of over 75 beds outside London or over 100 in London the Secretary of State must know what these developments are for.
I trust that the Government's assurances of good faith are not going to be viewed with suspicion by your Lordships. We do not desire or intend to do anything further in the matter of private practice than carry out the provisions of this Bill; we do not therefore have plans to abolish private practice. Our aim is to foster harmony between the people who work in the National Health Service and who work in the field of health for the people of Great Britain.
We sincerely hope by this Bill to remove a long-standing source of bitterness, anger, frustration and disruption, and to get back to the most important thing; namely, the care of patients. It is because we are concerned with the care of patients, particularly those who have to use the National Health Service, that we have brought in this Bill. My Lords, I commend the Bill to you and hope that you will give it a Second Reading.
§ Moved, that the Bill be now read 2ª.—(Lord Wells-Pestell).
§ 3.49 p.m.
§ Baroness YOUNG
My Lords, I should like to begin by thanking the noble Lord, Lord Wells-Pestell, for introducing this Bill to us today and for explaining so clearly its purpose and its background. It is always a pleasure to work with the noble Lord, Lord Wells-Pestell, and on many occasions in the past we have found ourselves in complete agreement over a great many things, but as he himself has indicated it will not be the case on this Bill which is a highly contentious measure. I regret to say that the only congratulations I can offer him are offered because he has made the best of a very bad case. At the start I should like to offer my good 1489 wishes to the maiden speaker this afternoon the noble Lord, Lord Stone, and to say from this side of the House that we wish him well.
The Bill before us is important. It comes to us at a very late time in the day. As I understand it, it has only just managed, with one day to spare, to avoid being caught by the Parliament Act. I believe a month is required from the First Reading to the end of the Session, and in fact the Government have allowed one day over that time. However, I find it astonishing that the House of Lords, whose prime function is as an amending Chamber, should have so little time to consider a Bill which must inevitably affect all patients in the National Health Service in hospital now, a Bill which has been subject to a great many tied votes in Committee in another place and one on which finally the guillotine fell.
It comes to us at a time when the House seems to have been in almost continuous session since September, and many Members of your Lordships' House must feel that enough is enough. It seems to me that all the more deplorable such an important Bill should arrive here so late and with so little time for debate; for, despite the fact that the Bill has been looked at very thoroughly by another place, there area great many detailed points to which we shall want to return on Committee; and quite properly we should return to them on Committee. I cannot accept the reason given by the noble Lord that at two Elections the population voted for this measure. He will be as well aware as I am that only 28 per cent. of the population supported the Labour Government in October, 1974, and to claim by any stretch of the imagination that most people want this Bill is simply wishful thinking.
The fact is that although the Bill is entitled "Health Services Bill", it does absolutely nothing to help the National Health Service patient or to improve his care. I listened with great care to what the noble Lord said in making out his case and I cannot see that he advanced one single practical way in which the ordinary National Health patient will be better off when this piece of legislation reaches the Statute Book. I have looked very hard for evidence to find out how this Bill would make the care of a patient 1490 better. It is because I have been unable to find any at all—because I do not believe any exists—that we on this side of the House are opposed in principle to it.
The noble Lord, Lord Wells-Pestell, has explained the Bill, which does, broadly speaking, two things. First, it phases out 1,000 pay beds from the National Health Hospital Service; secondly, it introduces new controls over private hospitals, their building and maintenance. By the separation of the Health Service and private practice it created a kind of medical apartheid.
I am sure that no one wants the care of the National Health Service patients to decline. The doctors do not want it and I am sure the trade union leaders and their members do not want it; nor do the Government or the Opposition. At first sight it may be contradictory to say that we believe that National Health Service patients will be worse off because of this Bill; but so often is it the case that the full effects of a piece of legislation are not appreciated at the time that that legislation is going through the House. It seems to me therefore worth while to consider what will be the practical effects of this piece of legislation on the Health Service.
The first effect must he on the doctors, and because of that, its effect on the patients. I do not come from a family of doctors; but all my family have been engaged in the professions, particularly in education. The fact is that in the education world, if you get a good head of a school he or she will attract and will appoint good staff. The pupils, as a consequence, will be well taught. So it is in medicine: the quality of the service is measured by the quality of the staff. We in this country have, rightly, been proud of the National Health Service, which has been in many respects the envy of the world. It is the present generation of consultants and others in the Hospital Service who have to a very large extent given the National Health Service the reputation that it has. One consultant who came to see me put it to me that he was glad in 1948 to join the National Health Service. Before the National Health Service, medicine was not always an easy profession to enter, especially for a young man or young woman starting out. 1491 The introduction of the National Health Service meant that it was no longer necessary for a doctor to see enormous numbers of private patients in order to make a living, and that the staffing of the hospital was geared to the needs of the population and not dependent upon a generation of need by private patients. There were therefore great advantages to the doctor in joining the National Health Service; and beause there were great advantages to the doctor, there were great advantages to the patient, and a bargain was struck.
It is no exaggeration to say that many consultants have worked far more than the hours they are obliged to work by contract, and many will work as much as 30 hours a week over and above what they are obliged to do, because they believe in the Service. Part of the bargain was that they should be allowed private practice and that they should be allowed private practice in hospitals. The consequence has been, whatever the noble Lord, Lord Wells-Pestell, may say—and I do not doubt for one minute his sincerity—that they feel that this trust has been broken. The argument for taking the private beds out of the National Health Service hospitals is that somehow the doctors are doing something that is morally wrong.
What is being said—and all that the doctors are asking for—is the right to sell their skill in the market place after they have fulfilled their contracts, and frequently more than fulfilled their contracts, to the National Health Service. This, after all, is not a surprising request. If a plumber or an electrician works in the evening or at weekends in his own time, taking private clients after he has fulfilled his contract to his employer, what has he done that is wrong? If the teacher in his spare time coaches a backward child with reading difficulties and gets paid for it, is this a crime? Indeed, if the university lecturer lectures to the Workers' Educational Association two evenings a week, what is this but a form of private practice? Nobody is suggesting that any of these people who do things quite properly in their own spare time are doing anything but something which is a help to the community at large; and if it helps themselves in the process, there is nothing morally wrong with that at all.
1492 The fact is that many doctors see this Bill as a step in the direction of a full-time salaried Service, of a Service in which there will not be the freedom to practise medicine privately after fulfilling their work in the National Health Service. Everybody must realise that if this came to pass the care of the patient would inevitably deteriorate. What such a full-time salaried Service would mean is that minimum standards of care would be set, and not maximum standards, and so the patient would suffer. I cannot believe that this is the intention of the Government.
The noble Lord, Lord Wells-Pestell, has explained at length those parts of this Bill which have been written in to guarantee the right of private practice to doctors. But what are people to think? All sorts of guarantees were given in 1948. Legisation cannot guarantee because we cannot bind our successors; and what, above all, is needed is trust. That seems to be one of the most important things that is missing at this time.
The centre of my argument is that, as a result of this legislation, it is the patient who will suffer, and I should like to consider in detail a number of other points. The first is the question of finance. We are all agreed that we are in a time of economic crisis when money is scarce. I am not sure what the final sum is that it is accepted that private patients contribute to the National Health Service, but in the last figures I saw it was generally thought to be about £23 million a year. This money will of course be lost, and it seems to me very difficult to argue that when £23 million is going to be taken away from the National Health Service, National Health Service patients will be better looked after.
Secondly, what will happen to the pay beds when they are phased out? We must have an assurance from the Government that they will in fact be used for National Health Service patients. It is disturbing to learn, for instance, that at University College Hospital 24 pay beds have been phased out and the accommodation is now used for administration. As the Bill stands there is no guarantee at all that these beds will be used by patients in the National Health Service, and if this guarantee is not given, there can be no shortening of the National Health Service queue—if that is the aim 1493 of this Bill—and the position will remain precisely as it is now. As I see it, the Government's difficulty about giving such a guarantee at present is that it would undoubtedly cost the Service more money, because the money which paid for the beds and paid for the staff will not be there. The Government will have to find the money to pay for the beds and to pay for the staff, and it will find it difficult to do that with a background of the July cuts, when the National Health Service and the personal social services were asked to lop £70 million off their expenditure.
I find it exceedingly difficult, therefore, to see how having less money for the Health Service is going to help the National Health patient. By phasing out the pay beds from the hospital system and by replacing them with private nursing homes or private hospitals, it will be necessary in many instances for consultants to have to travel some distance to a private hospital or a nursing home to visit their private patients. That means inevitably that the consultants will have less time altogether to care for all of their patients. It is perfectly true that Clause 8 of the Bill sets out the terms under which the private hospitals are to be set up and indicates that they must be readily available for the patient. But it is equally important that they should be readily available for the consultant. There arc, after all, only 24 hours in a day, and if much of that is taken up by travelling then clearly there will be less time for all the patients—less time for the consultant to discuss his National Health Service patients with junior doctors. This will become inevitable, sooner or later.
The fact is that at present the overwhelming majority of consultants who work part time for the National Health Service—by which is meant nine-elevenths of their time—are able to do a great deal of extra work for their National Health Service patients because they are in the same building and can go from one to the other, seeing their National Health Service patients in the evenings. I cannot see that the National Health Service patients will benefit if consultants have altogether less time.
My Lords, modern British medicine is much respected all over the world. British standards of medical education are high 1494 and there is an international market for the skills of British doctors. In December, EEC regulations will come into force allowing a much freer movement of doctors within the European Economic Community. If doctors and consultants feel dissatisfied with conditions in this country they will emigrate, and it is distressing how many have already done so. For the reality of the situation is that emigration today does not mean going to the other side of the world and leaving one's family and relatives here for very long periods of time; it means working in Paris, or Holland, or Germany—in some cases no further than moving to a different part of Great Britain. In so going the doctors would find themselves going to societies that want them, respect them and appreciate them. Emigration is not simply an empty phrase but a reality in front of us all, and I cannot see how the National Health Service patient will benefit when large numbers of doctors emigrate if they feel that they are under threat in this country.
There are many other points that I should like to make but there are a number of other speakers and we shall have an opportunity to go into these points on Committee. Among the many matters that we need to discuss is the right of an individual to spend his own money as he chooses. If, after he has paid his taxes, he wants to spend it on a doctor of his own choice, why not? If a woman wishes to see a woman consultant of her own choice, why not? It may well be that if the doctors feel deeply disturbed, these rights of individuals will gradually disappear, not just through this legislation but because of what is implied behind it. We shall want to look carefully at the terms of reference of the Health Board and its composition and whether its freedom is guaranteed. It must be possible to see that it is impartial. We shall need to consider the problem of private facilities for anyone living in a new town, which at the moment seem to be almost an impossibility.
I am sure that we shall all listen with great interest to the speech from the noble Lord, Lord Goodman. We appreciate the work that he has done to bring about a compromise in a very difficult situation, and I am sure that he will know as well as anyone that what is needed now is trust and that we have somehow to 1495 establish trust, because if we do not, all patients will suffer. I believe, however, that we need more than to establish trust. Nothing could better illustrate the ills of our country today than the situation that now exists in the Hospital Service and, if I may say so, the reasons that the noble Lord gave for having this Bill. We, as a country, have got to learn to live together; otherwise we shall die by a series of self-inflicted wounds. The internal fights going on in the Health Service are damaging the doctors, damaging the patients, are damaging the country. Sooner or later all of us are going to require medical services, and it is a terrible thing that we cannot find a way out of these difficulties. For our part, we shall do what we can to be constructive, to try, in what is a very difficult situation, to make matters better than they are now. It is not our intention to vote against the Second Reading of this Bill or in any way to be obstructive.
I should like to conclude in much the same vein as the noble Lord, Lord Wells-Pestell, for it seems to me that what we should be talking about today are the real problems of the National Health Service: the need for extra money; the problems of health care in an economic crisis; the problems of an ageing population, when even now 40 per cent. of all National Health Service beds are occupied by the elderly and when the largest growth in our population is of those over 75 years of age; the problems of staffing in mental hospitals, and the relationship between the National Health Service and the personal social services. These are very big issues calling for the undivided attention of Parliament, of Ministers and of civil servants alike. It is to these problems that we should be turning our attention and not to this unnecessary and unwanted Bill.
§ 4.8 p.m.
§ Lord AMULREE
My Lords, I should like to join the noble Baroness who has just spoken in thanking the noble Lord, Lord Wells-Pestell, for the very good and clear way in which he explained this not entirely uncomplicated Bill to us. But as that is the kind of thing we have come to expect from the noble Lord, I am not really surprised at how well he did it. Before I came into this Chamber to speak 1496 this afternoon I looked up the preamble of the National Health Service Act which was introduced to help the sick, and it says:It shall be the duty of the Minister … to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people in England and Wales and for the prevention, diagnosis and treatment of illness…My Lords, that purpose was carried out very well in the Health Service when it first came in, and it went along very satisfactorily for a long time. Then we had the Bill which was introduced by the Party on my left for the reorganisation of the Health Service, and so far as I can make out that did nothing, or nothing appreciable, to help the care of the patient. It was a great managerial revolution, but that is about as far as it went. Now we have the present Bill coming along and, in spite of what the noble Lord has said so kindly and persuasively, I cannot see that it is going to be any help at all to the patients in the National Health Service. Therefore we have not got much "for-rarder".
I will begin by saying that I have no particular feeling myself either for pay beds or against pay beds. I have used them extremely rarely and that was for geographical and topographical rather than for ideological reasons. I think I admitted only two patients into the private beds of University College Hospital where I was on the staff; and one of those, I must say, was admitted at the urgent request of Transport House for a senior member of the Party opposite who was in need of medical care. That was in the happy days before there were bodies called by curious names, like NUPE, COHSE, and NALGO, with whom I have been associated for a very long time. Therefore I am not really a person who uses the pay beds; but there they are.
I remember once dining out privately in the company of Aneurin Bevan—that was shortly after the Health Service had come into being and we were talking about it in a general kind of way. He and I were both agreed that one of the really good things, among many others, that it had done was to have got rid of quite a lot of expensive and not very well run nursing homes, because the patients who would have been in them got into the private wards in the National Health Service 1497 hospitals. That must have been about five or six years after the Service had started; I am sorry that I cannot remember the exact date.
Therefore, I can see no real reason now for trying to phase out permanently the pay beds and I would agree entirely with the approach that if they are not wanted for paying patients they should at once be used for National Health Service patients. The noble Baroness referred to the sad fact that one of the floors of the private patients' wing at University College Hospital now has become the offices of the Area Health Authority. It is therefore lost to patients. I assume that that was the result of the National Health Service Reorganisation Act. I do not think that it has anything to do with the Bill in front of us now. I would very much hope that that kind of action will not be taken again and that if beds are not required for private patients they will be used for Health Service patients and not for administrative offices.
My Lords, one is not quite sure of what is the gain in money to the Health Service from the private sector. Perhaps the noble Lord when he comes to reply will be able to give me some idea. I have seen figures of between £20 million and £40 million, although I should have thought it was probably more likely to be the lower figure. Supposing that money were to continue to be available—and because it is going to be taken away I am going to regard it as money that could be used for something different and new—one wonders whether the sensible thing to do with it would not be to increase the number of people working in the National Health Service hospitals—particularly the mental hospitals and, particularly, those mental hospitals that take care of elderly patients. One has seen in the Press several accounts of troubles and disturbances and of things that go wrong in these hospitals. I am quite sure that the main reason for this is lack of staff and not lack of good will. That it can be the latter, I would not believe for a second. You do not need to have your hospitals fully staffed with trained nurses. Provided that you have a few good trained nurses in charge of the wards or departments they can make use of partly-trained people of good will to do quite a lot of the care and work that needs to be done in these hospitals.
1498 My Lords, that is where I should like to come back to the pay bed question and to refer to the strange tale of the amenity beds. These were mentioned in Section 4 of the National Health Service Act, the provisions of which would allow hospitals to use single rooms or small wards to provide accommodation for people who wanted them—provided they were not needed urgently for general medical purposes—on the payment of a relatively small weekly charge. These never get mentioned, so far as I know, in all the discussions that go on—and I am pleased to see that the noble Baroness, Lady Lee of Asheridge, agrees with what I say. It has always seemed to me that that was one of the weaknesses in the pay bed argument; that there were these amenity beds available which could be used on practically every occasion if they were required. One wonders whether their number is going to be increased or whether they are gradually going to fade away. I am not quite sure what is to become of them.
I am pleased that there is no intention to abolish private practice because, speaking purely as a consultant, I have found that to have a little private practice, one which was not big enough to make any appreciable financial return to myself, was extremely good for me from a training point of view. It made one think. For example, if I had been a full-time employee of University College Hospital and an elderly patient had come in, he or she would have been seen by my registrar or houseman or someone like that. It would mean that I came in at the end to give the final diagnosis, if I possibly could, or say something; whereas, in private practice one can get called out by a GP (and I can quote several cases like this) to a flat on the top floor of a converted house to find an elderly couple living by themselves, aged, say, 75 and 73, one of whom has had a stroke and the GP wants to know what to do. Unlike the hospital situation, you have nobody to call upon. You have to make up your mind; you have to think about it. I am sure that my friends in this House who are consultants will agree that it is a good thing for consultants to be made to think from time to time—it is very easy not to.
I now come to the question of waiting lists. I have always been rather sceptical about them. I agree that they are 1499 probably longer than they should be, but I wonder whether anyone has made a genuine inquiry into waiting lists and found out the number of patients kept waiting because it was more convenient to them as they wanted to settle their business affairs, and so on, before going into hospital; or, in the case of children, whether it was more convenient for them to go into hospital during the school holidays. So waiting lists pile up in a very odd way.
Then one finds that quite a number of people tend to be on the waiting lists of more than one hospital. I remember that when I first began to work in the geriatric department of University College Hospital we had a long waiting list which, luckily, was from a comparatively circumscribed area. The only way to find out what to do was to visit them all. One found that a certain number had died, a certain number were on the waiting lists of more than one hospital, and a certain number were not at all suitable for hospital and ought to go into a welfare home. So it did not take very long before that rather formidable waiting list vanished away to normal, workable size, and I wonder whether there could be a similar inquiry on a big scale. It would be an expensive operation, but it might save a great deal of trouble.
Finally, I should like to refer to what the noble Baroness, Lady Young, said about the waste of consultants' time if pay beds are moved from Health Service hospitals into private hospitals. It will mean that a consultant, whether male or female—I do not mind what sex a consultant is—has to travel a long way to see patients, which in London takes a very great deal of time. Whereas, if they are working in the same building, the private patients and the National Health Service patients will see their consultants for a longer time than if they are merely working regular hours—although I agree that most of them work considerably more than their official hours—and they will not be able to give so much time. Therefore, I am lukewarm about this Bill, which seems to me unnecessary, and the advantages of getting rid of unwanted private beds could have been achieved in a far less traumatic way than is proposed.
§ 4.23 p.m.
§ Lord GOODMAN
My Lords, I regard it as a considerable privilege to be enabled to address your Lordships this afternoon, and to say a word about a matter in which I was very much involved in time and effort some months ago. May I first say this? Perhaps I may be permitted, in relation to explaining my personal position, to incorporate in my speech two brief extracts from a letter that I wrote to The Times in April this year. I said—and here I am wholly in agreement with the remarks of the noble Baroness, Lady Young—that:I have already expressed my own view that the restoration of real confidence will only be achieved if the Government indicate a proper sense of values as to which voices are to have the Greatest influence. A medical service must be guided by informed medical views and it is imperative that doctors should feel that this is the spirit in which the present proposals emerged and will be operated. That does not mean that other views enjoy no relevance.The other extract which I should like to quote is this:The new Secretary of State has a grave and ever terrifying responsibility to restore tranquility to a profession which traditionally wishes to get on with its job. But he also has an historic opportunity. What he says and how he says it will to a considerable extent determine the matter. He must convey to the doctors that he understands their feeling that the profession cannot be restricted to State employment and retain the independence of action and judgment towards their patients about which the struggle s largely concerned. I believe he does recognize this and I hope indeed that he will succeed in conveying this recognition in sufficiently generous and reassuring terms to end this dangerous conflict.The tone and atmosphere in which the debate has been conducted this afternoon have been, in my view, exemplary. I think they create a situation and background in which, with a little luck, the whole of this unnecessary dispute can be resolved. Perhaps I ought to say this. I have not come here to urge these proposals on your Lordships. There is an honourable arrangement. If the medical profession contrive to defeat this Bill, they are regarded as entitled to do so. This assurance was given to them by the former Prime Minister, in my own hearing, in the clearest possible terms. I have come here to say—and to that extent I am prepared to take a partisan view—that I think it would be a mistake if they defeated this Bill. I say that for this reason. I wholly agree with the 1501 noble Baroness, Lady Young, and the noble Lord speaking from the Liberal Benches, that this Bill will not do anything to assist the patient. But I would ask the House to take into perspective, and into proportion, the nature of the problem.
We have, I believe, something like 400,000 hospital beds in the United Kingdom, and we are dealing with 4,000 beds—1 per cent. That is the extent and nature of the problem in terms of beds. But one also has to take very much into account the consideration that those beds are at the moment extremely expensive. They are not available to the great majority of patients, because of their cost. A much more urgent necessity today is to make provision for solitude, to make provision for privacy, to make provision for the things that a lot of people need and require on a mass scale, and these cannot be provided by dint of 4,000 beds out of 400,000.
What I would venture to say to noble Lords on the Opposition Benches is this. The importance of this Bill is not to provide additional facilities for National Health Service patients; it is to reassure doctors that private medicine will remain in this country, and remain indefinitely; and the importance of that cannot be exaggerated. It is to make the doctor, whether he is employed full-time in the State service, whether he is employed part-time in the paid service, feel that he has a liberty of choice if he wishes to take it. It may be a very limited field of choice, in terms of the availability of offices and appointments. But the fact remains that preservation of that liberty of choice makes him continue to feel that he is a free man operating in a free country; and that is very largely what the trouble is about.
The doctors suspected, and with justification—not with cause; I do not think their suspicions were well founded, but they were rational because of what was said and because of an unfortunate Consultative Document—that they were going to be squeezed at both ends. They suspected that the phasing out of hospital beds, accompanied by additional restrictions on the licensing of private beds, would mean the end of private practice. That was the suspicion entertained by all of them which it was impossible to dispel. I think it would be unreasonable if the doctors today, in the light of these 1502 recommendations, continued to maintain their suspicion. One of the most unfortunate parts of the whole matter is that suspicions are not easily dispelled. They remember the Consultative Document.
The noble Baroness herself said—and I think she might reflect, having regard to the generally conciliatory and helpful tone of her remarks—that it is not much use legislating at all, if one is going to take the position that that legislation can be repealed, revoked or amended by a subsequent Government. We must take legislation at its face value. It is no use saying that we have suspicions, doubts and misgivings about what people will do in the future. If we do that, then no action taken by anyone can ever be reassuring in a troubled situation of this kind. Also, I think it is important to remember that these proposals were not very acceptable to or very well loved by the Government. They have been accepted as a compromise proposal.
The Government's problem was a very real one. I do not know how well they handled it, or how ill they handled it. But their problem was that they had a number of people, who I do not think had any right to behave as they did, in key and crucial positions in hospitals, who were making what I consider to be unjustified and unreasonable demands. However, it is not much use saying that the demand is unjustifiable or unreasonable if some threat to the personal comfort of the patient and to the continuity of the health scheme can be maintained, and the Government have to deal with the situation.
I have no comment to make on how well or how ill they will deal with it, nor do I wish to say that if I had been asked to recommend what to do in the situation before the trouble started I should have said that any such legislation as this was necessary. In the light of the minute nature of the problem—the 4,000 out of the 400,000 beds—and in the light of the fact that in most parts of the country there was relative tranquillity, there was no reason why things should not have been left alone, but for some reason, and the history is well known to many of you, the situation arose where, things not having been left alone, an increasingly corroded atmosphere arose to a point where great numbers of consultants went on strike.
1503 In this country the medical profession is very largely a splendid and a great profession. We are doing remarkable things here which ought to redound more loudly than they do. To take an instance, the EMI scanner was invented by a young man who refused to take any personal reward for the royalties that came from the scanner; he insisted that the money should be put back into a fund for research. That is the kind of spirit which should till us with great pride and pleasure when we hear that it is happening in this country. There have been other discoveries. We were prominent in the development of the kidney machine and we now have an experiment with a new liver machine whose aid and assistance is sought all over the world. I could multiply considerably these details.
Our profession is one of which we can be proud and it should be a source of shame to all of us that the profession was nearly brought to a standstill by a relative trifle of this kind. I say "a relative trifle" in relation the the number of beds, their utility to the population at large and to the fact that the most was made of the difficulties, not because of the real issues but because the medical profession suspected, and suspected with justification if not with cause, that an attempt was being made to phase out private medicine. It would be the highest degree of folly in relation to the medical profession that the suspicion should be allowed to be maintained by doctors that private medicine is in peril.
As I have said before, and I do not apologise for repeating it, I believe that private medicine is indispensable for a healthy medical profession in this country. That does not mean that all our efforts and attention should not be concentrated on the real question of how to give an adequate medical service to the great number of people who are now without it at all. Some of them are rich people. I am inclined to believe that the rich are the worst doctored section of the community. They listen to every kind of nonsense that is talked, they consult every kind of doctor who has the most dubious qualifications and they end up in the cemetery long before anybody else. I strongly recommend rich people to take advantage of the specially established medical advisory service that will give 1504 them, free of charge, a list of addresses of honest, decent, simple doctors who can look after them.
However, that is not the issue before the House this afternoon. The issue today is for this House to consider whether, having regard to all the circumstances, it would be sensible to seek to defeat this legislation, remembering that it is legislation—I make no bones about it—that we could well have done without in different circumstances. It is legislation whose only utility is that it has resolved the problem that caused a great number of doctors, men to whom such behaviour was totally alien and contrary to the tradition of generations and centuries, to go on strike.
I know from my conversations that the great majority of consultants who went on strike were profoundly uneasy and unhappy; they did not think that it was right that they should go on strike, because it went against a tradition and they did not like the notion. However, they said to themselves, and it was difficult to answer, "What are we to do? How are we to achieve what we want if we do not take the same industrial measures as are available to the rest of the population?" It was no use putting to them what I regard as the total answer: "It is not available to you to take such measures. You have entered a profession which is akin to Holy Orders, a profession where you do not have the choice of undertaking industrial action in order to support material claims for your livelihood. You must leave it to the rest of the community to rate you properly." A society where the efforts of doctors are not rated properly and a society which sees that doctors do not get their proper return is one which deserves the kind of confusion that has operated here.
I have not come here to reproach doctors for considering industrial action. I have come here to say one thing only: that in my view the medical profession, in all the circumstances, is much more likely to be withdrawn from the political arena, and that there is much more likely to be peace and tranquillity if this Bill is passed into law than if, once again, the whole question is thrown back into controversy. That is the real merit of the Bill.
There are all kinds of points that I could raise, and I could carry on for hours 1505 but I will not. For instance, 1,000 beds are to be phased out immediately. I do not think that it is a matter of dispute that the experts, with whom I have had long discussions, have all agreed that something approaching 1,000 beds were redundant and unnecessary. The basis upon which the agreement was reached was that they had said, "We do not need these 1,000 beds; we can do without them." There has been argument and discussion, as the noble Lord speaking for the Government said, in immense detail about where the 1,000 beds should come from. Happily, I have not been involved in those discussions. I believe that a substantial measure of agreement may have been reached already, but that there was a considerable number of surplus beds was a matter of general agreement.
Nor is it quite true to say that the Bill is resolutely opposed by the entire medical profession. In private conversations with doctors one finds that there are great numbers—I would not presume to say a majority or a minority—who see the end of this dispute as the happiest thing which could happen to them in many years. They can historically maintain their grievances. At medical dinners over the years they can explain how it came about, how wronged they were and what misfortunes they have suffered; and that I think they are entitled to do. It is a very small return for the discomforts and irritations that they have suffered during the course of the negotiations. However, I do not believe that there is universal hostility to the measures, and I believe that a great number of people would willingly support them on the basis that it is the end of the battle, and that it will enable doctors to get on with the valuable and important work with which they are concerned.
One of the real problems has been that doctors are sturdy individualists. To get doctors around a table is one of the most interesting, frustrating and irritating operations that any human being can conceive. To find two doctors in agreement on anything is a near impossibility; to find three doctors in agreement is a total impossibility. To find a doctor who does not wish to express a view on a highly political matter is also a near impossibility. They will agree about the things that they know about: about remedies, prescriptions, operations and so on. But when it 1506 becomes a matter of medical politics, fortunately they have had no experience of the matter. They continue to do their work alone in their surgeries over the years.
May I make a few more specific observations about the Bill. I believe that the Bill represents pretty fairly the proposals that were put to the Government. I think that the Government have quite honourably discharged their obligation to produce proposals which were in conformity with the arrangements made to end the consultants' strike. Equally I say, as I did at the outset, that the Government and the doctors are absolutely entitled to urge your Lordships' House to reject the proposals in total.
I should like to see another ballot because I believe that that ballot said more than that the doctors were merely approving those proposals as a basis for ending the strike. I think they were expressing very general agreement that the proposals, for good or for ill, were better than they had been offered and that they might be wise to accept them and call it a day. In that respect, may I quote from the British Medical Association's own letter when they sent the proposals to their members. They said:Clearly it is difficult to assess the validity on the one hand of the assurances given by the Goodman proposals and on the other the anxieties expressed in debate that so much remains a matter of individual interpretation and, so far as implementation is concerned, a matter of good faith".I could not emphasise that too strongly. The letter continues:If the proposals were to be implemented as intended by Lord Goodman, then a significant measure of protection for the future of the independent practice of medicine would be achieved. If, however, the proposals were to be distorted by Government and Lord Goodman's aims were not to be preserved, then there is no doubt that both private practice and the independence of the profession would suffer.That is an objective and fair statement of the position.
If the Government continue as they have begun by enacting the proposals in a decent and honourable form, subject to some Amendments which seem to me might reasonably be called for, if they maintain that spirit and if, again and again, they will assure the profession, as the former Prime Minister did, that they have no intention whatever of attacking the continued existence of private medicine but 1507 intend to allow it to continue to exist side by side with the National Health Service, I think that we might in the end find that something rather good comes out of the whole of this unfortunate matter. That is my belief. I think that might well happen.
If the Government distort the proposals, if they allow people who are not doctors to have an undue sway in medical matters, if they allow situations to arise where patients can regard themselves as being at risk because they are private patients, I think there will again be trouble because the consultants have discovered that they have a muscle they did not previously think they had. If I may say so, it is a sorry discovery and it would be better if they had never discovered it, but I do not think they can be blamed for it. The fact remains that the day when the first doctor went on the first strike was the day when we ought all to have been alerted to the very real danger to this great profession which is so crucial to all our needs.
I should like to conclude by making just a few observations on matters in the Bill on which I think possibly there is need for reassurance. The first is, as I think was introduced by the noble Baroness, Lady Young, that there is a provision in the Bill that private medicine should have accessible and available to it facilities in National Health Service hospitals for specialised operations, so that if a specialised operation is required by a consultant he can use the National Health hospital if it is available, use the equipment and use his team, and in a sense that is a much greater assurance than has existed in the past in relation to these matters. But the wording is a little ambiguous and as there is a considerable degree of mistrust and lack of confidence I think it behoves the Government to see that in any case where there is ambiguity they should not seek to rely on the preferable interpretation which they think removes the ambiguity. I think they should accept an Amendment which enables one to point out to the most controversial and political of doctors and say, "Nothing on earth can make this mean anything except this and that". I think this is most important when dealing with the medical profession.
In the particular matter with which I am concerned there is a provision that these facilities should be available—I think the 1508 wording is "at a hospital accessible to the patient". It has been pointed out, validly pointed out, that this would be not only unreasonable but rather foolish. If there is a busy consultant in London and he has a patient in Bradford or in Newcastle it is an absurdity to suggest that he should travel to Bradford or Newcastle to carry out an operation with a brand new team of people, with equipment with which he is not familiar and in unfamiliar surroundings. I think this will be a very small concession to make, and I have a feeling from a conversation that I had with the Secretary of State—and I should like to pay a tribute to him, if I may, because I think from the outset he has approached this matter with a desire to restore confidence—that this was an arrangement he would like to accept.
There is another matter which concerns the profession and I think it is one where they are straining interpretation. It is on the nature of the alternative accommodation that the hospital board can accept as justifying the phasing out of a bed or two—or three or four. The Bill contains a provision that that accommodation shall be reasonably suitable. 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. If the restoration of a little confidence can be achieved by adding a couple of words at the expense of the common printer, I would say let us add those words and make quite sure that everything the doctors want that is reasonably required by them should be provided and this Bill should be set off under the very best possible auspices.
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 1509 means. I would urge the Government to give it to them in every single case. I think they deserve it. I think they have had a very rough time. As I say, how far it is their own fault will be a matter for historical examination, but I do not think that this situation need have arisen if it had been treated in a different way and with perhaps a greater recognition of the extraordinarily sensitive and suspicious nature of men who are engaged in a specialised activity all day long and who do not have time to come here to notice what an exceptionally reasonable and trustworthy people we all are.
I am very pleased to note that the debate is being conducted in a spirit where we are not spending our time describing how individual members of the Government have pay beds in Wellington Clinic—or wherever it is. I may say, perhaps unkindly, that on some occasions when I have been in this House—very rarely—I have had the feeling that it would not be a bad thing if the whole of the Government were occupying pay beds. That is an unkind comment and it relates to some of the activities of last week.
I should like to conclude simply by saying that this is not a highly political measure and it ought not to be made a highly political measure. In so far as in Committee we can improve it, let us do so, but I believe that when it is passed and when it is clear that the Government intend to accept it in the spirit in which it has been offered it will go a long way towards solving the problem that we observed at the beginning of the year and also at the end of last year—a problem that ought never to have happened and which can cause great rifts between the Government and a profession which should be held in high repute—and that this Bill will enable the sort of young man I was talking about who made that important discovery, and other young men, to continue their work and to make a real contribution to medical science, instead of endless argumentation on arid political themes.
§ 4.47 p.m.
§ Lord STONE
My Lords, after that great speech by my noble friend Lord Goodman I crave your Lordships' indulgence—a double indulgence. First, may I declare a vested interest in this Bill in 1510 that I am a practising medical practitioner. In my long experience I have often heard from patients such remarks as, "I've got butterflies and flutterings in my tummy". I have looked for them, felt for them and listened for them, but never found them. I now know, feeling as I do at this moment, here and now, that they can and do exist. In my maiden speech it is not for me to comment deeply on the Health Services Bill which is being presented to your Lordships today. Sufficient that it will allow me, at a later stage, to make comments in further debates.
I was in medical practice before 1948 when the National Health Service was inaugurated, and have been ever since. I find myself in a strong position to assess it right up to the present day and I wish to say at the outset that in my opinion it is the best Health Service in the world, despite what one reads and hears to the contrary and that—and I quote—"It is on its last legs". Not a bit of it! I know it all because I have been in it for such a long time. Given time, the present difficulties will settle themselves and those who are young in the profession will realise that in any field of medicine a good doctor will always make a good living (never a fortune) and he will learn that his reward will be the warmth of the satisfaction he gets by just helping along and being involved with the daily problems of people, old and young.
In the light of my experience I am in favour of the phasing out of pay beds—with emphasis on the "phasing". Let it he gradual and not dramatic and all will be well. I hope, too, that the present Bill will not overload the already top-heavy—indeed far too top-heavy—bureaucracy that now exists and that it will be realised that the backbone of the medical profession is the general practitioners, who are hardly brought into the status in the profession that they rightly deserve, despite the fact that day by day, and every day, it is the GPs who are dealing with a majority of patients who are in need of daily medical attention without having to be referred to hospitals or clinics for the purpose. One must remember that the GP as a family doctor finds himself involved, as well as with illness, in all manner of human domestic problems—in the young and the old, the diligent and the lazy, the scholar and the slow learner; with drug problems, the question of 1511 alcoholism and all kinds of social and marital and even legal problems.
In my long experience as a doctor I have seen tremendous progress and advances in medicine and surgery. Thanks to the enormous developments in anaesthesia surgeons have been able to perform what, at one time, could only he considered "miracles": the removal of lungs, the transplant of hearts, kidneys and even of the liver; replacement of joints, corneal grafting—I could go on. On the medical side we have seen the eradication of diphtheria and whooping cough and poliomyelitis, all brought about by mass inoculation. Tuberculosis has become a rare disease as a result of mass radiography and therapy of the highest order. One could go on and on. Smallpox has been eradicated all over the world. Recently, I learnt that the last pocket of smallpox in Eritrea has been eliminated. It has all been so exciting and stimulating—researching and developing all the time. Let there be no restriction on them. ft is all for the benefit of the human race, Catholic and Protestant, black or white, Jew or Moslem. Even so, let us be wary of recent advances; let us be cautious of the noxious gases and chemicals we hear so much about and, not least, the applications, ramifications and dangers of the advances in nuclear energy, and their trial experiments.
My Lords, when I was elevated to this House a friend sent me a message saying, "How do you feel now you are a Peer of the Realm?" I answered, "Highly honoured—but terrified". I still feel highly honoured but, as this speech is now over, I no longer feel terrified. I thank your Lordships for your kindness and indulgence in listening to me.
§ 4.51 p.m.
§ Lord FERRIER
My Lords, it falls to me to congratulate the noble Lord, Lord Stone, on his excellent maiden speech. His speech contributed very considerably to the general tone of the debate which was commended by the noble Lord, Lord Goodman. Now that the noble Lord, Lord Stone, is no longer terrified I think your Lordships will agree that we can look forward to hearing from him again.
1512 My Lords, on the subject of being terrified, I am a little terrified myself at the moment. I should have liked to hear more speeches from medical men before I brought my own contribution to the notice of your Lordships. But I must say that I was greatly fortified by the speech of the noble Lord, Lord Goodman, which held out a real hope—and I hope he is right—that this Bill, which he admits will require some amendment, may lead to a thorough improvement in the general atmosphere as between the public, medicine and the hospitals.
I followed the speech of the noble Baroness, Lady Young, with great interest. She covered nearly all the ground that I proposed to cover in my own speech and, therefore, I will spare myself and your Lordships from going on too long, except that there are one or two comments I have to make with regard to my own feelings. First of all, queue-jumping is the big headache so far as the public is concerned. Obviously, we do not like it and, obviously, it is to be avoided. I rather doubt whether the contents of this measure will do practically anything to reduce it. The way to avoid queue-jumping is to avoid a queue.
Reading the Explanatory Memorandum, I feel that the complications in terms of bureaucracy and expenditure are somewhat underestimated. As the noble Lord, Lord Stone, said, he hoped that this was not going to lead to more and more civil servants. I am thinking of Scotland, which is to have an individual Board of its own. The noble Lord, Lord Amulree, touched on the question of the money that will be spent. An eminent medical man with whom I was talking only last night, said he felt that to some extent the Bill was a mistake because there were so many more priorities. But here we are. We have all been heartened by what was said by the noble Lord, Lord Goodman, that this represents something which, when somewhat amended, will work. Let us hope he proves to be right.
My Lords, speaking of queue-jumping and waiting lists and the provisions of the Bill, I believe that in the North of Scotland the waiting list, for example for an operation on the hip, is very long. I have heard mentioned a figure of two years on the waiting list for an ordinary bed. I reinforce what was said by the 1513 noble Lord, Lord Amulree. Are these waiting lists really as long as that? Or are the figures for those such as children who can be dealt with only during the school holidays, and old people who cannot in winter travel long distances such as are necessary in the North of Scotland? When there are long distances to cover, there is also the difficulty that visitors cannot come to visit old people. Hospitalisation can be a lonely business.
I do not propose to take up the time of the House in repeating the catalogues of objections. I feel that the Bill might increase the overall burden of Government expenditure out of all proportion to the amount with which it will improve the overall—and I emphasise the word "overall"—treatment of patients, whether in pay beds or otherwise. At one time, I had thought that, with all the pressure on the shoulders of your Lordships as a result of the log jam of Bills, this was one which really could be dropped in order to give your Lordships' House and Parliament more time to give proper attention to going over legislation which comes up from below.
My Lords, I only hope that the tone of this debate will continue as it has begun and that it will not tend to make the matter a divisive one. I was greatly heartened by the speech of the noble Lord, Lord Goodman, as I have already said. One of the reasons why I am speaking is that I feel it proper to protest at what was said in the Commons the other day, when the right honourable gentleman the Prime Minister said:I have no doubt that the other place will continue with its self-appointed task of mutilating Bills…"—[Official Report, Commons; 19/10/76, col. 1111.]I hope your Lordships will agree with me in objecting to the phrase "self-appointed". No noble Peer is self-appointed. It is really a very odd idea.
The present form of the House of Lords is that laid down by Parliament by enactments of successive measures of reform by both Parties in Parliament assembled, introduced from time to time. To play, "Let's pretend" in the way in which the Prime Minister did does not do any good. This is the case, and I feel that the Prime Minister has just got to "lump it". I, for one, as a Life Peer feel offended that there should be the faintest 1514 suggestion that we came here of our own volition and that we choose to be beastly, which we do not. We are doing a duty laid down by Parliament here assembled, and if people go on knocking the Second Chamber then, as sure as night follows day, the spring from which comes the supply of individuals willing to serve your Lordships' House will dry up, but that is another matter and I will leave the subject there.
I got an angle on the relationship between the private and public ward some time ago that was new to me. A patient was to undergo an orthopaedic operation and the surgeon was warned that she was occasionally subject to severe attacks of asthma and that she might get one at any time. The surgeon and his team decided that she should be in a public ward, because they felt that if she suddenly had a seizure, that was the best place for her to receive immediate attention. In fact she had such an attack, but the skilful measures taken in time avoided further trouble. I had another curious experience in that orthopaedic hospital. I was visiting a patient and noticed that there were eight empty beds. "We hear about enormous queues for hospital beds, but here are eight empty ones. Why is that"? I asked, and I was told that the hospital, which was built between the wars, had accommodation designed to meet the surgical and medical post-operative experience of those days.
The noble Lord, Lord Stone, mentioned the enormous advances that have been made in anaesthesia in surgery and post-operative treatment. The theatre accommodation in that hospital was insufficient to keep the beds full because patients were being released so much earlier than used to be the case. In fact, the surgeon told me, "Those two old ladies over there could have been released last week but we happen to know that they live in not very commodious accommodation with lots of stairs. They are far better off here because we have the accommodation, nurses, heating, food and so on."
I give these illustrations to show that the money, every penny of it, which will be spent in perhaps bureaucratic ways to support this Bill could be spent on improving conditions in hospitals and elsewhere or in improving, as the noble Lord, Lord Amulree, said, the amount of 1515 staff available in geriatric, mental and other hospitals. Money spent in that way would be money well spent. Perhaps I should add that for all I know an additional theatre has been built at the hospital about which I have been speaking; my experience there occurred four or five years ago. Nevertheless, it illustrates how money should be spent on hospital developments. I would go so far as to say that we should save and scrape until we get the money we need for that purpose.
The medical man with whom I was speaking last night is desperately anxious, as I am, to see waiting lists reduced and no need for queue jumping, if it takes place. The noble Baroness, Lady Young, pointed out that one could not get away from the fact that the number of private patients, particularly in private hospitals, means shorter queues elsewhere. I feel that what should go out from this House when we have done with the Bill is a sense of compassion for all those involved, a feeling of confidence in our medical staff and a belief that the existing hospital arrangements under the National Health Service can and should be made to work as well as possible.
§ 5.6 p.m.
My Lords, I join in the congratulations that have been expressed to the noble Lord, Lord Stone, on his excellent maiden speech. It was delivered with the kind of clarity and directness that I have come to expect rather more from general practitioners than perhaps from consultants, and I agreed with much of what he said. I am not sure that I will always agree with him, because, as the noble Lord, Lord Goodman, said, one need get two doctors together for only a couple of minutes for them to arrive at a state of total and utter disagreement. Nevertheless, it was a pleasure to hear from a fellow general practitioner speaking in that way, and I am sure that we all look forward to hearing him on many future occasions.
I wish to make it absolutely clear at the outset that I have no interest to declare in this matter. Although I worked all my professional life in the National Health Service, inside and outside hospitals, I have no private patients and I have no present intention of acpuiring any. I 1516 might add that I not only worked in the NHS but perhaps I could be forgiven for saying that I worked very hard for it for many years, not only working in it but trying—through television, the Press and journalism—to help it to function; to help to overcome in this co-operative venture some of the misunderstandings between the two sides which have sometimes caused difficulties; and trying to help on official bodies. Going further back than that, I remember perambulating about the country making speeches, trying to persuade my fellow medical men not only to join the Service but fully to support it. That was in the days before 5th July, 1948. I hope, therefore, that it will be accepted that I speak from that standpoint.
My purpose in criticising the Bill, as I shall, is not to defend private practice but to try to defend and preserve the Health Service and the principles that underlie it. I would not shed many tears if private practice disappeared altogether, provided it disappeared for the right reasons and in the right way. Reference has been made, and rightly, to Nye Bevan, as it was made frequently in debates in another place and to his book In Place of Fear. Nye Bevan looked forward to the disappearance of private practice and I had the privilege of discussing this matter with him on two separate occasions way back just before 1950. It was my impression then that his view was the the same as mine; he looked forward to a day when the NHS would be so constructed and so working that private practice would disappear because of lack of need. In other words, there would no longer be a supply because the demand would have disappeared, and I think he was right.
He was certainly right to say that that would happen, and the proof of the pudding is in the eating. If we look at areas of this country where the Health Service is flourishing, where there are new and modern hospitals, fully staffed, where the doctor/patient ratio is adequate, where waiting lists are short if not non-existent and where there are enough nurses, physiotherapists and the other ancillary workers who go to make the whole business of medicine, we shall look in vain for evidence of private practice.
On the other hand, the worrying thing is that if we look at other areas—and I regret that there are too many of them— 1517 where the Health Service is beginning to fail, where the waiting lists are long, in my view disastrously long in certain respects, despite what the noble Lord, Lord Ferrier, and the noble Lord, Lord Amulree, said, we find in those areas that once the Health Service begins to run down and there is a suspicion that it is no longer giving an adequate service, there is a re-emergence of private practice. That is the area in which it flourishes. So my aim is to see what I can do and what we all can do in your Lordships' House to see that the National Health Service ultimately reaches the required standard for everybody, so that this argument about private practice can disappear. But I am afraid that at first sight I can see nothing in the Bill that can do anything to improve the standards of the National Health Service or to bring that Service everywhere up to the ideal standard that exists in certain areas.
First, I believe that the Bill will precipitate a conflict or at least arouse resentment and antagonism. The noble Lord, Lord Goodman, has talked about this and I believe that we are all indebted to him for what he has done to try to arrive at some kind of compromise which could perhaps minimise the degree of resentment and antagonism. However, I believe that he would agree that while what he has done may have cooled the atmosphere, it has certainly not extinguished the flames altogether. Whether we like it or not—and I do not like it—one of the results of the Bill will he trouble, antagonism and resentment. I am not saying that that will be reasonable, nor am I saying that this House or any House should be blackmailed by unreasonable people, but I am saying that we should be realists, that we should accept the fact that real people behave like real people and that, if we possibly can, we should avoid promoting conflicts unnecessarily.
It seems to me that the National Health Service at the moment already has enough troubles of its own without having extra ones added to it by precipitating some kind of confrontation. Indeed, to me, the timing of this measure seems to rank in folly with Mr. Heath's decision to take on the miners at the time when we had suddenly become totally dependent upon coal. I hope 1518 that my fears are groundless and that we may not have difficulties of that kind, but, if we do—and I believe that we probably shall—the trouble will be that that will make it much more difficult to do the things that really are necessary.
I agree entirely with those noble Lords who have said, and said rightly, that something must he done to deal with abuses that exist in a system in which private and National Health Service practice exist side by side. I am talking about queue-jumping and the other undesirable—indeed, deplorable—things that have been suggested. I believe that the way to get rid of them is by agreement. I do not believe that we shall get rid of them all by Statute or by a policing system, but I feel that the more we can retain the mood of co-operation with those upon whom we are dependent, the more chance we have of getting rid of all those abuses by agreement and conciliation, given time. My theory is that some of the effects of the Bill may make it difficult to get rid of this kind of abuse and to get the degree of co-operation we undoubtedly need to get in order to drive out the abuses.
My next objection to the Bill is that it does nothing to create new resources. The plain fact is that there is a global volume of medical work to be done and that the total volume of resources to do that work is at present inadequate. We must accept that. No amount of manoeuvring within the limitations of those resources will create new resources. I believe that there are a lot of fallacies about the extent to which we can somehow draw new resources from the abolition of private practice. Indeed, I wandered into the other place the other day to hear the Third Reading debate, and Mrs. Short was talking about queues of private patients going along to the laboratory for a blood test. So what? Is it suggested that these many private patients having successions of blood tests to the point of extreme exsanguination are somehow having them for fun, or is it accepted that they need blood tests? If they need blood tests, they must have them, and whether they have them privately or publicly makes no difference at all to the total amount of resources that are available. I believe that there is a kind of assumption that if a patient has his appendix out privately he occupies two beds instead of one and makes work for two surgeons. All right, 1519 the queue-jumping point is a real one and must be dealt with, but do not let us run away with the idea that this kind of manipulation with a very small number of beds within the private sector will somehow liberate a tremendous amount of new resources and that that will put the Health Service to rights.
§ Lord WELLS-PESTELL
My Lords, will the noble Lord allow me to interrupt him? He knows better than most people what is the average bed occupancy in the course of a year. When we are talking about 2,500 to 3,000 private beds that are occupied for private purposes, I wonder how many patients he would say would occupy those 2,500 beds in the course of a year, an average bed being occupied by, say, 12 different people in the course of a year.
My Lords, I do not think that I can venture on doing public arithmetic with the noble Lord. I take his point, but the real point is, by whom are these beds occupied? Are they occupied by patients or a sort of hotel visitor? If the people concerned need medical treatment, they will occupy a bed whether they are private or National Health Service patients. Admittedly, the queue-jumping point comes in, but the point of total resources remains. Let us accept that the queues are too long and that waiting lists are too long. I say this to the noble Lord, Lord Ferrier, and Lord Amulree, who mentioned this point: in parts of the country, waiting lists are deplorable. There are people waiting for two years for so-called "non-urgent" operations. The degree of urgency or otherwise of any operation depends on who is to have that operation. If it is one's own operation, one tends to feel that it is not so non-urgent after all.
There are other aspects of this matter. When the wage earner has an uncomplicated, non-urgent, irreducible inguinal hernia and has to wait for two years to have it operated on, there will be economic effects. He will be a burden upon the social services and so will his wife and his family while he is waiting. I agree with every noble Lord who has said that we must do what we can to get rid of waiting lists. I agree, too, that we must 1520 do what we can to get rid of queue-jumping; but let us not run away with the idea that, somehow, new resources will suddenly become available and that the Health Service in some of the worst areas—and I practice in Salford, which is not the best—will somehow magically become better. I do not think that it will.
I come now to my last point, a point that was made by the noble Baroness, Lady Young, who referred to the introduction of apartheid in our medical services. I think she has a point. There may be difficulties in having private and public practice side by side in the same hospitals, but at least people can see what is happening and do something to control it. But when one has once separated the two and built up outside the National Health Service a wholly separate private service and that wholly separate private service is flourishing, it will bleed the National Health Service white.
We have already heard about consultants on nine-elevenths of time. I can tell you that I know many consultants who would like to go full-time. One may talk about their private earnings but they say that they would love to have a full-time contract. However, in many cases hospitals cannot offer them a full-time contract. Perhaps that is in part because the hospitals are already getting full-time work out of them although they are paying them for ten-elevenths. They will not get full-time work out of them when the consultants are on two-elevenths and not in the same hospital but a very long way away.
So I put that forward as a little bit of a fear: deliberately and as a matter of policy to build up two separate services, one the Health Service and one a private service outside, is I believe, inviting resources to go to the private service. Money will go to it; money for research will go to it; many workers will leave the one and go to the other because, perhaps mistakenly, they think that they will have more freedom, better opportunities or better facilities. There will be many reasons, but I nevertheless predict that, if we ever establish this "apartheid" system of a private sector outside the National Health Service, it will bleed that Service white.
I have said enough. But it seems to me rather sad that in my day, working in this area for the National Health Service, we began with a private sector which was 1521 then terrified by the prospect of the introduction of a new, free public service. We have arrived at a situation where we now have a public sector free, which is now so frightened of an expensive private sector that somehow it feels that it has to hide it away. The wheel has turned full circle indeed. It is my view that with the right priorities, with the right use of our resources, with efficient administration and the abolition of waste and duplication, it would be perfectly possible for our nation to mount a fully comprehensive health service, free at the time of use to every man, woman, and child in this country. It is on that that we should be concentrating our attention.
After I sit down, my Lords, you will hear many eminent doctors speak and, if I may say so, you will also hear many eminent patients speak. The views of both sides are equally important. But I hope that at least all of them will be speaking from the point of view of preserving and cherishing and maintaining our National Health Service.
§ 5.22 p.m.
§ Lord HUNT of FAWLEY
My Lords, I, too, should like to thank and congratulate my fellow general medical practitioner, the noble Lord, Lord Stone, on his maiden speech. I much enjoyed listening to what he said, and I hope that he will speak to us often in future. Many points in this Bill are complex and a large proportion of doctors will agree with my noble friend Lady Young when she said that not enough time has been given for their proper consideration by the medical profession and by your Lordships' House. The British Medical Journal, in a leading article (10.5.76) has called the Bill, "hasty, ill-considered legislation". With this and the guillotine imposed in another place there is an element of truth and some significance in the colloquial question put to me recently: "Are the Government pulling a fast one on the medical profession by introducing this Bill just now?" In some ways many doctors think that they are.
We owe a great deal to the noble Lord, Lord Goodman. We realise that the Bill now contains much that has become known as "the spirit of Goodman", and we all thank him for this and for the hard work he has done for us. But— 1522 and it is a big "but"—we must appreciate that at no time has the medical profession as a whole (as represented by the Royal Colleges and Faculties, and by the British Medical Association) accepted any compromise over its total opposition to this Bill, even with the Goodman proposals incorporated in it.
Last week I met the President of the Royal College of Surgeons, Sir Rodney Smith, who is chairman of an important Working Party (of the Royal Colleges and of the BMA) which is studying the ethical responsibilities of the medical profession within the framework of the National Health Service. I met also Dr. James Cameron and Dr. Elston Grey Turner (Chairman of Council, and Secretary of the BMA). They all told me that the Royal Colleges and Faculties, and the BMA are still implacably opposed to this Bill. They sincerely believe, for reasons with which your Lordships are by now familiar, that it will do British medicine, the National Health Service, patients and doctors a great deal of harm; and they rely on Parliament to have the good sense not to pass it in the face of this strong medical opposition. The suggestion which I have heard, that we should accept the Bill for fear that if we do not do so something worse might be proposed next Session, is to my mind a weak one. To accept it meekly now might easily encourage our opponents to add something very much more unpleasant soon.
What my profession has said is that if the day is lost and the Bill receives Royal Assent (when the doctors could not then act against the will of Parliament), they would do their best to make it work, provided it includes the negotiated Goodman compromises which are better than those suggested in the original Consultative Document. The word "compromise" implies agreement, and this is the only agreement which my profession as a whole has made so far; and it will act on this only if and when, against its wishes and advice, this Bill becomes law.
The right honourable Mrs. Barbara Castle, in another place on 12th October—only nine days ago—issued a warning to your Lordships' House. She said:I issue a warning … If this compromise is to be challenged and injured … there will be no 1523 peace in the NHS. Their Lordships will have reopened the gates for industrial action, and it will be upon their own heads …"—[Official Report, Commons, 12/10/76; col. 306.]That would not be on our heads alone, my Lords, for no one has forgotten that it was her Government which started all this trouble over a mere 1 per cent. of the beds in the National Health Service. She has thrown down the gauntlet at your Lordships' feet, and we shall have to decide quite soon whether or not, on behalf of the medical profession, we accept her challenge.
If this Bill is passed and we act along the lines of the Goodman proposals I, as a practising doctor, am particularly interested in three points in them. First, the phasing out of pay beds in National Health Service hospitals, if and when this takes place, must be done in an orderly and reasonable manner, and only when consultants are convinced that good altertive private bed accommodation of equal quality and availability for patients and doctors is provided. This alternative accommodation must be in addition to the beds at present in private nursing homes and hospitals which are, in Central London anyway, already fully occupied (but not always so in the Provinces); and this is before any phasing out begins. This is an important point which I do not believe is fully appreciated.
Secondly, the proposed Health Services Board must be seen to be truly independent politically, and unbiased. Thirdly, the Government, trades unions, local authorities and others must agree that there will be no interference in future on political or ideological grounds with the building, staffing or running of any of the private hospitals mentioned in the Bill, nor with private beds and facilities which remain in NHS hospitals during the period of phasing out. And there must be no interference, either, with private medical insurance organisations.
I know, my Lords, that this Bill aims to take private practice out of the NHS and not to abolish it; and I agree with what the noble Lord, Lord Goodman, said about this. Many senior members of the Labour Party, including Sir Harold Wilson, Mrs. Barbara Castle, the noble Lord, Lord Wells-Pestell, and the present Secretary of State for Social Services have 1524 said time and time again that they wish to preserve a healthy private sector of medicine in Britain. I gave some of these references to this House in my speech on 3rd December 1975, and here are two more. Mrs Barbara Castle, at the first meeting of the Select Committee on this Bill said:It would be intolerable in a democratic society to prevent people buying private medical care if they felt that it was an essential part of their personal interest."—[Official Report, Commons, Standing Committee D, 18/5/76; col. 38.]The present Secretary of State for Social Services, the right honourable David Ennals, confirmed this attitude on 27th April this year, at the Second Reading of the Bill in another place:This Government have said … that it is no part of their policy to abolish private medicine."—[Official Report, Commons, 27/4/76; cols. 207–208.]If the National Health Service does not improve soon, it will need a great deal of help from the private sector in these days of financial stringency. The private sector will then gradually and reasonably expand. I am in full agreement that the quality and standards of hospitals both within and without the National Health Service should be kept under careful scrutiny, and that some equilibrium must be maintained between the two sectors. Every patient who chooses to be treated privately saves the National Health Service money, equipment, personnel and much else, and standards of total pateint care depend on both sectors. If any Government in future, for politically motivated doctrinaire reasons, try to strangle the development, by quantity licensing, of private hospital beds, that will be a most damaging action to prevent the private sector playing its proper role. Sooner or later, and the sooner the better, everyone must accept that the public and private sectors of medicine in Britain must learn to work together in harmony, helping each other with good will and understanding, with reasonable and friendly liaison between the two, each making a useful contribution, as happens with public and private transport on our roads. This symbiosis should logically take place within the walls of our large and famous hospitals, and in many smaller hospitals too throughout our country. It will be much to my regret if Party politics and this proposed Bill make this impossible, so that they will have to work 1525 from separate establishments, to the detriment of both.
My Lords, during the last few minutes of my speech I should like to ask you three questions: Should my profession ever accept, without a struggle, politically-motivated direction imposed upon it by any Government? If doctors dislike that direction strongly, should they fight and, if so, how? Or should they emigrate in appreciable numbers? First, should the medical profession accept quietly, without opposition, arbitrary doctrinaire control imposed upon it by Government or trades unions? Such unopposed direction must lead to impairment, or loss, of professional independence of action and judgment, with curtailment, too of clinical freedom both for patients and their doctors. One example of this would be a patient's freedom of choice as to who would operate on him, and when and where?
Second, should my profession fight for these freedoms and, if so, how? If a Government, for Party-political ends, is dictatorial and unreasonable with a great profession, forcing through a Bill like this, which the noble Lord, Lord Goodman, himself agrees was not really necessary in the first place, that profession must defend itself, as would any other. The legal profession, for instance, has been considering this problem seriously, as the President of the Law Society has so clearly pointed out recently. What he said was published in The Times on 8th October. But what can we do if discussion is cut short, our views are ignored and agreement cannot be reached? Most doctors would agree with the principle proposed by the President of the Royal College of Physicians, Sir Cyril Clarke, when he wrote in a letter to The Times of 30th July about his Royal College:We do not believe it is right to take any action which may bring harm to patients.But what effective practical alternative has been put forward? None. The Royal College of Physicians has suggested a, "Council of Conciliation", the Working Party of the Royal Colleges and of the BMA (which I have already mentioned) has not reported yet, and the Government have refused to put the pay bed dispute to the Royal Commission, as many doctors thought they should have done.
1526 During the past 12 months, my Lords, the mood of my profession has hardened, and it has learned how to fight. Medicine is not an industry, so "industrial action" is an incorrect, inappropriate, and misleading term when applied to doctors. They are learning how to take what is better called "professional action"—highly-selective action of various kinds—within the law and within their contracts and terms of service, which they can take either individually or collectively with the support of the British Medical Association.
In December 1975, it was the collective professional action of doctors which played a large part in persuading the Government to introduce Lord Goodman's proposals into the Bill. More recently, it was collective professional action which helped the junior doctors to obtain what they wanted in their dispute with the Department of Health and Social Security. No doctor wants to inconvenience or harm his patients in any way which can be avoided. Neither does a surgeon who operates, say, to remove an abdominal tumour, want to hurt his patient; but, as Hamlet says:Diseases desperate grown,By desperate appliance are reliev'd,Or not at all.The surgeon and his patient appreciate and accept that a certain amount of temporary inconvenience and pain are necessary for a cure. So it is with doctors taking collective professional action. The President of the Royal College of Surgeons wrote to The Times of 2nd August an immediate addition to that of his fellow President, pointing out the dilemma facing the medical profession now:If a Government acts in a manner so damaging to the practice of medicine that harm to patients must result (and one must include in this measures that reduce the morale of those working in the NHS) how can doctors oppose if the most effective means of opposition might itself harm patients?It is the conviction of many thousand members of my profession, now, that collective professional action may be justified, under certain circumstances, for the benefit of British medicine in the future. These circumstances arise when there is a serious risk of erosion of our professional freedoms by Party-political moves such as the forcing through of a Bill like this, and when no conciliatory mechanism exists which will ensure that both sides will listen to reasonable arguments and respond to them. The 1527 noble Lord, Lord Taylor, who as a young doctor and Labour M.P. for Barnet—Stephen Taylor—was responsible to a considerable extent for the inception of the N.H.S. by influencing and advising Aneurin Bevan, wrote this about doctors on 10th March this year in the journal World Medicine:Doctors must remember that Parliament cannot bind its successors in perpetuity. If future legislation were to threaten their essential professional freedoms, they would be justified, in the long-term interests of their patients, in fighting the proposals by every means in their power.My third and last short question, my Lords, is, "Should our doctors emigrate?" Inevitably, better facilities, conditions of service and freedom from political and trade-union interference are attracting gifted medical men and women to other countries, as my noble friend Lady Young has already mentioned. Many of us firmly believe that it will be far better for the future of British medicine for our good doctors to stay here caring for their patients, and fighting for their principles and beliefs, rather than that they should move away to other countries taking their talents and the fruits of their expensive training, and their experience, with them. Such emigration of even a small proportion of the flower of our profession will do our patients and the National Health Service far more harm, in the long run, than will any temporary collective professional action taken now. You will appreciate, my Lords, that I and many of my colleagues are in a fighting mood. We are determined to protect our patients and our own legitimate and reasonable professional freedoms whatever happens to this particular Bill.
§ 5.40 p.m.
§ Lord PLATT
My Lords, I should like to congratulate—I was going to say "Dr. Stone "—the noble Lord, Lord Stone, on his maiden speech, which we were very pleased to listen to and very glad that he has got it over because obviously it was a great relief to him. He is now what I may call a fully paid-up member of your Lordships' House and he will be able to intervene in our debates and discussions in Committee stages and so on.
1528 I have a feeling when I have been thinking about these problems of the Health Service that one of the most important criteria by which we should judge any proposed change or innovation is what will be its effects on the reputation of British medicine at home and abroad. I think that that reputation still stands very high, but I do not know how long it will go on standing high in the present state of the profession. The reputation of British medicine will not be served by threats of mass resignations, by strikes, by consultants working to rule, all of which I am afraid I find completely unacceptable. I agree there with the noble Lord, Lord Goodman, who likened our profession to joining the Church in which that kind of action is no longer available to you because you have joined a profession which is a service. I did not come here to disagree with my friend of many years the noble Lord, Lord Hunt of Fawley, but on that point I disagree. But I cannot disagree with him without trying to answer his question.
The question was a very reasonable and notable one: What other measures can we take? I think that this really begs the question altogether. I think the question is: who allowed the situation to get as bad as this? I do not think that the profession itself can say that they are not guilty when threats of strikes and so on have been mooted almost before the subject has been discussed. If he wants an alternative, I personally believe that the only solution is a real collaboration between the Department and the profession which I do not think has ever happened since the beginning of the Health Service. In order to facilitate that, I have no doubt that some kind of body which does not belong to the Government or any Party and is not overloaded by members of the medical profession should meet as a conciliatory kind of body and try to solve these problems seeing the seriousness of them before they reaach that stage.
Neither is the reputation of British medicine served by the disastrous reorganisation—I am sorry to use that word but it is my favourite word for it—of the Health Service in 1974 which made communication more and more difficult when communication was firston the list of what needed to be improved in the Health Service—communication between 1529 doctors and patients: "My doctor will not listen to me"; communication between GPs and consultants: "He does not get a letter from the consultant for three weeks after the patient is in hospital" communication between doctors and nurses; communication between doctors and doctors; and finally between the profession and the Department. The result of the reorganisation was to make communication more difficult at a time when it was the only solution to the difficulties. Neither will the reputation of British medicine be served by this Bill. Not at all.
What is called in America the geographical wholetime system is surely the best of all—perhaps the only thing in American medicine that I agree with, but I agree strongly with it. That means that a man's first loyalty—and these are top consultants, medical scientists and so on—is to the hospital or the medical school—which is the same thing: the hospital being part of the medical school. His first loyalty is to his hospital and although he is allowed private practice and allowed to accept fees he does his private work geographically in the same place as he does his other work. He is then—coming now to translate it into British terms—always available to his National Health Service patients. He is not in Hampstead or at Lord's cricket ground when he ought to be at Guy's Hospital. He is in Guy's Hospital. If at the end of the day when he is ready to go home he wants to pop in and see one of his NHS patients whom he saw in the morning and about whom he is worried he does so; but he will not come all the way from St. John's Wood or wherever to Guy's Hospital to do that.
He is also subject to a continual scrutiny by his colleagues and junior staff. Everybody knows what he is doing, what his standards are, what his ethical standards are. I think this is a tremendous advantage and to throw it away is madness. There is no advantage in doing so. There is a lot of very grave danger in doing so. This, I am surprised to say, does not seem to have been mentioned. I have listened to almost every speech, although I missed a little of the noble Lord, Lord Winstanley, at the beginning, and it does not really seem to have been considered. All right. The private sector can go on building up. Nobody is going to interfere with private 1530 practice. But are we going back to the old inefficient nursing homes? No. We are going to see that any new nursing homes or private hospitals that are built are visited and that their standards are up to the standards required nowadays of people practising modern medicine and surgery.
Fine! But who is going to scrutinise the doctors who work in them? Who will they be? If you go to a private bed—and I only take London as an example as many of your Lordships live in and around London—in a London teaching hospital, St. Thomas's or Guy's—you know the consultant in charge has been through the mill with proper training, of gaining appointments and of distinction in them and that he is a thoroughly qualified specialist in the job he is setting out to do. Will there be the same scrutiny for the private sector? Will somebody say, "No, you cannot practise here. We think you are a second-rate doctor and we only want first-rate doctors." Who is going to say that? Nobody has answered that question. It is crucial. Your Lordships know what happens in America where all kinds of people operate on patients who do not need operations and they do not even always do the operation very well, as we know in one notable example in public life.
I think this is bad and I think it will lead to a division in the profession either slowly or quickly where the loyal people will spend more and more time in their hospitals and those who are out to make money will spend more and more time in the private sector. I think that they will gradually grow apart and then, as I say, useless operations may be performed; the people who abuse the Service now and about whom much has been said will be the very ones who will abuse it in the private sector and the premiums for insurance against malpractice will go up sky high. A Californian nose and throat surgeon writing in a journal the other day said that his premium for insurance protection against actions for malpractice was 16,000 dollars a year, roughly £8,000. The rate varies and for specialties such as neurosurgery and gynaecology probably the premium would be more. this is the kind of thing we do not want to encourage in this country.
We have a National Health Service, we have pay beds in hospitals with all the 1531 facilities, and we have got the men—though, of course, there are a lot of things we have not got. But why change it and leave it open to all these abuses? As to the abuses charged against workers in the National Health Service, the chief one seems to be the one of queue-jumping. This is serious; it means that if you pay something you get into hospital sooner. This Bill will do nothing whatever to prevent it. Ordinary chaps—I was going to say like you and me, but we are rather a mixed bag—would say, "I can afford a consultation fee. I do not want to go and wait in an out-patient department. I might see the registrar when I really wanted to see Dr. So-and-So. I will pay his consultation fee and see him in his consulting rooms" (which are preferably in the hospital itself). He sees the doctor, but Dr. So-and-So is not satisfied and he says, "I think this is what is happening but you must come into hospital for further investigation", or, "It is imperative that you have an operation". The patient says, "How much is this going to cost?", and the doctor says, "It could run into £300 or £400 easily". The chap says, "I cannot afford it" and the doctor says, "I will take you into one of my beds".
If the doctor is less than absolutely scrupulous with his conscience, this is where the queue-jumping comes in. He is liable to have pressure brought on him by the general practitioner handling the patient who says, "Mrs. So-and-So whom you saw a week or so ago is getting no better and should come in", so Mrs. So-and-So gets higher up the queue than perhaps sheer medical necessity would dictate. That is the main abuse and this Bill does absolutely nothing for it. It allows you to have a private consultation and it does not prevent you from going into an NHS hospital after it, so from that point of view it is useless.
Bed occupancy was discussed and there was a little passage between the noble Lord, Lord Wells-Pestell, and the noble Lord, Lord Winstanley, on mathematics. The question was: how many of these private beds are occupied? The occupancy level is bound to be less because the patients are not staying so long. For several reasons many patients in Health Service beds stay in much longer than they need. Sometimes surgeons have different ideas as to how long patients should stay in 1532 hospital. They are not paying for it so it does not matter. Sometimes the consultant comes round twice a week; he sees the patient on Tuesday and thinks that he ought to get the gall bladder X-rayed and on Friday he comes again and it has not yet been done. On Tuesday it has been done but the report has not come through from the X-ray department so that patient can stay in hospital for 10 unnecessary days. The bed occupancy is 100 per cent. but the use that is being made of it is 0 per cent., whereas the private patient naturally says, "How long need I stay? This is costing me so much per week". That has to be taken into the calculation, my Lords.
Amenity beds have been mentioned. I am sure the noble Baroness, Lady Lee of Asheridge, will almost certainly refer to these. I thought what a splendid idea amenity beds were. Ordinary people, perhaps more likely to be professional people than manual workers, would say they wanted privacy, they wanted to be alone and so on; some of them were rather shy about it all. However my experience—which of course covers only a few hospitals—is that these beds just do not work. There were so few of them that they were always needed for some ordinary patient—ordinary in the sense that he was not asking for an amenity bed but was very ill and had to be nursed separately. If you got the amenity bed system to work it would not help with the queue-jumping. Either a person wanted an amenity bed and there were enough so that he got it quickly or there were so few that he would have to wait longer, so the queue-jumping is not solved by amenity beds.
Waiting lists have been mentioned. I am sure that if a real concerted attack between the profession and the department were made on waiting lists we should find that there is an awful lot of nonsense about them. Whether it is true that the less scrupulous members of my profession like to have long waiting lists so that they can say to the patient, "I shall have to keep you waiting for two years" I have no evidence one way or another. There are certain people in my profession "who I would not put it past", if that is the right expression. The high reputation of British medicine depends on the most notable people in the profession, many of whom have achieved their celebrity by research and teaching others, by the 1533 wisdom, knowledge and integrity of their advice. We want these people to have their first loyalty to the hospital in which they served. Why do we push them out to do their private work somewhere else? It seems to me to be madness.
I was greatly stirred by reading an article in The Times yesterday which reported that Sir Alec Merrison, the Chairman of the Royal Commission on the Health Service, made it clear that we need not wait two years for his report on some major issue; they were willing to give a running commentary from time to time. If this was not a broad hint that the Merrison Commission were not greatly pleased with this Bill, then I have misinterpreted his words. It seems to me a very broad hint. So let us hope that if we are going to pass this Bill the phasing out of pay beds from the National Health Service will be so slow that we shall have the Merrison Report before we get any further.
§ 6 p.m.
§ Baroness LEE of ASHERIDGE
My Lords, I too should like to congratulate the noble Lord, Lord Stone, on a charming maiden speech—not only charming but obviously based on many years of dedicated service as a general practitioner. I cannot resist quoting two sentences from In Place of Fear, the reference made by Aneurin Bevan when he was writing in 1951 to the feeling about the tempestuous atmosphere of that early time. He wrote:I have a warm spot for the general practitioner despite his tempestuousness. The family doctor is in many ways the most important person in the Service. He is also the most highly individualistic member of the medical world".It is fascinating to compare the atmosphere in which we are discussing the Health Service today with the atmosphere in another place in the 1945–50 Parliament. We have had a militant, rousing speech from the noble Lord, Lord Hunt of Fawley, who holds opinions obviously fervently, and of course with deep sincerity. Not so much in this House but in the other House, we have had speeches of equal fervour taking an opposite point of view. I hope and believe that neither of these forms of "a 100 per cent. my way" or "a 100 per cent. your way" are going to win.
This is such a passionate subject that we must congratulate the noble Lord, 1534 Lord Goodman, and those who worked with him. It is almost a miracle that he has so much understanding of the compromise which he thinks ought to be adopted. Your Lordships' House must know that most of the giving has been from our side. Before coming here today I was looking through some old papers. I came across something that was written by Dr. Somerville Hastings about Aneurin Bevan at a moment of great grief, when Aneurin Bevan died. Although there was a strong personal affection between the two men, Dr. Somerville Hastings fought his Minister for the health service he wanted. He said:Do you realise some of us in the Socialist Medical Association have given the best years of our lives to prepare the way for the Health Service, and we want this Health Service to be available to all of us as one great family? We do not want anyone advantaged by wealth and we do not want anyone disadvantaged by poverty.This sentiment was expressed with great ardour.
Regarding pay beds, how he chided his Minister, who was also his friend! He said: "How can you make these kinds of compromises?" The answer in that Parliament was that certain compromises had to be made or we should not have had our National Health Service. We had to bring in the great teaching hospitals. We had to deal not just with the legitimate fears of the medical profession but with a great deal of ghosts and bogey men. If the noble Lord, Lord Hunt of Fawley, will forgive me, I heard an echo of them today. Surely no civil servant and no politician is going to interfere between a doctor and his patient.
It is not in the philosophy of those of us who are democratic socialists that we want to prohibit private medicine. We believe in a mixed economy. We want more on the public sector than noble Lords opposite do. I do not think any Conservative now would say that lie wants the whole of industry in private hands. We could not survive that. Noble Lords will not find those of us who are democratic socialists saying that we want 100 per cent. nationalisation of all industry, because we know, too, that that would be the road to an authoritarian society.
We have to consider the genuine fears of doctors. The Goodman compromise must go a very long way to answering their fears. If it is necessary to have it 1535 put in an Act of Parliament that private medicine should exist side by side with the Health Service, well and good. When we have been talking about our hospitals we have been talking quite properly about the dedicated men and women who are nurses and doctors. My only claim to intervene for a short time tonight is that I know every nuance of the struggle in the early days of establishing the Health Service. I know that I am speaking in the presence of many in this House who in recent years, as some are doing at the present moment, have given a great deal of time, energy and services, some professionally and some in an administrative capacity. I do not share that experience.
I am a grateful patient of the National Health Service, and I am glad that we have heard from all parts of the House expressions that we have the best National Health Service in the world, with all its faults. When there is a serious illness in the home, when an emergency operation is required, all would agree that our Health Service is superb. All would agree that the care of the expectant mother and child is superb. There is a great field in between where of course we need a better service, more money spent on hospitals, and so on. You cannot run a great hospital with nurses and doctors alone. There has to be the ambulance service, the auxiliary workers, the cleaners and the cooks; in other words, there has to be a good atmosphere in the hospital embracing everyone, whatever part he is playing.
In my experience, there is more impatience among the auxiliary workers in hospitals against private beds. They know that originally a compromise was made to get the Health Service started. The belief was that once the Service was started there would be less and less need for private medicine. If anyone wants private medicine in our society they ought to have it; but I do not think pay beds can survive in the general hospitals, because it is against the spirit of the age. The people serving in many capacities do not like it and they feel that when we are ill we should all be treated in the same way.
I am glad that several noble Lords mentioned amenity beds. I agree with the noble Lord, Lord Platt, that the 1536 amenity bed has not done the job that Aneurin Bevan and the other founders of the Health Service wanted it to do. The amenity bed ought to reassure those members of the public who have such a great distaste of going into a public ward that they would almost keep out of hospital altogether. I can remember visiting hospitals with Aneurin Bevan. A great deal of attention was paid to personal privacy, drawing curtains round a patient's bed and so on. I have spent much time recently as a visitor to one of our great London hospitals and was impressed by the efforts which are made to give privacy in public wards, whether the patient requires a bed pan or some minor attention. Great improvements have been made.
We have not nearly enough amenity beds. It is no good having a leading member of the Cabinet or Shadow Cabinet in a public ward; they are a confounded nuisance. They get too many flowers, too many telegrams and upset the rhythm of the ward. We must have common sense about this. If there is a side ward, which is private, then they can get on with reading their official papers or receive masses of flowers, and all the rest of it. That seems a sensible arrangement. Or you may be a businessman who has a broken leg or something that means that you can still do a good deal of work; and you may have that kind of reason for wanting an amenity bed. But if there is a scarcity of beds, then these beds must first go to those who require privacy for medical reasons. That is why I agree with the noble Lord, Lord Platt, that there are not enough amenity beds. I should like to think that when we come to the Committee stage we can again reassure not only doctors, who have far too many fears that are not really founded, but also members of the public who also fear a violation of their privacy, and that we shall give real attention to this particular matter.
My Lords, I hope that before anyone again tries to suggest that the first Minister of the Health Service was in favour of private beds or was in favour of a part-time consultancy service they will go to the Library where they will find his book. They will then see quite clearly that the essential thing—and we all agree now that it was essential and we do not have the fierce opposition of earlier days— 1537 was to get the National Health Service started. We have got it, we are proud of it and proud of all those who serve in it, in whatever capacity they serve. On the subject of the Goodman compromise, which does not please me and which does not satisfy many of my friends, just as it does not satisfy the noble Lord, Lord Hunt of Fawley, we may have to agree to differ, and if it is the will of the majority of Parliament that that compromise should go through, then let it go through and let us all work to make it a success.
§ 6.12 p.m.
§ Lady RUTHVEN of FREELAND
My Lords, may I join with other noble Lords in congratulating the noble Lord, Lord Stone, on his maiden speech. It was very much to the point and nice and short, which is what a maiden speech should be.
I hesitated to address your Lordships tonight as you have already listened to so many excellent speeches and some brilliant speeches from the medical profession, but I felt that as I had been for so many years, in an amateurish way, involved in the Health Service on organisation and administration perhaps I should be "doing a St. Peter" if I did not stand up and be counted, because I do not like this Health Services Bill and I feel that I must justify my views on that point.
Much of my time has been given up to this Health Service. I even go on now, in my old age, visiting many hospitals for the League of Hospital Friends, and so I still keep in touch with what goes on in the Health Service. I should like to say how much I agree with what has been said by so many of my noble friends on this side of the House and also with the speeches made by members on the Liberal Benches and on the Cross-Benches. I have listened with the greatest interest to all that they have said, and particularly to the noble Lord, Lord Hunt of Fawley, who interested me intensely.
The Health Service sets out the Government's plan for phasing out all the pay beds eventually. It seems very hard that sick people able and willing to pay the full cost of their treatment should not be allowed to do so. The architects of todays' Hospital Service, the old voluntary hospitals, had for some considerable number of years built private wings, 1538 often financed by grateful patients and others interested in medical and nursing care for those in need. The revenue from the private wings, after meeting the cost of treatment for the patients in those private wings, was then used towards the overall costs of the hospital service. When the hospitals were transferred to the Ministry of Health on the introduction of the National Health Service in 1948 the private wings were also transferred, and the Government of the day set aside the beds and facilities provided by the private wings for the use of patients who would be willing to pay the full cost of their treatment. At the same time, Mr. Aneurin Bevan—whom I am glad to say was a great friend of mine and I was pleased to hear the noble Baroness, Baroness Lee of Asheridge, speak just before me—created a system under which consultants in the hospitals could choose to give up a part of their salaries in return for the freedon to do some private work for patients in the private beds.
Until the last year or two this system worked well. Unfortunately, other things have intervened and the system is now breaking down. Not only has the National Health Service patient benefited from the care of many brilliant doctors who, without this freedom, to do private work might never have joined the National Health Service, but the fact that they have been able to combine public and private practice in one hospital has meant the saving of countless hours of travelling and countless lives have been saved in emergencies. The patients have benefited from the private facilities of the National Health Service hospitals and it will be the patients who will suffer if the pay beds are phased out of the hospitals.
Cuts are already being made in the expenditure on the Health Service. Hospitals are being closed and many wards are empty. They cannot be staffed because of lack of money. Waiting lists are just as long and will be until the Government are able to release more money to open these closed wards and to recommence work on curtailed building pogrammes. Our Health Service is not measuring up to what the public has come to expect from it, and it is not the admiration of all eyes as it was in the past. I spent a lot of time in America in years gone by, visiting hospitals, and I was always asked to speak about our Health Service. 1539 There were "Oohs!" and "Aahs!" and questions I was not always capable of answering. But it was the admiration of the American world; I know that, I rather doubt its being so now.
The Bill to phase out the pay beds will not shorten the waiting lists, but it can and it will increase the shortage of doctors in the National Health Service hospitals. The long-term effect of this could be disastrous, especially to the teaching of the young doctors should the consultants choose to leave the National Health Service hospitals for the private hospitals and nursing homes. I cannot emphasise too strongly the loss of teaching material, particularly from the London and big provincial teaching hospitals, if all private beds are abolished. I know one particularly interesting case on which a friend of mine, a professor of dental surgery, was teaching his students. The patient was discharged but had to return for further treatment, and when the patient arrived she found that the pay beds of the hospital where she had been had been eliminated and she was in a private nursing home. The professor was able to visit the patient after his day's work was over but unaccompanied by students. The loss of teaching material is of great consequence and seems to have passed unnoticed by the Department when it drafted the Bill.
There will always be a section of the public which will want to have private medical attention, and those members of the public should be allowed to have it and to pay for it over and above the contribution that they make through income tax and through the Health Insurance tax. To encourage members of the public to have private insurance cover to pay for private treatment in hospital would appear to be a sensible way of attracting additional revenue for a starved National Health Service. I must say that I subscribe to one of these societies. Though I have been in many private rooms, several times I have been in National Health Service hospital wards. I know which I prefer, although that is neither here nor there. It would seem more sensible to have more pay bed facilities than to force private treatment to go to an extension of private hospitals like the London Clinic, the Wellington and many others, the profits from which benefit no one but the shareholders of public 1540 companies. I should like to end by saying that the care of the sick should, in my view, be everyone's concern and should not be allowed to become a matter for Party politics.
§ 6.20 p.m.
§ Lord PORRITT
My Lords, may I add my voice to previous speakers and congratulate the noble Lord, Lord Stone, on his maiden speech, which was both simple and brief—two very fine points. As an ex-member of the profession, belonging to that part which has been somewhat rudely criticised this afternoon—the specialists and consultants—I congratulate him on a straightforward statement from a genuine doctor. I hope, now that he has got over his terror, that we shall hear him often.
I have been fortunate in having spent two-thirds of a fairly long life in the practice of medicine, both clinical and administrative, and half of that, at least, has been under the aegis of and concerned with the National Health Service. I am glad to be speaking this evening from the Cross-Benches, and I want your Lordships to believe that even if some of my remarks may seem rather hard, this is a completely unbiased statement of a firmly held belief. My only bias is towards medicine. To me, it is sad enough and bad enough that, over the years, medicine should have become more and more involved in politics. This was obviously going to happen when the fascinating experiment of nationalising a profession for the first time in history was attempted in 1946–48. That has happened and we accept it, but when medicine is being used as a Party political football to be kicked about by ideologies and ideologists, then it is nothing but tragic. That is how I look at this Bill. I feel that it represents that last statement.
Another great interest of mine over the past 50 years has been the Olympic movement, and your Lordships will all know what has recently happened in that sphere in Canada, which will continue to happen with the same result and for the same reason. Those are two ideals, medicine and Olympism, which promoted both health, in its fullest sense—mental, physical and moral—and friendship, mutual trust and understanding between peoples; both already tarnished and at 1541 risk of ultimate destruction because of unnecessary and ever-increasing doctrinaire methodology. Your Lordships will note, I trust, that I have categorically defined the NHS as an ideal. This I believe it initially was. Equally, I have no doubt that it has done immeasurable good to a great many people who could not otherwise, except through its influence, have received the benefits which they have had. All the more sad it is to see it slowly strangled by the octopus of over-administration, and swamped by the crushing weight of top-heavy bureaucracy.
At one time, it might have been described as the best State medical service in the world, and that has been mentioned once or twice already today. That, sadly, I suggest, was a long time ago. Nationalised medicine in one shape or another has been inaugurated in many countries throughout the world, and not one of them has seen fit to copy our Service. The best health service in the world is one in which all patients are private patients. This has been very nearly achieved in Canada.
That brings me back to this Bill, this pathetic, rather small Bill, which was barely half discussed in the other place, was guillotined, is full of contradictions and omissions, is often vague and sometimes very difficult to understand. And for what purpose? It benefits neither patients nor doctors; nor for that matter the National Health Service itself. It starts off by stating in the Explanatory Memorandum that its main purposes are, first, to separate from National Health Service hospitals accommodation and facilities—often, life-saving facilities—used for the private practice of medicine; and, secondly, to introduce new powers of control over private hospital building to safeguard the NHS. Safeguard from what? Is the mighty NHS so frightened, or perhaps so envious, of the quality of the service provided in the relatively minuscule private sector that it must legislate against it? I think this is bringing the whole business of British medicine down to the lowest common denominator. Is it not patently obvious that the health and stimulation which a virtually bankrupt NHS could obtain from a well supported and flourishing private sector is just the very thing that it wants more than anything else?
1542 Without doubt, the worst disease from which we as a nation are suffering today is the canker of egalitarianism. All men, my Lords, are not born equal nor alike. It is a genetic impossibility. Let us harness the attributes of those who are better endowed, whether mentally, physically or materially, for the benefit of those less fortunate; but let us remember that there is no class distinction between these two groups of people. Despite the stated purposes of this Bill, which I have already quoted, the only real objective is to fulfil a Manifesto pledge expressive of a narrow sectional interest which, with its overtone of Marxist dogma, just cannot offer any benefit to the community as a whole. Surely the exclusions and restrictions of this Bill constitute a direct attack on the basic freedoms of the individual, both patient and doctor—a point which I was very interested to see was underlined by the noble Lord, Lord Goodman—and if that be the case no Amendments, however well-intentioned, no bargain, should be allowed to cloud the simple issue that we are dealing with primary principles. The pay beds issue, which has already created so much disruption and ill-feeling in the Service and in the profession, is essentially a deliberate, contentious red herring introduced for Party political purposes.
However, even if we stick to the private beds in NHS hospitals argument, let us remember—and it has been remembered quite frequently this afternoon—that there was a proviso. I learned from the noble Baroness, Lady Lee, on a previous occasion not to call it a promise, which it was not. But there was a proviso at the very beginning of this Health Service which allowed it to be set up, and which was an agreement with the Royal Colleges to allow private practice to take place in National Health Service hospital beds. Reverting to my Olympic analogy, the situation seems to resemble very closely that which occurred immediately before the recent Games in Montreal, when the host Government of Canada went back on its written promise to admit competitors from all countries. Again, in what we are discussing this afternoon, if it is not a promise—and I have said that I now take that back—an agreement is being broken, an agreement entered into in good faith, and it is unilaterally being set aside. I think that this is what the profession 1543 fears so much; that an agreement which it accepted and worked for 30 years is now set aside. The profession is frightened about other agreements or promises being set aside in future.
Furthermore, in the original Manifesto which gave birth to this Bill, although pay beds certainly featured to a marked extent, no mention whatsoever was made of limitations on private practice outside the NHS, which appear in Part III of the Bill. This is an addition which was not in the Manifesto. These limitations include the imposition of controls on the provision or extension of private hospital facilities, with consequent authorisations for planning permission, fees for such authorisation and certifications, and the appointment of inspectors with a right of entry to oversee all this new work. I suggest that regulations such as these, however much they may be camouflaged in honeyed words, cannot hide the stark truth that this is a positive preliminary move towards the total abolition of private practice, and the establishment of a monopolistic State service. With the best will in the world the profession could not, in all honesty, put any other interpretation upon such measures.
This brings me to the extremely serious question, in my view, of the effects, direct and indirect, that this Bill will have upon the standards of British medicine, effects which have been mentioned by one or two noble Lords and which I think need to be stressed. Surely this is a matter of prime importance to the National Health Service as a whole, as it was initially set up to provide for the people of this country the very best medical care obtainable.
Your Lordships will be well aware that for the first time in the 30-year history of the National Health Service the Royal Colleges and the specialist faculties, whose primary concern is to ensure that the overall standards of medicine are maintained and improved, have been constrained to enter the embattled arena of medical politics during recent months. I need not go into the details of the reasons they have given for their fears that this Bill will have a deleterious effect on these standards. A number of statements have now been issued putting forward cogent and, I would humbly suggest, almost 1544 irrefutable arguments against the withdrawing of private beds from the National Health Service hospitals and against the limitations of private practice in general.
It seems to me an extraordinary situation that the Bill should aim to establish two separate tiers of medical practice—the very antithesis of the original National Health Service ideal. As one noble Lord has already said in this debate, it represents apartheid in medicine in this country. The practice of medicine is an entity. It may be quantified by bureaucracy, although that is difficult enough, but it cannot be qualified by dogma without great detriment to the community at large.
This debate, being only a Second Reading, is probably not the place to introduce detailed consideration of the many contentious matters contained in the Bill, but I venture to mention one or two as, very sadly, I shall be leaving the country shortly, though not because of the Bill, and will be absent for the rest of the discussion. Therefore I should like to mention one or two rather general aspects.
I note that despite all the detailed methods described in the Bill for withdrawing private beds from National Health Service hospitals no mention is made of means for establishing such accommodation in areas where provision is inadequate or absent. And these areas do exist. It would he very interesting to learn of the use which has been made of private accommodation which has already been vacated. This point has just been mentioned by the noble Baroness, Lady Young, among others. It would not seem that the creation of office space, of storerooms, or even of its use for geriatric patients, who obviously can only be indifferently cared for in single room accommodation, are justifiable purposes to which to put previously fully used general medical beds.
Again, in today's age and in these present economic conditions, can there be the slightest justification for the financial outlay which is inherent in implementing the measures included in the Bill? Apart from the admitted loss of a substantial sum from private patients' accommodation fees, a sum which, as noble Lords have heard, has been variously estimated but 1545 is probably at least £20 million a year, there are boards to be set up and staffed not only centrally but also in Scotland and Wales. And I ask myself, not understanding these things, what is to happen in Northern Ireland? Inspectorates are to be set up and paid for and there is to be yet more paper work, more form filling and more bureaucratic waste of time and work. Is this not a most profligate waste of funds, funds which are urgently needed in other spheres of the Service?
And yet again—I know that this point has been mentioned already—is it really necessary to bring into the Bill that well worn red herring of waiting lists and queue jumping? There is only one reason for waiting lists and that is the shortage of operating theatre accommodation and of the staff to put into them. This shortage requires extra funding facilities, and those we are now going to spend upon setting up the unnecessary measures suggested in the Bill. For no really valid reason the Bill proposes to squander financial resources on measures which achieve nothing either for National Health Service or for private patients.
Your Lordships will be well aware by now that I am no politician and what I am about to propose may be administratively impossible, or even constituttionally out of order. But what a simply magnificent gesture it would be on the part of the Government if they offered, under existing circumstances, to withdraw the Bill, even temporarily, or perhaps, as has been suggested before, to refer it to the Royal Commission for study (for this is where it surely belongs) so that, as the noble Lord, Lord Goodman, has said, it can be put into perspective in the context of the medical set-up of this country as a whole. A magnanimous gesture of this kind not only would instil a breath of fresh air into the turgid hours that we have spent in this Chamber during the last few weeks, but would raise a cry of joy from the medical profession and do untold good in healing the disastrous rifts which have occurred in the last year between the medical profession and the Government. It would show a genuine desire for genuine co-operation and this is what is so very badly needed. By avoiding putting at risk the standards of British medicine, which are so dear to the hearts of all of us who are medical 1546 men both in this country and overseas, it would achieve what, after all, is surely the prime, initial and continuing object of the National Health Service—the best possible medical care for all patients in this country.
§ 6.37 p.m.
§ Lord AUCKLAND
My Lords, one of the more impressive features of this somewhat depressing debate has been the maiden speech of the noble Lord, Lord Stone, to which the whole House listened with enormous interest and respect. We hope that we shall often hear from the noble Lord.
I must echo what my noble friend Lady Young has said about the timing of the Bill. Certainly I exclude the noble Lord, Lord Wells-Pestell, from any blame. All those who know him and his contribution to medical matters have a deep respect for what he has done and what he will continue to do, whether or not we always agree with his point of view. However, it is an intolerable situation when the careers of many who are in medicine now, and, above all, of many who are planning to enter the profession—not to mention the most important people of all, the patients, who are so very conscientiously looked after by our doctors, whether they are British or Commonwealth doctors—are going to be very seriously jeopardised by many of the provisions of the Bill.
I must say at once that I have never been a private patient, nor have any members of my family, and I am never likely to be one. We have always received the very best treatment from the National Health Service. Recently, I re-read the debates which were held in the middle and late 1940s on the National Health Service. I believe that the country owes a considerable debt to the late right honourable Member for Ebbw Vale for introducing the Service, despite all the resulting problems and shortcomings. If he were alive today, just what he would be thinking of this legislation as at present drafted I do not know, but I have a shrewd feeling that he would be very disappointed at much of it.
Much of what I wish to say I will save, if I possibly can, for the Committee stage of the Bill. But, as other noble Lords have said, and particularly those in the medical profession, I feel that this shuttlecock on the National Health Service which 1547 is being passed from Government to Government is immensely damaging; but I am bound to say from these Benches that I had no more enthusiasm for the reorganisation of the National Health Service which was carried out by the Conservative Party than I have for this Bill. I must make that point; I should be very much less than sincere if I did not because I served, as have many other noble Lords (I have mentioned this in your Lordships' House before and I apologise for repeating it), prior to reorganisation, on the house committees of both a children's hospital and a mental hospital. It is no use crying over spilt milk: the fact is that reorganisation has taken place. It is obviously not in order to discuss it on a measure of this kind, except to say that a great deal of the demoralisation of the National Health Service has hitherto been caused by this, although I believe that those who work in the Area Health Authorities and the community health centres are doing their jobs as diligently as their terms of reference allow.
We now have a Bill on which, admittedly, there has been some consultation with the doctors but I submit that there has been not nearly enough. In many ways the Bill has been ill thought out and I believe that one of its worst aspects is the second Schedule, which mentions the number of beds which are to be phased out, among them as I understand it, the first 1,000 within the first six months from the date when the Bill goes on the Statute Book, if unhappily it does so.
For example, I cannot understand why in Cambridgeshire 20 beds out of 56 are to be phased out, which is almost half. Cambridgeshire has one of our leading teaching hospitals in Addenbrookes. How are they going to fare under this? Then as my noble friend Lady Young mentioned, there is the question of the new towns. We do not quite know geographically—at least I do not—how this will work, but I should have thought that the money which is to be expended in setting up these boards would have been better spent in equipping hospitals in some of the new town areas, particularly, for example, Milton Keynes which will have at least a six figure population. How much of the money could have been diverted to that area, where there will 1548 be a mixed population of young, middle-aged, those in work and those who have retired? I wonder how much consideration the Government have given to that.
Then there is the future of the nurses. Many of us have daughters who are nurses; or, in my case, I have one who is 17 and is going to be a nurse. It is a very good thing for nurses to have experience in all types of medicine and in many areas—the Potteries at Stoke-on-Trent, where they meet people who may perhaps talk roughly but have hearts of gold, or the patients of the East London Hospital, which is one of the finest hospitals in the country and which I was privileged to tour not so long ago. I believe one has to give some thought to those who are not only practising at the present time but will be in the future, be they from this country or be they the overseas doctors and nurses on whom we place such reliance and who give us such faithful service, whatever the colour of their skin and whatever their nationality.
The noble Baroness, Lady Lee of Asheridge, in what I thought was a most impressive speech, even if I did not agree with every single word of it, mentioned that absorbing book In Place of Fear which I re-read not long ago and which I—and I hope all noble Lords—will reread between now and the next stage of the Bill because it has much which is germane to medicine and the National Health Service today. I listened with interest to her comments about side wards for those who are prominent politicians, and perhaps for those who are prominent in other walks of life. The only trouble with that is that if there is a shortage of nurses, as there is in many hospitals, one does in fact get better treatment in a public ward. That is a point which has to be considered, but of course the wards where there are three or four patients can give a young doctor or a young nurse a great deal of experience.
I have just two more points to make at this stage of the Bill. This debate today has one advantage. We have heard, and are going to hear more, from members of the medical profession, consultants and general practitioners. The other point—the final one—is this. We can never divorce ourselves from the fact that our National Health Service is one 1549 of the finest in the world. I have travelled a fair amount this year; I have been to Czechoslovakia and seen one or two very large hospitals there, with modern equipment, some of which would make the mouths water of those who are running our own big teaching hospitals. But in Czechoslovakia, too, there is a shortage of nurses and doctors. So I do not think we should necessarily blind ourselves to these facts. There is much work remaining to be done on this Bill, particularly in some of the points enunciated by the noble Lord, Lord Goodman, in his very good speech. I hope we shall get plenty of time to devote to this Bill and that it will be carried out, as it has been today, in a non-partisan but constructive manner.
There is much in the Bill that is very wrong; there is much in the Bill which is almost unworkable, and there is much in the Bill which will have a very bad effect on the morale of those working in the Health Service. I do not wish to be unduly controversial, but some of the industrial disputes have been engineered by those who do not carry out the nursing of the patients. Of course, the hospital porters and others have a perfect right to give their views, but, after all, whether it be a private hospital, a general hospital or a geriatric hospital, or whatever type it is, a hospital is run by the nurses and doctors who administer to the patients. This is what we should have in the forefront of our minds as this Bill goes through its various stages, possibly taking many long hours.
§ 6.52 p.m.
Lord WALLACE of COSLANY
My Lords, I am not a member of the medical profession, but for over forty years I have been engaged in a campaign for a National Health Service. I was proud to be in the House at the time when the Service was introduced, and took part in the celebration dinner with the late Aneurin Bevan, the only time I have felt "tiddly" in all my life. To get back to the present day, I am involved in the lay administration of the Health Service. I bitterly regret the political battles and attacks which are being made on the Service at the present time. I am very concerned about this, but I will develop that theme later.
There is one point I should like to clear up straight away. The noble Baroness, 1550 Lady Young, mentioned the loss of billions of pounds to the Health Service as a result of withdrawing private beds, and other speakers have made various comments about the figures involved, but I want to know what is the actual net figure involved, because private beds in hospitals are very expensive to run. There is not only the question of the medical attention, nursing attention and the work of the ancilliary staff; there is also the cost of drugs, of equipment and of many other things, especially certain of the things supplied with the private beds that do not normally apply to an ordinary bed. So a private bed in a hospital is more expensive to administer than an ordinary bed. Therefore I should like to know what is the actual figure of loss, if any—and I am hoping to receive the information—ensuing as a result, say, of the transfer of 1,000 beds out of the private beds service. It has already been said that many of the beds are not being used anyway, so perhaps later in the debate we could have this important information.
My Lords, I do not think any noble Lord or noble Baroness will quarrel with the statement that it is an essential human right in this modern age that the sick should receive the best available treatment and care, irrespective of class, colour or wealth. I do not think anybody would object to that. At least the great majority of people, particularly on the other side of the House, will pay lip-service to it. At the moment, I am a member of the Social and Health Questions Committee of the Council of Europe. One of the problems we have been dealing with is that of people abroad, or people going to the Council of Europe area for work. We have had cases of the fantastic cost falling on individuals because they have suddenly become ill or involved in accidents and because the country concerned charges expensive fees for the treatment of the sick. Some people insure when they go on holiday, but not everybody. There are problems. We are introducing a possible health card and are trying to overcome the problem through the making of a claim on the member country of the person involved. But this is the point: that in this country we have something that the rest of the world have not but which the rest of the world admires.
I welcome the Bill because, in essence, it goes a long way to ensure that in the 1551 State Health Service the possession of wealth shall not purchase priority or, indeed—and this is a point that should be borne in mind—carry the feeling that some payment of fees can produce a cure or prolong life. I know there are some people who pay fees in the desperate hope that such payment will secure a medical miracle to prolong a life. It is a fact, and we cannot ignore it, that in many cases queue-jumping does take place. It is no good dodging the question; queue-jumping does take place. I do not object to private health schemes outside the National Health Service, although we must bear in mind that the great majority of doctors in such services in any case will have received their expensive training and experience in the State Health Service, much of it at public expense. In fact, private schemes as they exist today could not exist if it were not for the doctors attracted or extracted from the Health Service.
One of the arguments for pay beds in National Health Service hospitals is that they ensure privacy for the patient. This argument overlooks the fact that amenity beds will continue to exist, and in any case the need for a room away from the ward should be based primarily on medical need. As I know full well from my own experience, in many cases where the medical need is evident and it is possible to do it the doctors cut out the regulations and the patients get the private rooms they need because of the state of their health. That applies not only to amenity beds but to the private beds as well.
Even today, when we refer to private schemes I would point out that they have their limits. For instance, only a few days ago we heard that BUPA has now stated that they are not prepared to continue the care of many elderly members needing long-term care; the extremely difficult problem of the care of the chronic sick and of geriatric nursing is for the National Health Service alone—in other words, private treatment is selective; it takes the plums and leaves the problems.
This Bill has received, and will receive, the strongest opposition from the Conservative Party. This comes as no great surprise to me, remembering their strong 1552 reputation as the Party of privilege. Their support for the National Health Service is lukewarm and certainly suspect. I remember that they voted against the National Health Service on the Third Reading of the Bill in the other place when the Health Service Act was brought in. It was a Conservative Government that created the reorganisation of the Service which today has created a bureaucratic system strangling patient care with excessive cost and remote impersonal control—I would say, apart from the argument of the consultants on the pay beds, one of the primary causes of unrest in the Health Service in our hospitals today.
Now reports are coming out of the recommendations of the Conservative Working Party which, if adopted, could wreck a Service which has gained the world's respect. The right of an individual to purchase privileged treatment outside the National Health Service because of ability to pay or through subscriptions or fees to private schemes, I would not challenge; that is the right of the individual. But to suggest that those schemes should be boosted by generous tax reliefs at the expense of the State Service and the majority of tax payers is downright immoral. Yet such proposals, if the reports are accurate, are being put forward to the Conservative Party. At the risk of electoral defeat, Conservatives would adopt those proposals, although it would be outrageous if they were brought into effect.
This is a Bill of principle and not of political Party dogma. The principle behind it is need rather than ability to pay, the very basis of the National Health Service as originally conceived and of which many of us are greatly proud. We wish it to overcome its difficulties and become the great ideal which Aneurin Bevan and many others had in mind but which is today being frustrated by political dogma, not from this side but from the other side of the House.
§ 7.2 p.m.
§ Baroness FAITHFULL
My Lords, I am the fifteenth speaker in this afternoon's debate and everything that I had intended to say has been said. However, unashamedly I intend to say it again. I wish at the outset to pay tribute to the 1553 noble Lord, Lord Stone, for his maiden speech. I am not a doctor, but I have cause to be very grateful to the medical profession and I speak as an ordinary person. I speak against the Bill, but in doing so I recognise that there is much to be said on both sides of the question whether private pay beds should eventually be abolished or should remain in the Health Service.
These arguments concern certain specific areas but they are, I submit, indicative though irrelevant to the main issue. The specific areas of contention are well known and have been referred to many times today and therefore I will not speak for too long on each. On the question of queue jumping and queues generally, I support the noble Lord, Lord Porritt, in wondering why this position has not been referred to the Royal Commission which, after all, was set up to consider the best use and management of the financial and manpower resources. If a system could be worked out to prevent queue jumping to give a good service to both National Health and private patients, which in many cases is received at present, that would dispose of the allegation made by the right honourable Mrs. Barbara Castle when she said in another place that the argument over pay beds was fundamentally one about money and nothing else because money was made out of queue jumping. It would have been scientific, realistic and enormously helpful if the Royal Commission could have looked into this and could have suggested a system by which queue jumping was dealt with; that is, if queue jumping exists to any great extent.
The second area is dual standards. What are these dual standards? I can find in Hansard of the debate in another place no reference to dual standards in medical treatment by doctors. So far as I could see, the dual standards applied to such things as food, and here again, with proper management, this need not be so and indeed the difference in diet between National Health and private patients does not exist in many hospitals. In another place the Minister talked of the marriage of pay beds and the National Health Service and said that it had not been a happy one and that there had been intensity of feeling in hospitals. Why is there this feeling and where does it come from? The number of pay beds in the 1554 National Health Service, as has been said many times in this debate, represents only 1 per cent. of the total. It is perhaps understandable that nurses and ancillary staff might think that they should be paid extra for working with patients who are paying a fee to the National Health Service. Again, surely this situation could be looked at, either by the Health Service or by the Commission. It cannot be an insuperable problem and it should therefore be dealt with.
Those who are against the Bill make specific points. The cost to the taxpayer is estimated to be £3 million rising to £20 million in 1980. The money coming in now to the Health Service as a result of pay beds is difficult to estimate, as has been pointed out, but it should be known that the chairman of an area committee told me with despair that four months' income from the private use of National Health Service beds would build phase two of his general district hospital. Can we afford to lose this money?
With regard to the desire for privacy and the right to chose one's consultant, and pay heavily for doing so, is it so very anti-social? It is a question of preference. Two Cowley workers on the shop floor at British Leyland commented to me on this subject. One man said that he was paying into the British United Provident Association because, "My old Dutch likes privacy and when she's ill she's going to have it". The other said, "My wife likes the gaiety of a public ward but I prefer privacy, so I will pay". Surely people have the right to choose.
I have touched on but a few points in a glancing way. The reality of the situation, contrary to what has been said, is that the Government and the doctors are looking at the Bill from entirely different standpoints. I would very much welcome a philosophical debate with the noble Lord, Lord Wells-Pestell, with perhaps a Prelate in the chair, because the noble Lord has described this as a moral issue. Is it really a moral issue? Is it not a question of political ideology, to which people are of course entitled? Cannot we be honest and say that it is not a moral issue but one of politics? It cannot be for economic or medical reasons or because it will greatly benefit the patient. It is hard to see how the patients will receive a better service from 1555 the doctors because 1 per cent. of pay beds are removed from the Service. Could it be that the abolition of pay beds is dictated by certain sectors, other staff, in the Hospital Service?
On the other hand, as the noble Lord, Lord Goodman, said, doctors are not political beings; they are not interested in politics. In medical policies, yes, but in politics, no. They are committed to their hospitals and the medical care of their patients, some might say so much so that in the past they have tended to be isolates, but I think that this has passed. Since the passing of the 1946 Act they have made the National Health Service work by putting in long hours and giving good service. Why else do people come to this country for medical treatment? I suggest that the doctors apprehend that the Bill is the first step along a road which will eventually threaten their freedom to practise as their professional skills dictate, and they fear the break-up of the spirit of the Service which has characterised it for so long. They foresee that eventually the patients could receive a poorer service. Medical practice will be dictated to by the bureaucratic machinery and eventually professional freedom will be eroded and the practice of medicine will be subservient to bureaucratic controls.
Upon what am I basing this statement? In a new hospital which I know there is no room for the doctors to meet together. Such a common room is essential to the doctor's trade, and to the service of the patient. It affords privacy for a doctor to discuss his cases with colleagues, to share his worries with friends, to receive advice and support from colleagues, and in it, instead of going home, he can wait for his patient to come round after an operation. Such a room enables doctors to work better. In a hospital that I know doctors have requested such a room to help them and have been refused on the grounds that, if they have a room, the cleaners should have one and, if the cleaners have one, the porters should have one. I believe that the cleaners and the porters should have one. I believe that the cleaners and the porters should have a room, though I do not believe that they need a room in order to do their work better. If they had one, they might be happier and more sociable. But the doctors need a room for the sake of the 1556 patients and I maintain that, in the building of hospitals, if we are going to say that we cannot afford a room for the cleaners and the porters and that therefore the doctors cannot have one, we are yielding to bureaucratic inflexibility.
§ Lord CASTLE
My Lords, can the noble Baroness indicate in what section of the Bill the building of hospitals and the provisions in those hospitals are provided for?
§ Baroness FAITHFULL
My Lords, the noble Lord knows the Bill as well as I do. I am talking about the future and about how the doctors see their future if the pay beds go out of the National Health Service and they lose their independence. That is what they are concerned about.
Secondly, I should like to mention the chairman of a Health Authority who wrote in October 1975 to the right honourable Barbara Castle asking why, in the Consultative Document on the separation of private practice from the National Health Service, Area Health Boards were not included in the consultations. Such lack of consultation by Whitehall gives cause for concern. It is such instances as these which concern the doctors for the future of the National Health Service they have served so well. Furthermore, they foresee a polarisation of the National Health Service and the private sector and, despite what is said, doctors care not only about the 1 per cent. of private patients but also about the 99 per cent. of National Health patients.
§ 7.14 p.m.
§ Lord BROCK
My Lords, in discussing this difficult, unwelcome and poorly thought out Bill, I begin, like so many other noble Lords, by referring to the original arrangements of 1948 which recognised the great advantages that would follow from obtaining the cooperation of doctors in the organisation of the National Health Service. By arranging that some private practice was to be allowed in the NHS hospitals, it added to the efficiency of the Service by ensuring that doctors who wished to do some private practice were able to do so on a geographical full-time basis. This not only helped the doctors but also helped the patients and the National Health Service. So much has been written and spoken 1557 about this 1948 arrangement that I do not wish to expand upon it further, but it is necessary to emphasise how successful it was. It has worked much to the benefit of patients in the National Health Service. Indeed, in 1972 it was the subject of a White Paper in which it was decided that the advantages were so greatly to the benefit of the National Health Service that it should be continued. Now, almost 30 years after that start of the National Health Service, as the noble Lord, Lord Porritt, has emphasised, we are confronted with a Bill that seeks to alter this successful and honourable arrangement. However, when we examine the Bill carefully, we find that many of its contents are uncertain and that many things in it are ill-digested and have not been thought out to their logical conclusion.
We live in times of economic stress and it is certain that savings must be made and additional expenditure avoided, yet those who control our destiny do not seem to be aware of this. Take, for instance, the cost to the National Health Service of the closure of pay beds. It has been estimated that when we add to the loss in revenue from paying patients the extra cost of employing more consultants full time instead of part time, this will result in a loss of some £40 million a year. The Minister of State declares that this is far too large a sum and that this Department estimates the extra cost at only some £7 million to £8 million a year, and even that figure has virtually doubled over the last few weeks. It is very difficult to reconcile such a difference, but at any rate the Minister admits that he is aware that the closure of pay beds will result in extra cost. However, he thinks that it is worth it.
I find it difficult to accept a statement that at a time of financial crisis such as we are facing, any extra expenditure is justified, especially when there are so many things against it. It is characteristic of so many statements that are made in an attempt to justify this cruel and spiteful action. They can only be described as glib. Not only are such statements glib and even naive but, when one seeks to inquire into their full significance, one finds that they are far from complete—are, in fact, grossly incomplete and have just not been fully worked out. I should like to take one or two specific points and try to get a clear and logical amplification 1558 of what they signify. It is proposed that, initially, a thousand beds should be closed and that this number will steadily increase. I can understand how this will affect the total number of pay beds in a National Health hospital, but I just cannot get precise information about how this will affect private wings or blocks which are attached to the larger teaching hospitals both in London and the Provinces. Almost without exception, these were originally given by private acts of benevolence. An example is Nuffield House, which was given by Lord Nuffield to assist people of "moderate means".
I understand that Parliament has power to overrule any charitable request and, since 1948, has gathered all these private wings under the control of the Minister of State. I can understand that they should fall into his possession to continue as hospital accommodation within the National Health Service, but I do not see how the Minister can justify their closure as accommodation for sick people and their use for a different purpose such as offices. We have been told that this has been done at University College Hospital. Suppose that 10 per cent. of a private wing with 75 beds or rooms is to be closed: what is to happen to the seven or eight beds thus put out of action? Are they to be used as offices or store rooms or for some lesser purpose, connected in a feeble way with the care of patients, but in no way comparable to the way they have hitherto been used? Or are they to be neutralised and left to collect dust? These are important matters, and I can see no directive or explanation of what is to be done with this accommodation and what is to be its ultimate fate. How far has this been worked out in a serious and responsible way, having regard to the importance of our scarce accommodation for patient care?
There is another glib statement that is made in connection with pay beds, another bare statement that does not seem to have been worked out or even thought through to its conclusion. It is stated that British nationals, for whom these beds were provided by a act of charity or benevolence, may not use them as pay beds but that foreigners—that is, people from overseas—can do so. It is also stated that the fees that these overseas patients will have to pay for their treatment will be taken by the Government, and that 1559 the doctors and others connected with this treatment, often of a highly skilled and responsible nature, will receive no fee apart from their full-time salary. I ask; has the full significance of this step been carefully considered and has the resultant disorder and dissatisfaction that will accrue been fully thought through?
I am told that many of these overseas patients will be accepted under an arrangement between a foreign Government and the Department of Health, often a sort of package deal. This is largely conjecture as no precise information has been given. But I can foresee all kinds of difficulties in such an arrangement. Who, for instance, is to look after the investigation and treatment of the patients? Ordinarily the selection of a consultant or specialist depends on a personal arrangement and recommendation made by the patients' own doctor and results from his knowledge and consideration of the skill and achievement of the consultant. He advises the patient who to go to and the patient trusts him. At once we encounter a difficulty. If the patient's doctor suggests Dr. X to take care of his patient, is some administrator in an office going to direct him to Dr. Y or Dr. Z, as may well happen if Dr. X has heavy commitments?
Another thing, there must be a limit to what any doctor can undertake or be organised into doing. I think especially of those surgeons concerned with the more complex and generally more exacting operations, such as neurosurgery, hip replacements or open heart surgery. As I am more familiar with the circumstances, I take this last as an example. Not only the surgeon but the whole team work for many hours on an operation, say until well into the evening. But their involvement does not finish then. They must be alert and on duty for the whole night at least and often they have to do a secondary operation when things are not going smoothly. This period of anxious post-operative care may continue for two, three, or more days, and in the meantime one or more open heart patients have to be operated on. The sum total of effort over a week may be almost intolerable and virtually ruins any maintenance of family or social life.
In this matter I foresee that the limits 1560 of human endurance can be reached, and therein I see that a great deal of trouble is being laid up. It certainly impairs the efficient running of the National Health Service. In fact, it can lead to the dangers of refusal to work—something to be avoided at all costs, as the noble Lord, Lord Platt, has emphasised. I emphasise what an unsatisfactory state can be engendered by a Government directive not being thought through as it should be. Even the full-time academic who does not expect to receive a personal fee is going to object to being exploited to excess.
I am worried about the future of overseas patients. At present their reception and treatment brings much added prestige to Great Britain and this should not be allowed to suffer or to decline. It is, however, something that can easily be damaged if it is handled carelessly or without imagination. From a profit point of view alone—I mean profit to the country—it may not be significant. It is scarcely as important as the sale of aeroplanes, tanks or motor cars, but it does have its own intrinsic economic value. But even more important is the prestige factor. I think that we should be careful of not driving these overseas patients away from Great Britain to other European countries or to America.
I am also worried about the curtailment or cessation of out-patient facilities for the use of private patients, either from overseas or from this country. Great harm to patients can be done by interfering with the facilities and services they can now use. Let us remember that patients from this country have already paid for their treatment and deserve to receive it. They should scarcely be prevented from having it just because they have to pay a special private fee to the National Health Service for it. I think especially of the use of highly specialised equipment, such as for deep x-ray therapy, and of complex diagnostic procedures and the special investigation of neurosurgical and heart diseases, and of cancer in its many forms. Surely nothing should be done to prevent patients from using these facilities, whether they are foreigners or our own nationals. Arrangements can always be made so that their use of the special apparatus does not interfere with its use for National Health Service patients.
1561 I have tried to speak of certain features of the Bill that I think present dangers to our care of patients and are to be avoided. From the experiences of your Lordships' House during the past two to three weeks, in which you have been faced with a torrent of difficult and controversial legislation to be rushed through in a short time, a seems that there is little or no point in attempting to advance even reasonable contrary arguments and Amendments. They will only be brushed aside when the Bill returns to another place. It would be good if we could feel that good sense and reason would prevail, but there seems little hope that it will do so; it will be faced with blind and stubborn prejudice.
Lastly, throughout the many months that this sad business of private treatment and the National Health Service has been going on, there is one more feature that has impressed me very much. Somewhere about one half of the personnel of the National Health Service are full-time and are not engaged in private practice. One would have thought that this moiety would not be interested in the matter of its curtailment, impairment, and even its possible obliteration. It is, however, a remarkable fact that even the full-timers, especially the younger ones, have reacted very adversely to what is planned. They fear of course a complete loss of professional freedom. The medical profession are united in their distaste for it and have closed their ranks. Surely this is a very significant happening that cannot be ignored, and to ignore it is bound to lead to increasing trouble and unrest.
§ 7.26 p.m.
§ Lord O'HAGAN
My Lords, I was born shortly before the National Health Service started, and therefore to somebody of my age the National Health Service is as much a part of the structure of Britain as your Lordships' House. I hope that during the ensuing stages of the Bill Members of this House who were Members of another place and remember the 1945 Parliament, will not be tempted to re-use their speeches from that era. I support the National Health Service fully; I believe in it; I wish it had more resources; I wish it could work better; and that is one of the reasons why I wish we were talking about that wider subject rather than about the limited area we are debating today, 1562 which is solely concerned with 4,000 beds—1 per cent. of the provision of the National Health Service.
I cannot claim to be an expert in this field. I feel rather similar to English Peers who intervene in a Scottish debate. One has a certain increased sense of one's daring in trespassing on the territory which is normally reserved for the specialist. But there are some points which the Bill raises which go beyond questions of medicine and go beyond the organisation of the National Health Service, and I should like to raise some of them. They are points to do with the liberty of the subject, the proper place of freedom under the law in our society, and they relate to the kind of considerations which my noble and learned friend Lord Hailsham of Saint Marylebone has been discussing, and I very much hope that I will not drive away the noble Lord, Lord Houghton of Sowerby, because I feel that they are some of the points which he found to be of interest during our deliberations on the Race Relations Bill.
I reject completely the attitude of the noble Lord, Lord Wells-Pestell, that there is some moral superiority in the stand of the Government on this issue. I do not think that compassion is the prerogative of any one political Party. I do not think that concern about the state of our society and provision for those who are ill or less fortunate is something which any political Party can seriously claim to monopolise or to command the right to speak about as if it did. I reject this. If the noble Baroness, Lady Lee of Asheridge, said that part of the reason for the Bill was the spirit of the age (and she meant particularly the concern of the ancillary workers—the cooks and the cleaners—who felt that it was unjust in 1976 that somehow the private patients should have special treatment, despite the historic compromise that had worked so well for so many years) then I say to her, and I say to the Government, that there is something else in the spirit of the age. There is an increasing distrust of the encroachment of the State. There is an increasing worry about the liberty of the individual to choose. There is an increasing anxiety that those who have been trained to do specific jobs are not going to be allowed to do them by the diktat of a minority Government which does not represent the whole country. My Lords, it is these libertarian and constitutional 1563 issues which I feel have a very real importance in our considerations of this Bill, and I am going to attempt to say one or two things about them, because I do feel they have a place, even if they do not at first blush seem to arise when one is looking at a Bill that deals with pay beds in the National Health Service.
My Lords, I do not think that the way that this Bill has arrived in your Lordships' House is satisfactory. It is alleged that it is part of a Manifesto pledge, and that may be so, but this Bill was not prepared by the Government. It is, if you like, the result of private practice. It was farmed out to somebody outside the Government to resolve a conflict which the Government themselves had not been able to resolve. It is no use the noble Lord, Lord Strabolgi, looking angry when I say that; it is true.
If we had a Bill of Rights or a written Constitution—and I am not saying that we should, but if we did—in which the rights of the subject were detailed and with entrenched clauses so that they were preserved, many of the anxieties that worry individuals and the professions would not arise. If doctors were allowed to get on with their work, and if their rights to do so were entrenched in a written Constitution, there would be no question of a Government's coming along and prohibiting their so doing. That may sound exaggerated and, of course, I do not want to attempt to undercut what other noble Lords have said about the importance of creating an atmosphere of trust. I hope that we, in our proceedings on this Bill at the Committee stage, will do what we can to improve it, but I think that when we are discussing the Bill on Second Reading we must look at the principles of the Bill, if it has any principles or can be said to have any principles, and we must also examine the principles behind the Bill. We must look at the reasons why we have the Bill at all and we must try to examine what we should do with the Bill in the context of its parentage.
My Lords, I have a special reason for intervening in this debate. It is that my wife and I happen to support a particular type of medicine which is not available on the National Health Service; it is homeopathy. In some countries, where the liberty of the subject is not as well 1564 entrenched as it is here, I should not be able to do so. I have a special reason, therefore, for wondering whether this Bill and the pressures which led to it are the beginnings of a process which will end up with the individual's right to choose the type of medicine he likes being prohibited. That is something that I feel we should take seriously, and it is not enough for those who do not think we should take this seriously to say that this is mere sabre-rattling and bogey-mongering.
In the Consultative Document that they issued in September, 1974, the Government sought to examine the reasons for the troubles that they were considering legislating about, and in paragraph 7 they said:The simplest way of resolving these tensions and controversy is to abolish private medicine entirely. To be effective this would require legislation specifically banning the practice of private medicine. Such an obvious solution has its strong adherents, though they are almost certainly a minority. It is perfectly possible to argue against any such ban while strongly disapproving of private medicine.They went on to say in paragraph 8:It is the clear and openly stated policy of the present Government that it does not believe that private medicine is something which deserves the support of the State.And then this is the sentence on which I wish to concentrate:The Government does not, however, believe it is desirable to express such a policy in the form of legislation designed to ban private medicine.My Lords, how cautiously phrased that is! It does not say "We will never ban private medicine." It does not say "We think it would be wrong to ban private medicine." It simply says, "The Government does not believe it is desirable to express such a policy in the form of legislation designed to ban private medicine".
§ Lord WELLS-PESTELL
My Lords, would the noble Lord give way? I covered that point. I made it perfectly clear when I spoke that the Government has no further plans to attack—if you like to use the word—private medicine or to ban it or to outlaw it. I should have thought that point was perfectly clear. I made the point very early on.
§ Lord O'HAGAN
My Lords, I wrote the noble Lord's words down. He said, "The Government has no plans to ban 1565 private medicine". He has repeated them, and I will refer to them in detail when I reach that point in my argument. Whatever the statements of the Government as a whole, there obviously are those inside the Government, and certainly inside the Labour movement, who wanted private medicine to be banned; and you have only to read the Second Reading debate in another place to see that there are members of the Labour Party who want private medicine to be banned.
The second quotation that I want to make—and I want to be fair to the noble Lord, Lord Wells-Pestell; I will be returning to his argument after I have made my second quotation—is from a statement that the Government made in its Consultative Document of August, 1975. It justified the proposals in this Bill on the basis of their being promised in a Manifesto, but in this Consultative Document, published in August, 1975, the Government said:Quantitative controlthat is, quantitative control over private practice—was designed to ensure that private medical care would not be allowed to grow beyond that which obtained within and outside the National Health Service in March, 1974.That was a statement that the Government made in 1975. That statement was not promised in a Manifesto, in either of the Manifestos, in 1974, yet that statement envisages, if you like, a freeze on the extension of private medical treatment.
My Lords, whatever the Government may say about having no plans to crack down on private medicine or restrict its growth, the fact is that in their Consultative Document in 1974 they did not promise to preserve private medicine and in their Consultative Document the following year they introduced a new restriction on private medicine which was not promised in either of their Manifestos. I trust the noble Lord, Lord Wells-Pestell. I like him. I do not think he is a Trotskyist or reads the works of Che Guevara at night. I am sure that he enjoys Miss Redgrave's acting and is not a member of the Workers' Revolutionary Party. But I think that those of us who are concerned about some of the actions of this Government are concerned because we see a shift in the centre of gravity inside the Labour movement which is reflected in a 1566 shift in the centre of gravity inside the Labour Party and therefore, inevitably, inside a Labour Government. It is remarkable, and worth remarking upon, that no legislation of this sort came forward during the 1964 to 1970 Administration.
I do not wish to stand here and say that this Bill is the beginning of the end of Western democracy. I do not wish to make wild exaggerations, but I do wish to say to your Lordships that when we are examining this Bill in detail at the Committee stage we should be looking at it in the context of the strengthening and development of the National Health Service. Yes, of course. But we should also be looking at its consequences for the liberty of the subject, for the freedom of professions to practise in a free society and for its constitutional implications. Because whatever the noble Lord, Lord Goodman, may come and say here to us in the role of a slightly more substantial Ariel and then flit off again, he cannot commit this Government or the next Labour Government. Because of the sovereignty of Parliament, to which prominent members of this Government are always referring, no Government can bind a future Government, and the noble Lord, Lord Goodman, cannot bind the future Labour Government.
Therefore, my Lords, if we detect a shift in the attitude of the Labour Party and the Labour Government towards private medicine there is no use writing safeguards into this Bill. Only history will tell us whether our fears are justified. I hope that when we examine this Bill in Committee we shall be able to extract some more substantial commitment from the Government, some more firm and binding undertaking to which they can be held, that this Bill is not the thin end of the wedge or even the thin end of the Wedgwood Benn.
§ 7.43 p.m.
§ Lord GISBOROUGH
My Lords, I was interested, when I read about the Royal Commission in October 1975, to see that public beds were not to be discussed in this Royal Commission. One could not help thinking that perhaps this was because the Government realised that there was no case for it and they would be frightened of the result. The demand for private beds is amply demonstrated by the number of people who 1567 insure themselves for health. Many people insure themselves privately out of their taxed income and they do it by choice. Some people perhaps have colour television, other people like to drink, others like to go betting and smoke; and some like to insure. It seems to me that there is no reason why the man who insures should be at a disadvantage to the man who drinks, which is what is happening. The Government virtually tell the squanderer that he will be in no way treated second to the provident man who has looked forward and tried to protect himself and his family by contributing to insurance. I suppose that this will be fundamentally disagreed to by the Party opposite.
As well as people having their own insurance arrangements, some firms pay for the insurance of their employees. I think it was extremely mean of the Government in April 1976 to make employees pay income tax on benefits received from insurances paid for by their firms. These health provisions contributed to a better relationship between employees and employers, which is a good thing: and it is essential for key personnel, as was brought out by the noble Baroness, Lady Lee. The noble Lord, Lord Goodman, rightly suggested that not too much attention should be paid to the campaigners against pay beds who themselves use pay beds. I should like to say that the number of well known politicians who go to pay beds are blatant examples of saying one thing and doing another. It is an extreme example of poor leadership. This sort of thing brings politicians into contempt.
The figures of numbers insured have been given several times. There were half a million in 1955 and these have doubled and redoubled to 2½ million in 1974. In addition, many people who are uninsured use private medicine. We know that no less than 38 per cent. of those who use the Nuffield Nursing Home are uninsured. Some 3 million people plus their families share 5,000 pay beds as well as the private sector. Some 11,000 people in 1974 used those 5,000 pay beds. Out of a total of 490,000, that is 1 per cent. and is really nothing.
In Hammersmith Hospital, which is typical, the pay beds are all in public 1568 wards. They are not particular beds; they are any beds. They can be one bed one week, and another the next. The food is all out of one kitchen and is described as equally bad for all. The fact that some of the beds are private pay beds in no way interferes with the patients there under the National Health Service. The noble Lord said that these beds take up facilities set aside for National Health patients; but this is not true. They do not in practice interfere at all with National Health patients.
The increase in the number of people who are insured is an encouraging trend. More and more people seem to want to have private medical provision. This includes many unions. The National Union of Seamen have agreements for some of their workers so that they can have private medical treatment. There is growing opposition to the Party policy within NALGO; although others in NALGO have been suborned to use their privileged position to file objections to new hospitals planned in their areas. Manor House Hospital is frequented by many trade unions. All this use in the private sector is a good thing because it relieves the strain on the National Health Service. The public demand for private medicine is expressed by the expenditure which many people pay out of their own pockets on insurance—even those who are violently opposed to the system. This expenditure which they are prepared to forego is rewarded now by the licensing controls over the building of new hospitals so that it will be difficult to put up any new private hospitals to meet the demand and virtually all increase will be stopped.
Government is surely meant to be by the people, for the people, and in this case including the people who are provident and wish to have private medicine. This Bill is regardless of the interests of people and the wishes of people; regardless of the interests of medicine and the interests of efficiency; and regardless of the interest of cost. It could be said that it is government by some militant unions for their political ideals. As for the surgeons, they need freedom to practise in the locations where they operate for their National Health patients. It is an enormous advantage for them to have their private patients in the same hospitals. If they have to go from one National Health hospital to a nursing home for their 1569 private patients, it seems to me that this travel represents extremely valuable time wasted. Furthermore—and I am sure this has been mentioned several times before—while at one hospital, they cannot deal with an emergency at another.
There is also the question of the duplication of expensive equipment which is unnecessary. By having plenty of pay beds in National Health hospitals you get better value from the doctors and from the equipment. The Government may say that they are not against private practice in private hospitals, but if there are no pay beds then the areas suffer and doctors will tend not to want to go to these areas. They do not like operating in nursing homes if this can he avoided. It has been said that in Scotland there are no pay beds, but conditions there are rather different. There are only three centres and they seem to get along without pay beds; they are used to the system. By and large patients are not referred to Scottish hospitals as they would he in England; therefore there is less opportunity for doctors there to gain the wide experience that they would in English hospitals.
Out of London there is less private practice and there will be greater pressure for consultants to be full time. This will make them more dependent on the National Health Service and also subject them to ever-growing union pressure. For example, one North-West consultant is at present suspended through union pressure as the result of a case where he found unexplained injuries to children in a hospital. The union took exception, with the result that he is temporarily suspended. A situation could build up where, to some extent, a consultant might put his own livelihood at risk through the threat of the unions and would have to weigh it up against complaining about conditions that might be detrimental to patients.
I am told that morale in the Hammersmith Hospital is the lowest it has ever been, and one assistant is going off to Canada in December. In another hospital in the North I am told that young doctors are "bolshie" and everyone is upset, and again one consultant is off to Australia. We have the continuation of a situation which was mentioned on 8th October in another place by the Secretary of State. She said that 1570 in 1976 106 consultants and registrars resigned from the Health Service to emigrate abroad. After December 1976 there will also be the freer movement throughout the EEC which will allow people to go at a faster rate if they wish. Junior doctors have accepted what they consider to be low pay on the assumption that they would eventually have some private practice, and they are upset that they will be unable to have a private practice. However, if some of the reassurance suggested by the noble Lord, Lord Goodman, is put into practice, this will go some way towards helping the situation.
As regards reward, in many cases without private practice there will be less reward. One consultant said that, just like dockers, they would work less like anybody else. However, the question of reward does not seem to be of high priority. Many of the salaries from private practice go into research. In the Hammersmith case, where consultants are part-time and get fees for private practice, they keep only 20 per cent. and 80 per cent. goes into school research. In some other hospitals consultants say that the amount they get from private practice rarely makes up for the difference between the health fees they would get from being full-time or part-time in the National Health Service.
The argument that there is queue jumping seems to be fairly strong and yet the Expenditure Committee in another place in March 1972 declared that the practice was only marginal and that there were other causes for the long waiting lists. If queue-jumping is the problem, surely it is only necessary to implement Clause 6 on common waiting lists. By proceeding with the whole Bill the Government are admitting that queue-jumping is not the real factor. It might appear that common waiting lists will solve the problem, but I am assured that no such policy will work because family commitments and other causes upset the waiting lists. In the North, and I expect also in other hospitals, queue-jumping is a myth; anybody who is ill gets in straightaway and there is no problem.
It has been suggested that staff resources would be released by the absence of pay beds and that 2,500 extra beds would be available. This is nonsense. The 5,000 1571 private beds would be available; but they would be at extra cost to the State rather than private patients—perhaps £3 million in the first year and £20 million in 1980. Of course the health authorities will have this made up by the Government, but it all comes out of tax. For instance in Teesside there are, at the moment, 20 pay beds and no private nursing homes. But at any one time there are about 200 empty beds, so the release of these 20 private beds would make no difference. They could merely remove the choice from the patient and from the doctor. It seems to us to be nothing but pointless political dogma.
There is much to criticise in the National Health Service, but pay beds are unworthy of criticism. To discuss them at all is a sad waste of time, energy and cost to the country, because they have very little effect in the National Health Service. The big demand for private medicine will be ignored. It brings in revenue, encourages the medical profession and serves a good purpose. Instead of the Government grousing about their countrymen who are provident and thrifty and look after themselves and their families by putting aside insurance, they should think constructively and try to build rather than pull down. The Health Service is almost paralysed for lack of money; staff feel themselves underpaid and casualty departments are abused. I am advised that, instead of going to their own doctors, many patients go to the casualty department.
For years the nation has been taught to think about public services; everything must be free. But, in fact, the Government pay and nothing is free, and people are just beginning to realise this. Everything has to be paid for out of taxes. When things appear to be free people take advantage. There is a limited amount of money and we are seeing deteriorating services, closing of hospitals and so on. I would prefer to see us going in the other direction and everybody having to pay when they go to hospital. Obviously many people would be unable to pay, but those who can should have to pay, perhaps for food or some aspect of hospital care. This would bring more respect to the services and less frivolous use; and soon the overall cost would be reduced and the service improved. 1572 Overall it would be cheaper, as a result, for everybody. With the situation as it is, with the hospitals closing and the shortage of cash, even though the idea of people paying may be unpleasant it may sooner or later be forced on the country. This is a dreary and pointless Bill. I do not think it creates; I think it destroys. The overstretched Service is now to be further hampered, not for medical reasons but purely for political pressures.
§ 8.1 p.m.
§ Baroness ROBSON of KIDDINGTON
My Lords, first of all may I apologise on behalf of my noble friend Lord Winstanley for his absence. He has a surgery first thing tomorrow morning at Salford and he had to be on a train at 8 o'clock. The noble Baroness, Lady Faithfull, said that she was the 15th speaker. I am number 19. Everything that can be possibly said in the Second Reading debate has been said. I want to make one or two general points and I will not keep your Lordships many minutes.
First, I want to welcome the fact that the Bill recognises the basic principle and the absolute right of members of the medical profession to undertake private practice. I welcome that because by inference it recognises the freedom of individuals to use their net income to insure for private medical treatment if they so wish. Much has been said about the danger of freedom, about the fact that a Government can legislate only for their own lifetime, and that there is no guarantee. I am not as cynical as the noble Baroness, Lady Young, or the noble Lord, Lord O'Hagan. I believe that the Government mean this at the moment, and that is all we can ever plan on. We have never had a Government that can commit the following Government. I welcome the fact that this Government have recognised that there is a need for private medical practice, for the freedom of the medical profession to practice as they wish, and for the freedom of individuals to make use of it if they want to. The removal of such a freedom is unthinkable in this country.
Having said that, I want to deal with three main problems which have been raised by the Bill and by the introduction of the Bill at this stage. First, I should like to ask the Government this. Why 1573 now? The noble Lord, Lord Platt, referred to the existence of the Royal Commission on the National Health Service. Yesterday they published their booklet The Task of the Commission. On page 6 it says:There are a number of important questions bearing on the relationship between the NHS and private practice which we shall have to consider. The most obvious of these is how far private health services help or hinder the task facing the NHS.When this Bill was discussed on Second Reading in the other place, the Secretary of State said it was not possible to refer this question to the Royal Commission because that would mean that the issue would fester for two years to no purpose. I read on page 9 of the same document that was published yesterday:We would certainly not expect the fact of our existence to hinder desirable development, and the Health Departments have agreed that we should have an opportunity to make effective comments upon major developments at a formative stage.It seems to me, reading that, that it means that the Commission could comment at any time during its life, and I believe that we should be legislating in a better manner if we listened to its advice before we rushed into the acceptance of a Bill such as this one.
Secondly, with such an overcrowded programme of legislation to get through, is there really time to examine thoroughly the clauses in the Bill in the time available to us? I do not believe there is. I think it is a serious Bill, one that should be given adequate time. One can also ask whether this Bill, or for that matter one to be discussed later tonight, is relevant to the economic problems that face us as a nation. There is one problem only, I believe, to which we as Parliamentarians should at the moment be devoting ourselves. That is, to get our country back on its feet, not to play about with minor matters which at such a time as this are not going to help to solve our problems. This Bill, and the one we are to consider next, do not help us in any way.
Now I come to my third point. I must declare an interest. As your Lordships know, I am involved in the administration of the National Health Service. I look at every bit of legislation that comes out relating to the Health Service to see whether it is likely to give me more finance so as to be able to run a better Service. Therefore, 1574 I look at this Bill. Is this Bill likely to enable the Health Service to run more efficiently, and thereby give us better value for money at a time of enormous financial difficulties for the Service? I do not believe it is for the following reasons. Many "guestimates" have been made in this House today about the loss of income that will ensue through the closing down of pay beds in National Health Service hospitals. They vary from between £3 million or £4 million and anything up to £7 million or £8 million in the first year. The overall loss in a full year has been estimated at anything from £20 million to £40 million.
Whatever the right figure is, the loss of finance is substantial. It is not only the loss of finance, because if we are going to use the beds released from the private section of the National Health Service in order to help us to reduce waiting lists, we shall need the equivalent amount of money from some other source—that is, from the taxpayer. As a regional chairman I know of the unlikelihood of the Service being able to acquire any more finance from the Treasury at the moment. Despite this, even by divorcing private practice from the National Health Service, the patients would still be there, and the beds have to be used. So it is inevitable that we shall need further money in order to keep them open.
I should like to mention a thought on the Bill regarding the 1,000 beds that are to be phased out six months after the Royal Assent of this Bill. I wonder whether some thought has been given to the fact that these might be used to increase the amenity beds that have been mentioned so often during this afternoon as being in great shortage. Another point that worries me is the additional cost of consultant cover in the major hospitals. Much has been said about the loss of time with the consultant having to move sometimes great distances from a private hospital to an NHS hospital. As long as private practice was within the National Health Service the cover of consultants could be much thinner because they were working in the private wing; they were on the premises. If I have a part-time consultant working six-elevenths or eight-elevenths for the Health Service, what am I going to do as a hospital administrator about the other five-elevenths or three-elevenths? Inevitably, the cost of running the National 1575 Health Service will have to increase because the doctors are not on the premises.
Something that disturbs me greatly is the loss of good-will money that comes from outside. A lot of that money comes from the private practice of the consultants, from the consultants themselves. I know many consultants who have all their fees paid into a research fund or a study fund for the hospital in which they work. Some of them have all their fees paid in, others support a research programme within their hospital.
If private practice is removed from the National Health hospital that research money will go somewhere else, and in the National Health Service we are certainly not over-flush with research money.
Something else that disturbs me in the discussion that has been taking place about private beds is that there seems to be a blanket discussion about private beds as such. But private beds vary enormously. There are some hospitals which have virtually a separate hospital, like University College Hospital which has a wing of its own which is literally a private hospital on its own. There are other hospitals where there are perhaps only two private beds stuck away somewhere in the hospital. There is a world of difference in how one should look at the problem of these two different types of provision and I am very concerned about a blanket phasing out. The job of the Health Service Board will be very strenuous indeed if they are to make certain that, if they have to be phased out, the right beds are phased out.
The only slight hope I see in the Bill itself is that through the setting up of the Health Service Board at least we shall not be jumping in tomorrow to abolish all the private beds in the National Health Service hospitals. It means that we are giving ourselves a certain amount of time. I hope the Government will agree that if after the period of six months, on the advice of the Health Service Board, they find that the scheme is not working out exactly the way they thought it would, they will have the courage to say so and we can come to a full stop before we destroy the situation altogether. I should also like to ask the Government to postpone the introduction of this legislation in order to enable us to listen 1576 to what the Royal Commission has to say and to enable us to put through some other legislation, and have our debate in the daylight hours without having to sit up all night. I believe that by waiting for the advice of the Royal Commission we shall in the end come up with better legislation.
§ 8.13 p.m.
§ Lord SANDYS
My Lords, as the twentieth speaker in this debate it is a pleasure to follow the noble Baroness, Lady Robson of Kiddington, who has just advised your Lordships of what I believe to be the kernel of the problem; that is to say, that the legislation should not be lying before us but that an issue should be laid before the Royal Commission. I have spoken with members of the profession, members of my own Party, members interested in the issue as a whole, and we have come to one conclusion: that the Government have made a totally fundamental mistake in introducing legislation long before that point in time when it was either desirable or necessary.
My Lords, to sum up, as I attempt to do in a few minutes from this side of the House, is a difficult task, but I have first of all the duty and pleasure of saying how much we appreciated the maiden speech of the noble Lord, Lord Stone, on this occasion. On a previous occasion, only a matter of months ago, on the 3rd December last year, we had two very notable maiden speeches on the same subject; that is, the National Health Service, with special reference to the problem of pay beds. On that occasion the most reverend Primate the Archbishop of York and my noble friend Lord Kemsley both made maiden speeches, both of them uncontroversial—like that of the noble Lord, Lord Stone, this evening—and both of a commendable brevity. We hope that we shall hear the noble Lord, Lord Stone, on many future occasions, because as a general practitioner he brings great personal knowledge to a field where, in your Lordships' House, this matter of personal association with the subject is rated very highly when we address ourselves to a matter of this importance.
My Lords, I turn to the speech of the noble Lord, Lord Wells-Pestell, and I must confess that he chilled me throughout with his references. I take issue, to begin with, with his suggestion that private 1577 treatment and the demand for private treatment is generally diminishing, because I believe the truth to be closer to what my noble friend Lord Gisborough said in quoting the figures which he did most clearly to your Lordships, that over 3 million people in this country are privately insured. I believe the figure to be possibly even higher than that, because it is very often difficult to quantify the number of private schemes. No doubt he was referring to the principal schemes concerned.
Here I must declare an interest, because I am not only insured with the British United Provident Association but also with Private Patients' Plan. I must say immediately that I believe this to be not a matter on which to search our consciences. I am proud of the fact that through these two organisations we, as contributors, are investing in private patients' resources, in the case of BUPA in further hospital beds and equipment in hospitals in the country. I should like to associate myself especially with what was said by my noble friend, Lady Ruthven of Freeland, who speaks from a wealth of knowledge of the work of the League of Hospital Friends.
I do not happen to be a member of the medical profession but I have taken an interest in the past in work in this particular field through voluntary organisations, and I should like to say with humility, and certainly with a limited knowledge of the field as a whole, that I believe there is a lack of appreciation of work done in the field prior to the 5th July 1948. Over a period of literally many hundreds, if not thousands, of years our medical skills were developing, and we are heirs to what has been at times a slow, a gradual and a very difficult process of development of care of people in hospital. We should be intensely proud of what has been achieved in this country, and I say that from the point of view of one who visits overseas territories from time to time as one involved in charitable organisations concerned with medical care. Going to certain countries in the Third World seeing hospital facilities in developing countries, one can appreciate the extent to which medical research in this country has helped overseas territories. The staff and facilities have benefited those territories enormously.
1578 I come to the point where I believe that what has been said in this debate this evening is related almost entirely to the proposals of the noble Lord, Lord Goodman, and, in listening to his speech I felt, to use an expression used by my noble friend Lord Harmar-Nicholls, that it was a "healing speech"; it had a quality about it which raised us above the question of inter-Party warfare in order to examine the position of the Health Service as a whole. My Lords, the Goodman proposals are probably not acceptable to anyone. Nevertheless, they are a point of departure. His arguments, as deployed this evening, were particularly significant in this regard, because, if one may quote his words, the medical service must be guided by medical views. That is the centre of the problem so far as the profession is concerned. The idea of the professions being directed from bureaucratic and doctrinaire points of view, as was so clearly demonstrated in the speech of the noble Lord, Lord Porritt, is something so wholly unacceptable and so wholly foreign to them as to need no further explanation. It is liberty of choice which is so important here, and I felt, during the speech of the noble Lord, Lord Goodman, that between the lines freedom grew.
Everyone practising in the profession in this country has been very well aware of the deep suspicions which he and his colleagues have held that they have been squeezed at both ends. They have been squeezed by a feeling of apprehension, which has been displayed by many of my noble friends around the Chamber, and I think it is fully justified. I heartily agree with what my noble friend Lord Gisborough said about the exploitation of the good will of the profession, and I am sure that he weighed his words most carefully.
It is not much to make a small charge for a prescription, which our Party has done in the past, and that has laid a degree of responsibility upon the patient which is perhaps from time to time justified. We are speaking in the context—and a very important context it is in regard to the National Health Service—of the effect of inflation on the cost of a hospital bed. If we start from the point at which the pound was registered at a datum of 100, in October 1973—an important date—and project that forward three 1579 years to October 1976, the decline in the value of the pound, I am assured on the best authority, is 100 to 56. Therefore, the cost of maintaining a hospital bed has very nearly doubled, be it in the private service or the public service. No wonder that the pressures on the Health Service, in maintaining our hospitals at the standard of efficiency which we all wish them to have, have been very great indeed. Therefore, it seems so totally illogical that 1 per cent. of the hospital beds—that is, the pay beds—should be at the centre of an argument which has lasted for more than 12 months, and which has caused a great deal of dissatisfaction for patients and acute anxiety for consultants, the medical profession, the nursing profession, the trade unions and all concerned. If it were not so sad, one would be justified in saying how wholly fatuous it is that this minute proportion of the beds being occupied within the Health Service should have been the cause.
I accept what has been said by noble Lords opposite, because they hold their views with deep sincerity. I accept what the noble Lord, Lord Wallace of Coslany, said, and I am sure he will accept what I say, because I speak with a similar degree of sincerity. But I think the point—and this was put by many of my noble friends—is that we want to see the Health Service get on with the job, which noble Lords opposite also want. The statements in the Journal of the British Medical Association were fully deployed by my noble friend Lord Hunt of Fawley, in a very carefully worded speech, and I was glad that the former Secretary of State was listening at the time.
I should now like to turn to the very important question of investment in the Health Service. I believe that this is a matter around which we should project our thoughts, as being something positive and not a matter at which we should be eternally looking backwards all the time. It seems to me that there is in this country a rich fund of good will for investing in hospitals, and I believe that future Governments—I include the present Government, if they would only listen—would be very well advised to consider this point most carefully. The noble Lord, Lord Porritt, referred to the Health Service in Canada, and noble Lords will be aware that in that country there 1580 operates a community chest. It is a principle of Canadian fiscal law that those who choose to deploy part of their income towards the community chest are permitted certain benefits. I see nothing at all immoral in investing in a Health Service, be it for kidney machines or for any other purpose. In fact, I should have thought it was wholly to the advantage of the country concerned, and I believe there is a case for the Treasury to consider this matter most carefully.
My noble friend Lady Ruthven referred to the work done by the League of Hospital Friends and, far from setting this aside as, perhaps, an unnecessary interference, which certain hospitals may be a little inclined to do from time to time, I believe it is true to say that, in present circumstances, more benefit is received through the voluntary organisations than hitherto, partly because of inflation and the lack of resources within individual hospitals. It seems to me that the Government should be more receptive to the fact that individuals wish to invest, wish to leave money to hospitals and wish—if not to dedicate a whole hospital bed, because in present circumstances that is a very expensive investment—to endow part of a hospital bed. This possibility should he made available to individuals in this country, through our fiscal system. I was delighted that the noble Baroness, Lady Robson, referred to this point. She felt that in present circumstances the possibilities were insufficient, and I agree with her. I do not want to quote from every speech which referred to this matter, but the noble Lord, Lord Winstanley, to whose speech we listened with great interest, said that the Bill does nothing to increase the resources in National Health hospitals and does nothing to reduce the waiting lists.
I feel that after 14 minutes I can draw my remarks towards a conclusion, as we have further business to consider this evening. But I do not want to do so without saying that I believe that the remarks of my noble friend Lady Faithfull were especially important. She wondered whether this is an ideological issue, a philosophical issue or a political issue, and she came to the conclusion, ultimately, that it is a political issue. I wholly agree with her, but I think it has strains of ideological and theological 1581 thought within it. Nevertheless, this is an issue which, prior to legislation, requires much more sensitive thought, and if only the Secretary of State and his advisers would consider the desires of the medical profession during a cooling-off period, when, as my noble friend and many other speakers suggested, the issue could be referred to a Royal Commission, that would give us a breathing space and would permit the suggestions of the noble Lord, Lord Goodman, and promoted by the Government into this Bill, to be set aside for consideration over a period of months. I conclude by saying this. On 18th October, The Times had this to say in one of its leading articles:None of the Bills before the Lords is vital to the national interest at a time of great economic peril. Some will be positively damaging; others will be irrelevant".
§ I agree wholly with those remarks.
§ 8.30 p.m.
§ Lord WELLS-PESTELL
My Lords, the noble Lord should not believe all that he reads. I have listened to every speaker, with the exception of the noble Lord, Lord Auckland, and I apologised to him before he spoke. I pointed out to him that I would not be able to be in the Chamber during his speech. It seems to me to be quite pointless to say anything at this stage. The best thing that I think I can do is to sit down, because quite clearly the vast majority of speakers, certainly those who sit on the other side of the Chamber, did not pay the slightest attention to anything that I said in my opening speech.
§ Lord SANDYS
My Lords, may I say to the noble Lord with the deepest respect that I have also been sitting here throughout the debate. I listened with the closest attention to the noble Lord's speech and made continuous notes throughout, and I quoted them to him. I hope that the noble Lord will accept that.
§ Lord WELLS-PESTELL
Obviously the noble Lord has not profited from the words of wisdom! It is quite clear that noble Lords on both sides who have spoken are still thoroughly and deeply entrenched in the views which they held when they came into your Lordships' Chamber. I do not object to that, but it seems rather pointless to spend a great deal of time trying to answer the various points which 1582 noble Lords have made, because whatever I say is obviously going to fall on to very stony ground.
The noble Lord, Lord Goodman, asked me to make a special point of apologising to your Lordships for the fact that he could not be here at the end of the debate. He has had to attend an important meeting, about which I know. It was imperative for him to be at that meeting and he begged to be excused. In the absence of the noble Lord, Lord Stone, I should like to offer to him my congratulations upon his maiden speech. It had all the advantages of a maiden speech in that it was not controversial, it was brief and it was very much to the point.
I am sorry that the noble Baroness, Lady Young, feels that the Bill is unnecessary and unwanted. It may well be unwanted by noble Lords opposite, but it is not unwanted by millions of people in this country. I am speaking mainly of the trade union movement and also of the Labour Party. Noble Lords have said that this is an ill-conceived and ill-timed Bill, but this is simply because they just do not know what is the position. We have been considering this matter for years, not months. So far as my Party is concerned, it has been a matter of principle for some years. I was reminded that at the last Election only 28 per cent. of the electorate voted for the Labour Party, although that gave us a Labour Government which presumably means that the Conservative Party obtained less than 28 per cent. of the votes. Is the noble Baroness, Lady Young, going to say that when there is a return of the Conservative Party as a Government on a minority vote they will not put into operation any of the matters contained in their Manifesto? Of course they will, because that is precisely the way we run matters in this country. I think I am right in saying that since the war no Government have been voted to power by a majority of the electorate. Although I am open to correction on this point, I believe that since 1945 we have always had a minority Government. Therefore, the Government that are elected must introduce their Manifesto. Consequently, it is quite pointless to say that the Labour Party had the support of only 28 per cent. of the electorate at the last Election.
The point was made, I think by the noble Baroness, Lady Young, and by a 1583 number of other Peers, particularly those connected with the medical profession, that this Bill does not enjoy the support of the medical profession. I never know what is meant by that term. I was at some pains to point out to your Lordships that the BMA sent a heavily weighted letter to consultants asking them whether they would accept the Goodman proposals or whether they wanted to resign from the National Health Service. That letter was sent to 12,200 consultants. How many of them said, No? In fact, 2,604 of them said, No. It is perfectly true that 42 per cent. did not return their ballot papers. Are we not entitled, therefore, to assume that 42 per cent. were not opposed to the proposals?
§ Lord SANDYS
My Lords, are we not entitled to suppose that the Post Office were unable to deliver certain of the letters because of incomplete records of addresses?
§ Lord WELLS-PESTELL
My Lords, of course the British Medical Association may be so incompetent that over 5,000 of the letters went astray, but I do not believe that for one moment—nor does the noble Lord.
§ Lord PLATT
My Lords, surely the question that was asked was quite absurd. The question that was asked was whether consultants agreed with the proposals or whether they would resign from the National Health Service. The answer I should have given would have been that I did not agree with them but I would not resign from the National Health Service. So what? The letter was utterly useless.
§ Lord WELLS-PESTELL
My Lords, if one believes the noble Lord, Lord Hunt of Fawley, it seems that the consultants are a very militant crowd and are ready to down tools tomorrow if you give them enough cause. If consultants are so militant, how does one explain that 42 per cent. did not reply and that 63 per cent. of those who replied were in favour of the Goodman proposals? Let us not misunderstand the situation; the consultants were behind the proposals. I believe that the speech made by the noble 1584 Lord, Lord Hunt of Fawley, was a mistake. I am on record on two occasions, if not three, as having congratulated the noble Lord, Lord Hunt of Fawley, on the balance of his contributions in your Lordships' House, but the militancy that he displayed tonight was almost an incitement to strike, and it is not going to help the consultants, the medical profession or the Government who are trying to deal with a very difficult situation.
I would ask the noble Lord, Lord Hunt of Fawley, as I would ask the noble Lord, Lord Porritt, and the noble Lord, Lord Brock, whether they could get up and, with their hand on their hearts, say that private practice is not going to be all the better for this Bill? Of course they could not do so and not one of them would get up and say so. They know jolly well that private practice is coming out of this a damn sight better than it is at present.
§ Lord BROCK
My Lords, may I stand up, put my hand on my heart, and say that I think that the noble Lord is wrong?
§ Lord WELLS-PESTELL
My Lords, what I have said, then, has had the desired effect. I wanted to know what noble Lords were thinking. I know what two noble Lords think and I think I know what the third thinks.
§ Lord PLATT
My Lords, as one who has nothing to do with this question, who has no irons whatever in the fire and who has had oceans of paper from the BMA, all of which he has put into the wastepaper basket, may I say that I do not agree with what the noble Lord is saying.
§ Lord WELLS-PESTELL
My Lords, I advise the noble Lords in question privately to have a word with the BMA. The noble Baroness raised a number of questions but I do not think that I can deal with all of them. The Government can fairly say that the Bill was given a Second Reading by a majority of 20. It does not get a majority of 20 as a result of its own members; it got a majority of 20 because they were supported in the Lobbies, certainly by the Scottish and the Welsh Nationalists, so it is not just only the Labour Party in the Commons that supports this. There is a wider support than just the Labour Party.
The noble Baroness raised a number of other questions which I should like to 1585 deal with. She mentioned—if I have it correctly—that the consultants have a right to sell their services (I think she said) in the market place. This is precisely what we are doing: we are creating a situation where they can sell their services in the market place. But let me make it quite clear that we do not regard the National Health Service as being the appropriate market place. Would the noble Baroness expect the plumber—I refer to the plumber because she mentioned the plumber—to sell his services in the market place and at the same time use his employer's facilities and equipment? That is what is happening today.
§ Baroness YOUNG
My Lords, may I ask the noble Lord this question? If he does not accept my argument, does he accept the argument of the noble Lord, Lord Goodman, that it is essential that consultants should have the right to use the specialist equipment in hospitals for their private patients? That was the very point on which the noble Lord, Lord Goodman, has asked for extra assurances and on which there is considerable doubt in the Bill. If the noble Lord does not accept that, he is going against the spirit of the Goodman agreement; and if he does accept it he must accept my argument.
§ Lord WELLS-PESTELL
My Lords, we are prepared to accept—and we state so in the Bill—that in certain circumstances where there are no facilities available in the private sector, or in a particular area where special facilities are needed, they can use those facilities. It is very different from the sort of argument which the noble Baroness put forward about the right to sell one's services in the market place. There is nothing between us on this. All I am saying is that it is one thing to sell one's services in the market place and another to use your employer's gear and equipment in order to do the job. The provision of these special facilities is a concession which the Government, through this Bill, are prepared to make for consultants in certain circumstances on certain occasions.
I want to say only one other thing which relates to what the noble Baroness said. I think she said that the existence of pay beds attracts better quality staff. She does not really believe that. How does she reconcile that with Bart's, where there are no pay beds at all—or perhaps I 1586 ought to be more correct and say that there are six, but they are exclusively for overseas patients because, as noble Lords will know, their ancient Charter does not permit them to have pay beds and it does not permit them to charge. Is she saying, in point of fact, that there is an incompetent staff at Bart's?
§ Baroness YOUNG
My Lords, I do not think it is an incompetent staff at Bart's at all. As I indicated in everything I said, I am actually a great supporter of the National Health Scheme and those who work in it. All that I said in my remarks is that if you undermine the trust of the doctors and the medical profession you will get a worse system, and of that I am quite certain. I am not in any way denigrating the system as it exists, because I support it.
§ Lord WELLS-PESTELL
My Lords, I want to go on to the point that was raised by the noble Lord, Lord Amulree, in regard to amenity beds, and he was not the only noble Lord who raised this matter. We are very concerned about (shall I say?) the inadequacy of the amenity beds at the present moment. We are not blind to the faults and the failures of the National Health Service and it is our intention that as more and more pay beds come into the National Health Service they will be used for amenity purposes, so that—and every one of us in your Lordships' House knows this to be correct—the National Health Service may be improved. I have spent many months as a National Health Service in-patient in a public ward, in a ward which specialised mainly in craniotomies, where I had an operation for a suspected tumour. I could have done with an amenity bed, and so could a good many of the others. One knows how important this is, and it is part of Government policy to try to do something about it when these beds become available.
The noble Lord, Lord Amulree, also raised a question about the private sector and the loss that we might suffer. The phasing out of the thousand pay beds, as I think noble Lords know only too well, means that the thousand are, in the 1587 main, the beds which were considerably under used, and the loss in the first year or so, if I may say so, is quite negligible. The higher figure that has been mentioned is not likely to be reached for some years. But one has to bear in mind that we are going to offer, for private practice to use, wherever it is required all over the country—and I do not want to go over all this again—facilities in National Health hospitals as and when they are needed because of certain emergency situations. We shall recover some money. I do not know how much, but obviously those facilities will not be provided free of charge.
A number of noble Lords have raised the question of the loss of revenue. There are sometimes things which are much more important than just the loss of revenue. A number of noble Lords have also raised the point that this is the wrong time, but most of your Lordships are too skilled in the art of politics not to know that no time is ever the right time. In 1945 we emerged a bankrupt nation; we had sold every pound of investment abroad; we had not a single pound. We had sold about £1,100 million of investments abroad in order to prosecute the war. We had not a penny. If we had waited for the right time to introduce a National Health Service we should never have had one. The time to do something is when, rightly or wrongly, it is considered to be the right time, it may be by this Government, it may be by another Government. if money is all that important, we might just as well have a whole chain of legalised brothels in this country from which we could draw a tremendous source of revenue. The fact is that many people realise that the price that one has to pay at times is probably not worth it.
I wanted to join issue with the noble Lord, Lord Winstanley, but as he is not here I do not propose to do so. I hope the noble Lord, Lord Hunt of Fawley, does not feel that I have treated him badly. I think he knows me well enough to know that even if I sound rather harsh there is never any venom in what I say. This is a Chamber where we have the right to say what we like, and in doing so perhaps we have to put up with a different point of view. I do not share his point of view at the present moment.
1588 My Lords, although, perhaps, noble Lords might not think I ought to be, having listened to the noble Lord, Lord Platt, I was gratified, because he brought an air of realism into the debate. I know the noble Lord has reservations, and it is only right that people should have reservations. It would be a disaster if we did not examine things very carefully. But I was grateful to the noble Lord for the contribution he made. The noble Lord, Lord Porritt, raised a number of matters about the action of the Government. The only thing I want to say is that the Government must always keep in the forefront of their minds what their major responsibility is and what their main priority is. To try to say what the main priority of this Government is is to repeat something that many of your Lordships have heard many times over the years; that is, to concern themselves with the health, wealth and happiness of the people of this country—and I say it quite unashamedly—from the cradle to the grave. This would be my answer, to some extent, to the noble Lord, Lord O'Hagan.
The Government have a responsibility for the wellbeing of people. I know that the noble Lord, Lord O'Hagan, will not disagree with me on this. We regard the provision of a National Health Service as an integral part of the service which this Government must offer the people. My noble friend Lady Lee of Asheridge dealt with this point. She said that as a Social Democrat—and that is what I claim to be myself—she regards the fact that in the Labour Party there are people on the extreme Left, on the extreme Right, and in the Centre, as no different from the position in the Conservative Party, who have people on their Left and people on their extreme Right—and, if I may say so, they have moved, in recent months to the extreme Right, or jolly near it. They have changed their emphasis, and some of us are terrified as to what might happen if they get into power next time. But this is the political set-up of every Party; they have people on the wings and in the centre. There is no difference. If you look at the behaviour in the other place of certain people whom you would regard as being on the extreme Left of the Labour Party, what have they achieved?
§ Lord WELLS-PESTELL
They could, perhaps, have achieved a great deal more. 1589 But the fact is that in this Party, and to some extent in the Conservative Party because we must acknowledge that they, too, have made their contribution to the wellbeing of the people, the emphasis is very different. We are not going to reconcile them. But this Government feel there is a responsibility to provide for the people in a certain number of defined ways. One of them is the National Health Service. If people want to buy health, we do not mind. We took the line in education that if people want private education, then the private sector must be separate from the public sector, and if they want to buy it, then they can buy it. We are saying precisely the same thing so far as the National Health Service is concerned. We feel it ought to be an all-embracing service for the people of this country. If there are people who want to opt out of it in the sense that they want to purchase health, medical services and medical attendance, we have no quarrel with that at all. But we say that there must be no misunderstanding, no confusion, no overlapping. The thing must be kept absolutely separate. That would be my answer to the noble Lord, Lord Porritt, who I do not for one moment think will accept it.
I want now to try to answer the noble Lord, Lord Auckland, who raised the question of the number of beds. I was out of the Chamber at the time, but I understand that he said that there would be 20 going out of a total of 56 in Cambridge. Each area, each hospital for that matter, has been considered very carefully. There are a number of private establishments in and around Cambridge. The acid test has been the occupancy of those 56 pay beds. It has been generally agreed that the pay bed situation at the moment would not be affected if they lost 20 of them. The noble Lord also suggested that the Bill was ill thought out, but I have dealt with that, even if the noble Lord is unable to accept what I have said. The fact is that over a very long period of time, we have given attention to this particular matter. If people say, "Why now?", my answer is, why not? There is no reason why we should not do it in this Session, or put it over to another Session.
The noble Baroness, Lady Faithfull, wanted to know whether this was not a matter that should have been referred to 1590 the Royal Commission. I can understand people saying, "You have set up a Royal Commission. Why not refer all these matters to it?". It is a well accepted view in political circles, on the part of the Liberal Party, the Conservative Party and the Labour Party, that there are certain matters which are of considerable political significance, and the Party concerned must make their own decision. This is not a matter that should be referred because very often these are matters of principle. So far as we are concerned, this is a matter of principle.
§ Baroness FAITHFULL
My Lords, I am grateful to the noble Lord, Lord Wells-Pestell, for giving way for a moment. My point was that if certain detailed things that were clouding the main issue were to be referred to the Royal Commission, the main issue would be more clear. Some of the things are being referred—for instance, queue-jumping. I think another noble Lord said that no research had been done into this matter. I was asking for certain specific issues to be referred to the Royal Commission for investigation, in order to clarify later what the main issue of the pay bed situation was.
§ Lord WELLS-PESTELL
My Lords, again, this is a matter of viewpoint. We have considered that there is a function for a Royal Commission on the health services, and it is a pretty wide one. But we reserve the right—as any Government have the right to reserve—to take certain things out of the ambit of their consideration. We have put into the Bill matters which we feel are of extreme importance that must be dealt with. There may not have been any cold research into the whole question of queue-jumping but many of us—including the noble Baroness, Lady Faithfull, and the noble Baroness, Lady Young—know that it happens. It is a very simple thing these days for a person who needs an operation which is not essential, or at least not urgent, so it can wait for months. One noble Lord, a member of the medical profession, said he can go to a doctor who will pass him on to a consultant; the consultant will take a fee and then say, "Well, if you want it done now I can have it done". But there may be a dozen or more people in the same area with the same complaint who would like their operations done now, but because they 1591 cannot go to the consultant and pay a fee, they do not get ushered into hospital. That is what we mean—
§ Lord PLATT
My Lords, if the noble Lord, Lord Wells-Pestell, is referring to something I said, he has every right to do so. But the point I was making was that this Bill would do absolutely nothing to abolish the practice.
§ Lord WELLS-PESTELL
My Lords, that remains to be seen. We are saying that there is extensive queue-jumping, and everybody in your Lordships' House knows this to be a fact. We are hoping that as a result of this it will at least, if it does not do very much, draw attention to how we feel.
I do not think I need delay your Lordships longer. I have spoken for 29 minutes and I am conscious of the fact that I have not answered all the questions that have been asked. I take some comfort and consolation from the knowledge that if I stood here for two hours I would still make no impression on some noble Lords, and therefore it only remains for me to ask the House to give the Bill a Second Reading.
§ On Question, Bill read 2a, and committed to a Committee of the Whole House.