HL Deb 06 July 1977 vol 385 cc347-418

2.52 p.m.

Lord AUCKLAND rose to call attention to serious problems currently affecting the Hospital Service and medical centres; and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion which stands in my name on the Order Paper. It was several months ago that this Motion originally went on the Order Paper. I am grateful to those who operate the usual channels for having enabled this important topic to be discussed today.

Your Lordships will have noticed that in the past few days the Motion has been substantially altered. This is because, as your Lordships will know, a Royal Commission is sitting or is about to sit upon the subject of the National Health Service as a whole, and in those circumstances it would be counter-productive to have a full scale debate on the National Health Service per se. However, I hope that this debate, some of whose participants are distinguished persons in the medical and social services fields, will at least give the Royal Commission some food for thought.

I have no financial interest to declare here. But, as many of your Lordships will know, like many other Members of this House and of another place, I have sat as a member of house committees in both children's hospitals and long stay mental hospitals, and so have my family before me for many years, both during the period of the National Health Service and also before the Health Service came into being. Therefore, I must at the first instance say with what regret it is that I feel myself compelled to criticise the reorganisation of the Health Service. All political Parties are, without exception, in varying degrees dedicated to the existence of a good, ever increasing, improving and improved Health Service.

The only dissenting remarks which I am going to make, I hope, in the course of my speech are to criticise two major Bills, one produced by the Party on this side of the House, and one by the Party now in office. My criticism will be very brief because these measures were debated very fully into the small hours of several mornings in your Lordships' House in the past Session. I refer, of course, to the phasing out of the pay beds.

So far as the reorganisation of the National Health Service is concerned, those who served on hospital management committees, house committees and so on, were themselves phased out. Area Health authorities and Community Health Councils have replaced those committees. I have not one word of criticism against those who serve on these bodies. I am sure they will do as fine and conscientious a job as anyone can. But, having spoken to people in the medical profession—doctors, nurses and administrators—I find that they all speak with practically one voice and say that the existence of the third tier has had a traumatic effect on communications. This is particularly true in long stay hospitals.

I recall very well serving on a house committee in one of the seven mental hospitals in Epsom, where I live. I went round the wards—there were 32 of them—with the hospital superintendent, the chief nursing officer, the chairman of the house committee and others, and talked to those patients who were able to talk, and to the staff, many of whom we came to know by name. Where there were minor problems—and a lot of the problems are minor ones—these could be solved a great deal more quickly than they can be solved today. Whereas we could go round these places and report at the next meeting of the hospital management committee, now the whole matter has to go through the Area Health Authority. Of course serious matters could not be solved on the spot, nor can they in any walk of life. I shall come back in a few moments briefly and specifically to the long stay hospitals.

However, I should like now to turn to the subject of general hospitals. One of the many problems at present which hospitals have had to face is, in some cases, industrial disruption. For a very obvious reason I do not want to say too much about this, but in one hospital near where I live there was one particularly nasty scene when a lady who had been operating a lorry which carried food into the hospital was accosted by some pickets; and, as I understand it, there was some doubt as to whether those pickets even belonged to the hospital concerned. The lady stood her ground and there was very nearly a nasty accident. It is no part of my speech this afternoon to discuss the merits or otherwise of the disputes concerning COHSE, NUPE or any other union. I would put only this very direct question to your Lordships: who runs the therapeutic side of our hospitals—doctors, nurses or the ancillary staff? These disputes so often end in elderly nurses and others having to push heavy trolleys loaded with food or hospital equipment, very likely watched by and sometimes with rather smirking faces, the strikers themselves.

It would be quite wrong, as I said earlier, for me to mention any names or any specific incidents. I did mention just one hospital, because I happen to know the circumstances; but I would say that this whole aspect of the debate really rests on the question of morale. A great deal is made in our communications media about morale in our hospitals and also the state of our hospitals. I think a lot of damage can be done here, but the fact that there are disputes of this kind, which throw a tremendous extra workload on those who minister to the sick in these hospitals is bound to cause exhaustion. It is a very tiring job anyway, as anyone who has worked in a hospital will know, and of course this affects morale very badly.

I should like now to turn to the long-stay hospitals, where I have had rather more experience as a house committee member than I have of general hospitals. Two nights ago I paid a lengthy visit to one of our busy paediatric hospitals in Surrey, where the most marvellous work is done for children suffering from diseases such as spina bifida and hydrocephalus and various bone infections. Some will recover; others will probably never leave their beds. Your Lordships may be aware of the cheerfulness of the staff and patients, the general cleanliness of the wards, the general neatness of these patients—and I would remind your Lordships that some are very difficult to care for, being doubly incontinent and needing constant care, being fed, and looked after 24 hours a day, seven days a week.

There are two major difficulties facing hospitals such as these. The hospital in Surrey which I mention is fortunate in having some lovely gardens, and is better placed than many other hospitals in the Midlands, in South Wales, in the Potteries and elsewhere, where there are still mentally sick people being looked after. One difficulty which I suppose faces all of us today—in industry, in private or in public, and in everything else—is the vexed question of finance. It was very disturbing to learn that the replacing of furniture in the wards is becoming more and more of a problem. As these children grow older, those who are ambulant obviously become that much more violent from time to time; furniture gets kicked about and other parts of the ward also become damaged. I am informed that, due to shortage of capital funds, these objects are becoming harder and harder to replace.

In many hospitals, the same is true on the nursing side. It is encouraging to note in many hospitals the increasing number of British-born girls and men going into nursing. That is true in mental hospitals as well as in general hospitals. In saying this, I would not desist for one moment from paying the highest tribute to those from our Commonwealth, old and new, and from other countries, whose presence in our hospitals is very vital—indeed, many hospitals would close down were it not for our overseas staff. But I think it is equally important that the greatest possible incentive is given to the recruitment of our own young people into the Hospital Service.

There are several questions I should like to put to the noble Lord, Lord Wells-Pestell, and I have given him notice of some of them. I do not think that I have mentioned the question which I am now going to put to him. It is this: what is being done in schools and colleges of education to encourage more nurses to go into our hospitals and, indeed, to extend the pupil-nurse system which I know some hospitals have employed? The last major comprehensive building programme was put forward in 1962, when the right honourable gentleman, Mr. Enoch Powell, was Minister of Health. I should like to ask the noble Lord, Lord Wells-Pestell, what plans the Government now have to publish up-to-date details of construction and renovation policy for the existing hospitals which badly need renovation—and one does not have to go very far to see such hospitals, where the greatest loyalties often exist—and also of the works completed.

Another question which is uppermost in the minds of many concerns the requirements and standards of English language, particularly for overseas doctors coming into our hospitals. Some of your Lordships will have read of the distressing tragedies which have occurred from time to time, when a doctor has given an instruction for an intravenous injection and, through the instruction being not quite understood, the wrong injection has been given for a relatively minor ailment. So as a result of a misunderstanding, the patient has been completely paralysed for life. Accidents will happen, and it would be folly to pretend that 100 times out of 100 tragedies of this kind will not occur, but even a slight improvement would be something. I know that the incidence is relatively small, but it is still too high for comfort.

This brings me on to the question of safety precautions in hospitals. One of the big problems, particularly in our long-stay hospitals, is fire hazard. Your Lordships will remember the case of the mental hospital near Sherborne in Dorset, where some 38 patients lost their lives when a ward was burned down. According to the inquiry, a lot of plywood was used in partitioning between the beds and that is an obvious fire hazard. I wonder whether the Minister can say what is being done about this. Presumably, it is the responsibility of the Area Health Authority, but are they being given sufficient funds to put the situation right?

On the question of large general hospitals, I was sent a very interesting article by the noble Lord, Lord Taylor, who was a Health Service Minister in the Government elected in 1945, stressing the vital importance of patient care and—as I understood his article—of hospitals not becoming too large. The 2,000-bed general hospital may be a fine sight to look at, but it is very difficult to administer. So the question which I and other noble Lords have put before is, What will be the future of the cottage hospitals? I particularly ask about areas such as Scotland. In Perthshire, which is a part of the country that I know very well, there are at least three splendid cottage hospitals, and near where I live in Surrey there are two. But they never quite know when the sword of Damocles will fall on them. Bearing in mind the essential relationship between doctor and patient, is it the Government's policy to keep these very fine hospitals going?

Finally, there is the question of kidney machines. Am I right in thinking that the kidney unit at Hammersmith Hospital is being phased out? If this is true, it is extremely disturbing news. I do not know how many people in this country who can work, particularly young people, are undergoing renal dialysis, but it is vital, even it it means spending more money, that extra kidney machines are provided: first, to save life and, secondly, to enable these people to give benefit to the community. I know the answer may well be that they are very expensive, but it is even more expensive to let these things slide.

I finish by quoting from a book written in 1952 by a very famous Minister of Health, now deceased, who did not always find his views shared on this side of the House, but who, nevertheless, in incepting the Health Service had a very good brain. He wrote: Doubtless other defects can be found and further improvements made in the Health Service. What emerges, however, in the final count is the massive contribution that the British Health Service makes to the equipment of a civilised society. It has now become part of the texture of our national life. No political party would survive that tried to destroy it". I believe those last words to be true. I would only add that it is incumbent upon successive Governments, whether of the Left or of the Right, to improve the Health Service. Those who work in it deserve this, and I hope that this debate and those noble Lords who are to speak after me will stress this point. My Lords, I beg to move for Papers.

3.18 p.m.


My Lords, we are very pleased that the noble Lord, Lord Auckland, has referred to so many of the problems which confront the Health Service at the present time, and I do not propose to follow along exactly the same lines and repeat what he said. But I have been a firm supporter of the Service from the moment it started. I worked as part of it for about 20 years, and it was with a great deal of sorrow and regret that I saw the first Act of Parliament which came in to reform the Health Service about five or six years ago. The sole effect of that reform has been an enormous increase in the administrative side of the Service. Between 1966 and 1974, which is the last year for which I have a figure, the number of full-time administrators increased by 77 per cent., whereas the figure for general practitioners was about 7 per cent. and for consultants about 13 per cent. One would not object at all had that large increase in administration led to a 77 per cent. increase of good for patients. But I do not believe, in general, that it has done anything at all to improve the lot of the patient; and, after all, the Health Service was intended for the care of the sick and those in need, not for the administration.

I know perfectly well, and I am sure that the noble Lord, Lord Wells-Pestell, will agree, that we are extremely short of money, and that we shall have to make do with what we have. Therefore, I have not for quite a long time been in favour of pulling down old hospitals and building new, larger and more splendid ones.

I did my work for the National Health Service in what was the infirmary of the old St. Pancras workhouse, which was built in the 'fifties or 'sixties of the last century. It was extremely well built and we spent a certain amount of money upon improving it internally. So, internally, it was a good, modern, attractive building, although I am afraid that from the outside it still looks like the infirmary of the old St. Pancras workhouse. However, that does not matter. That is why I wonder what people are frustrated about when they say that their hospitals are not modern. Provided that there is the will to work well and a certain amount of money so that equipment can be kept up to date, it does not seem to me to matter a great deal what kind of building one works in. That is why I am interested in what the noble Lord has said about the fate of the small hospitals.

At one time, there was a feeling that the small hospitals should be shut down and that all work should be done in district general hospitals with a minimum of 500 beds. I believe that there has been a change of heart. Now it is felt that more can be done with the small hospitals, provided that they are linked in all kinds of ways with the district general hospitals. I have been convinced for a very long time that it is most therapeutic for anybody who is in a hospital bed to be visited by his relatives and friends. Quite often that will do him far more good than the care that my profession and the other professions can give, because the general tendency of most illnesses is towards recovery. Therefore, I should like as many as possible of these small hospitals to be retained, so that visitors can reach them regularly and easily, and to be linked with the larger district general hospitals which can do work, particularly in this rather specialised world of medicine into which we are now moving, that cannot be done by the other hospitals.

There was an inquiry regarding nurses, the name of which I cannot remember at the moment but which sat at the same time as the social worker inquiry. It was accepted by the Government of the day that if nurses wish to rise to the top of their profession they should do so on the administrative rather than the therapeutic side, where the primary aim is to take care of sick people. That has done nothing to improve the quality of nursing or to make it a more attractive profession for young people.

One of the places where the reconstruction of the National Health Service went wrong—and here I agree entirely with what was said by the noble Lord, Lord Auckland—concerns the value of the hospital management committees. Both the noble Lord and I have served upon hospital management committees and we know that their value was enormous. One was in contact with the hospital staff and one knew what was going on. Also, one was in touch with the patients. All that has now gone. Instead we have bodies called area health authorities. Therefore, personal contact between those running hospitals and the patients has been lost. The local management committees have been replaced by a third administrative tier. I am certain that it would be no loss if one of the administrative tiers were to vanish, and I hope that it will.

So far as I can remember, when Aneurin Bevan introduced the National Health Service the original concept was that the Regional Hospital Boards and the teaching hospitals should have the real authority, that very largely the Service should be run by local committees, under the Regional Hospital Boards and the teaching hospitals, and that the Ministry should not be so powerful a body but one which formulated general policy for the country, so that the Regional Boards and boards of governors knew what was expected of them. Unfortunately, however, the power of the Treasury proved to be too strong. Therefore the Ministry of Health, or what is now called the Department of Health and Social Security, has retained an enormous amount of control, although I do not believe this to have been the intention when the National Health Service was set up.

There is one minor point which I should like to make on the financial side. It is a pity that arrangements cannot be made whereby money which is granted to a hospital authority in a certain year can be carried over to the next year. It happens from time to time that money which has been granted to a hospital cannot, for very good reasons, be spent in one year. If a hospital cannot spend the money during the year in question, I believe I am right in saying that it has to be returned to the Treasury. So when March comes the hospital authorities say, "Goodness! We have £5,000 to spend. What can we spend it on?" And they spend it upon many extravagant items which are not required. My Lords, those are the few random points which I wanted to make. I have made them before and, if I am spared a little longer, I shall probably be called upon to make them again, for it will be quite a long time before a good number of these points are taken up and put into effect.

3.29 p.m.

Baroness YOUNG

My Lords, I am sure that we are all delighted that my noble friend Lord Auckland has introduced such an important debate this afternoon. It is timely. Although the Royal Commission is sitting, we do not know when it is to report, nor, so far as I know, is it to issue an interim report. Even more important, we do not know whether, when the Royal Commission does report, its findings will command acceptance. In the meantime, to put a self-denying ordinance upon any discussion of the National Health Service or the medical services would not be helpful. It seems to me to be right that this House should debate the National Health Service, especially at a time when morale is so low and anxiety so widespread. The National Health Service, once the pride of our country and the envy of the world, is not what it was. At the very least, the debate today will reassure the many thousands who have been working so hard and so long in the National Health Service that there are noble Lords on all sides of the House who care deeply about the service and its problems.

My Lords, I regret that I must begin my speech with an apology to the House. Unfortunately, I shall not be able to stay until the end of the debate. I apologise in particular to the noble Lord, Lord Wells-Pestell, for I shall not hear his winding up speech. However, months ago I agreed to attend the centenary celebrations of my old school which fall this evening and I do not think that I can go back on the agreement that I made. Therefore, I apologise to the House, but I shall read with great care what is said.

My Lords, in preparation for this debate, I re-read the debate in your Lordships' House on 3rd December, 1975. There was much discussion then on two particular topics: the start of the National Health Service and Pay Beds. Unlike many speakers in today's debate I was not in politics at the start of the National Health Service and my only comment is that I am one of its beneficiaries. However, I should like to emphasise at the outset that my Party is firmly committed to the maintenance of the National Health Service. We believe that the first task of any Government, at present, is to restore morale in the Service and I shall return to that point later in my remarks.

As regards the phasing out of private beds in National Health Service hospitals, I wish to make only one remark. During the long debates on the Health Services Act, this House carried an important Amendment to the effect that those private beds which were phased out should be used by National Health Service patients. The spirit of this Amendment, although not its precise wording, was actually accepted by the Government in another place, no doubt because it would have been highly embarrassing to have to admit that, far from preventing queue jumping—ostensibly the reason for the Health Services Act—the Act would have actually had the effect of lengthening the queue.

Let us consider what has, in fact, happened. As far as I can ascertain, the private beds which have been phased out have not been used for National Health Service patients. I think that I can do no better than quote a letter from a doctor which appeared in the British Medical Journal on 28th May, 1977. He writes: On 20 May this year 10 beds on the private ward at the Gordon Hospital, a part of our hospital group, were due to be closed down. These beds will lie empty and gradually collect a veneer of dust. There is no question at—all of their being used for NHS patients and to help reduce our rapidly lengthening waiting list. Inquiries among my surgical colleagues throughout Britain have failed to reveal any example where the closure of a private ward has released a single bed for a NHS patient". My Lords, I believe this to be an indictment of the Bill and its consequences. I think that it is particularly serious if it is taken in conjunction with a report that has recently been issued called Common Waiting Lists for NHS and Private Patients in NHS Hospitals. If we look at the principal recommendation of this Report, which appears in paragraph 9 and which states: We recommend that all other private patients should be placed on the same waiting list as comparable NHS patients in the care of the same consultant"— a recommendation which I believe to be completely sensible and with which I personally agree entirely—we shall see at once that, if more patients go on to the waiting lists and there are fewer beds in the hospitals, the effect will be to lengthen the queue. I sometimes feel that we are in an "Alice in Wonderland" world and, as someone who believes that the object of this exercise is, at the end of the day, to help National Health Service patients, I think that it is a very sad reflection that the consequence of all this has been as I have stated.

The facts for the ordinary patients are now very serious indeed. There are over half a million on the hospital waiting lists in England alone, of whom 30 per cent, are, I believe, people who have been waiting for over a year. At the same time, there is a rise in the waiting time for out-patient consultations and a fall in the number of cases treated per doctor in the Hospital Service of over 7 per cent. As one doctor wrote to me—and I quote his letter— It is still possible, as a result of the commitment of all kinds of staff, to offer a good service to those needing emergency treatment, a fair service to the seriously ill with conditions imperilling life or health, but for those with conditions which although troublesome and debilitating do not carry a danger to life, there is a diminishing prospect of any treatment at all". My Lords, I hope that that doctor is taking too gloomy a view. However, I believe it to be true that, for example, for those suffering from arthritis who want what has now come to be considered a relatively common operation, the waiting time is, on average, 14 months. Sometimes, patients need to wait up to five years for such an operation.

What, then, are the causes of these problems and can we offer any remedies? The first, and obvious, cause of trouble is that the National Health Service is under-financed. When all the figures are juggled about there is simply not enough money for an effective, comprehensive Health Service. We have created an indefinite demand with a finite amount of money. This is made abundantly clear in all the Government reports on this matter. It seems to me that the first thing to he done is to explain the realities of the situation to the public so that they know what to expect in the present economic situation and for some time to come. Otherwise, the public are simply encouraged to blame the staff for the shortcomings of the Health Service and that, I feel, is completely unjustified because the staff are working very hard in difficult circumstances.

I hope very much that the Royal Commission which is looking, among other matters, at the financing of the National Health Service will look to see how the health services are financed in other European countries. I think that it would be extremely helpful for us to see how it is done. I think, too, that we ought to look at charges to see whether they really keep up with the rate of inflation. Certainly some of the charges have done so. For example, the income from dental charges has risen from 16 per cent. as a whole in 1975–1976 to 24.3 per cent. as a whole in 1977–1978. The income from optical charges has likewise gone up from 28.5 per cent. to 37.7 per cent. The income from prescription charges in relation to the gross cost of the pharmaceutical services has actually dropped from 5.8 per cent. to 4.6 per cent. I do not know why, but it seems to me that that is something that is worth looking at.

My Lords, I also believe that it is worth looking at the whole problem and question of encouraging more people to take out private insurance. It is an extremely curious fact that if one looks at the group of people who actually have to pay when they go into hospital, one finds that it is that group—those on retirement pensions, or sickness, invalidity or injury benefits—who are in the hospital for more than eight weeks. After that period, their pensions are reduced. The total number of retirement pensioners in hospital who have had their pensions so reduced has risen from 86,000 in 1973 to 88,000 in 1975. When one looks at the most up to date figures for the total sum of money involved, one discovers that the money going back into the Health Service for retirement pensioners alone has risen from £21 million in 1973, to £40 million in 1976. If we include in that sum of money those who have sickness, invalidity and injury benefits, the total for a full year would probably rise to £60 million or more. Of course, those figures take no account at all of supplementary benefits.

The argument that is put forward for removing pensions when people have been in hospital for more than eight weeks is that it would be wrong for them to have, as it were, pay twice—once by way of a pension and once again in hospital. Yet, when one has ceased to play with the words, the fact is that they are contributing to their cost. If what might well be described as the most needy group in the population—the elderly, the disabled and the injured—are required to do this, would it not be sensible at least to encourage the fit and the able to take out private health insurance schemes and so take away from the national health services some of the expense of the operations and other treatment required?

One concrete method of encouraging more private insurance schemes would be by way of tax relief for employers and employees. I think that this is something that it would be well worth the Government examining. I hope that the Royal Commission is looking at it very seriously indeed in order that all the patients in the National Health Service may benefit.

Finally, on finance I think we need to look at a much better use of resources and I know that my noble friend Lord Sandys, who will be winding up for us on these Benches, will be speaking about this. Both the noble Lord, Lord Auckland, and the noble Lord, Lord Amulree, spoke about the complaint, which indeed I have heard many times, that there are far too many administrators in all areas of the National Health Service and the National Health Service reorganisation is always blamed for it. In fairness to the Act, I believe that when the National Health Service Reorganisation Act came into force in 1974 not a single extra person was employed in the Health Service who had not previously been employed in the National Health Service or in the local authority services which were incorporated into the Service at that time. There were a number of redundancies and a special staff commission was set up to look at the problem of people who might be affected adversely as a result of the reorganisation.

The way in which the Service has developed since then cannot be blamed on the Act itself, and we recognise that there is a position which I myself much regret in which there is now one administrator for every four hospital beds. Surely this cannot be right, and we need to look at our resources to ensure that money is going in the right place. Therefore, I think there is a case for looking at the proportion of administrators.

The third area where I think there has been a great loss of morale is in connection with the staff. I should like only to say this about the nursing profession, which I believe is one of the great professions in this country. It is absolutely deplorable that nurses are so badly needed in hospitals and yet, at the same time, there are now 3,821 registered as unemployed, although fully qualified. Indeed there are many nurses in training who know that when they have completed their training they will not have a job. This goes side by side with empty hospital beds and ever-lengthening waiting lists. It is an Alice-in-Wonderland situation; something which would he a comedy were it not in this case a tragedy.

Equally serious has been the way the doctors and consultants have been affected by the various incomes policies over the last two years. Nobody who takes a serious interest in this matter can fail to have read the 1977 Review on Doctors' and Dentists' Remuneration. I believe its publication was somewhat delayed, and that is hardly surprising when we read the facts contained in it. The facts are that between April 1975 and April 1977 the average fall in living standards for the average wage and salary earner was about 6 per cent; the average remuneration for doctors and dentists fell by at least 10 per cent. and in some cases by 14 per cent. and, due to a number of anomalies, even more than that. The only other group of people whom I believe have fared equally badly have been university teachers. It seems unfortunate that this group of professional people seem to have been singled out for this unfortunate treatment. Although the review body does not suggest that there will be anything like a strike—and the last thing anybody would wish would be something like that—there is no doubt that there is considerable concern among professional people that, because of the dates at which the reviews have taken place, they have found themselves in a pay trap with their remuneration falling steadily behind that of others. After all, they work very long hours, they have to spend years studying in order to gain their qualifications and it does not help anyone to believe that at the end society feels they are of such little worth that they should be paid relatively less and suffer relatively more than other groups in the population.

Perhaps it is not surprising that a recent report in The Times of 2nd March showed that, in inquiries made of nine of the 14 Regional Health Authorities, for a total of 612 registrars' posts, only 1,009 applications were British and 7,796 applications came from overseas. Of those who were finally appointed, 385 were from overseas, representing 62.9 per cent. compared with 37.1 per cent. who were British. So we see a pattern emerging in which the opportunity to go into the National Health Service is not one which British doctors are seeking. It seems to be one which is more popular with those from overseas. Again we have the pattern emerging of ever-lengthening queues, unemployment among the nurses, demoralisation among the doctors and the filling of the posts in the hospitals by those from overseas. All this adds up to a very sorry tale indeed. They are serious facts and I think they explain the loss of morale in the National Health Service.

Therefore, I should like to finish on a constructive note. I believe we ought to be thinking constructively about the improvement of the Service. I hope the Government will look seriously at the question of pay anomalies, at the question of fully employing fully qualified nurses. In order to help the patients, I hope the Government will look carefully at the relationship between the National Health Service and the social service departments of local authorities. That is something which could be done without extra cost in money and it would help the discharge of patients into their own homes to come about more quickly and more satisfactorily for both parties.

In a debate like this, it is easy to talk about the National Health Service, the doctors, the nurses and the ancillary workers, and yet at the same time to forget the patients. At the end of the day, they are what it is all about. Perhaps I might quote one short story about the National Health Service which applied to myself. Not so long ago the school which my daughter attends telephoned me to say that she had had a very slight accident in the gymnasium and they thought I ought to take her to have her foot X-rayed. I collected the child from the school and I took her down to the casualty outpatients department of our local hospital. There is no car park so I had to leave her in the outpatients department while I went off to park the car. When I came back, to my surprise I found her outside the hospital, sitting on a chair. She had fainted from the heat and had now bruised her head very badly and so she had been put outside to recover. At any rate, I collected my child and we went back into the casualty outpatients department, and the House will be pleased to hear that in fact her foot was not very seriously hurt and three hours later we went home.

I have no complaint of the treatment. The doctor we saw could not have been kinder or more helpful. He looked quite exhausted; he told me that if I was not satisfied I was not to hesitate to come back again, but it emphasises the difficulties of old buildings, of hospitals without adequate facilities, of the difficulties of people who have to take children to hospital and of the time that it takes. I quote the story simply because these are the matters which people think about when they consider the National Health Service. I quote it not as a criticism but as a typical example of the use by patients of the National Health Service.

I hope very much that the point made by the noble Lord, Lord Auckland, and the noble Lord, Lord Amulree, about better relationships in hospitals will come about. I believe the worst possible situation for the Hospital Service would be for there to be further disputes between the consultants and the ancillary workers, because at the end of the day the health of the patient depends entirely upon the work and the skills of everybody in the hospital from the consultant to the doctor, to the person who provides the meals, the person who cleans the rooms. All are needed and all have their part to play. I believe that all in the Service should recognise that they are working for a Service in which the good of the patient must always come first.

3.49 p.m.


My Lords, I take part in this debate with a good deal of diffidence and some degree of reluctance, but if the whole trend of the debate tends to he somewhat critical, perhaps it may afford a degree of comfort to my noble friend who is to reply that I am to be the last speaker from these Benches who is to take part. When I first rose to speak in your Lordships' House, now over 12 years ago, it was on a similar Motion, also introduced by the noble Lord, Lord Auckland, and I am grateful to him once again for having raised this subject in today's debate.

That occasion 12 years ago was also notable for the maiden speech of the noble Baroness, Lady Brooke of Ystradfellte, who, I am glad to see, has been with us until a few moments ago. My subject 12 years ago was the existing malaise in the medical profession, particularly among general practitioners. That malaise has been a favourite theme of many maiden speakers since. I recall especially a striking maiden speech by the noble Baroness, Lady Stocks, who, alas, is no longer with us. This malaise in the National Health Service, however, is still with us, if anything to a far greater extent today than it was 12 years ago. What is so regrettable is the fact that it has since spread to the ranks of the con- sultants as well, in fact throughout the National Health Service, affecting nurses and hospital employees alike.

Our National Health Service may still be the best in the world, as we have grown so accustomed to reiterate, but it is nevertheless a service in the ranks of which enthusiasm is somewhat lacking. That perhaps is an understatement, but it is an understatement made deliberately. Of late we have seen many attempts on the part of the Government, sincere and well intentioned as they undoubtedly are, in our present difficult economic climate, to remedy the present state of affairs. I feel that every credit should be given to the efforts of Ministers and their staffs to solve the heavy problems with which they have been faced.

But, after all, the legislation for the abolition of pay beds, I suspect, precipitated a mountain of labour and produced only a mouse, and a somewhat impoverished church mouse at that. It has certainly made, I suspect again, no impression on our lengthening waiting lists. It has even given rise to the sad joke that our abortion Acts have added such a burden to the waiting lists of some hospitals that their waiting lists for abortions have now grown to over nine months. But all the attempts at creating common waiting lists for private and National Health Service patients, as the Wigoder Committee's Report only proved, have ended in failure. The only conclusion they reached was that in the last resort the waiting lists of our hospitals had to depend mainly on the medical staffs—a conclusion they might have known before they began their deliberations. So the whole issue of common waiting lists is back now to square one.

Meanwhile abolition of pay beds, phased as it was, has not added materially to our hospital resources, but only impoverished the health services still further. And has it finally brought peace to our hospital staffs? I suspect, again, the contrary. It has only maintained the spirit of discontent, created an attitude among the staffs dangerously close to beggar-my-neighbour, and certainly done nothing at all to shorten the waiting lists or to improve the lot of our long-suffering patients. I make this assertion subject to correction by my noble friend the Minister who is to reply, and I hope in his reply he will be able to prove me wrong and give us the exact figures of the reduction in hospital waiting lists following the first phase of the closure of 1,000 pay beds.

The uncertainty that prevails about recruitment of new students to our medical schools, fortunately, has not affected the quality of new entrants to the profession. There, at least, competition for entry is intense, morale is high, and the quality of intending students is as excellent today as it has ever been in the past. The desire to serve, to join the ranks of those who are striving to alleviate pain and conquer disease—that urge among our young people today is one of the most heartening factors in the gloom which at times tends to surround the outlook of our National Health Service. It is a factor which must be maintained during the years of training and apprenticeship, and afterwards harnessed for the benefit of our patients.

I would far rather we created too many new doctors than too few, and used our existing medical schools to the utmost of their capacity, despite the anticipated fall in our population. There is a crying need today all over the world for more doctors, and doctors of the highest quality, not only in the oil-rich sheikhdoms of the Gulf but in all the poverty stricken developing countries, with their teeming millions of population and their appallingly high birth-rates, so that, unlike our teachers, no doctor need ever remain unemployed. There are so many outlets through international sources, through the World Health Organisation, through our missionary societies abroad, where the services of any medical men found surplus to our own internal needs can be usefully employed. Look wherever you will—Africa, India, the Far East, South America, the Caribbean—the medical services are poorly developed per head of the population, and the need for medical aid is more insistent than ever.

What then is to be done in this country? I would suggest that three things are urgently necessary, though hard enough to achieve. First, to restore morale throughout the health services not only by means of pay, prospects and career structures, as has already been mentioned by the noble Baroness, Lady Young, but also by infusing among hospital staffs a new spirit of service and dedication with a realisation that, however, severe their own economic hardships, they are less than the physical sufferings of the hospital patients whom they have been recruited to serve. There is need today for a higher spirit of teamwork, even of self-discipline, for without these no hospital can prosper; and for recognition that the medical staffs are the keystone of the hospital arch, eroded though it may have been of late. For if the keystone crumbles the whole edifice will collapse.

Secondly, even today in the midst of our strained economic situation, more financial help for our hospital services is unavoidable, and excessive cuts in some directions could only lead to further deterioration. Thirdly, known glaring instances of waste in the National Health Service, especially in the hospitals, must be dealt with. Here constructive suggestions by the hospital staffs should be invited and a spirit of co-operation encouraged throughout medical staffs to remedy known waste both of manpower, especially on the administrative side, and of material resources. I hope that many more discussions on the National Health Service will take place from time to time in your Lordships' House, and that all our future debates may he held in a far more hopeful atmosphere than that which surrounds us here today.

3.59 p.m.


My Lords, ever since 15th February 1967 I seem to have made periodic speeches on the subject of the National Health Service. The date is firmly in my mind because it was then that I made my maiden speech on the subject, and the noble Lord, Lord Auckland, said that he was the first to congratulate me from those Benches. Now I can tell him I am the first to congratulate him from these Benches. I think he made a splendid speech. He raised matters of great importance, some of which have also been mentioned by other speakers and some not. I should like to refer to one or two things he said. He referred to what I call the two recent disasters to the National Health Service; namely, the reorganisation, and the phasing out of pay beds. He spoke especially for long-stay patients. I hope that the noble Lord who replies on behalf of the Government will be able to say something helpful to him on this subject. It is one about which I have no really practical experience.

The noble Lord, Lord Auckland, also mentioned two other matters to which I should like briefly to refer before I make some more general remarks. He spoke of kidney machines. I should like to ask the Minister pointblank: Is this not the only case since the introduction of the National Health Service in, I believe, 1948, where a deadline has been set, so that if one is below the age of 15 or above a certain age one cannot have a kidney machine or a transplant? I think that it is the only case.

That is not to say that people have not died through lack of facilities in hospitals. For instance, the local community or village hospital could not have the very latest facilities for cardiac surgery. There are plenty of instances where the patient has been unable to receive aid in time. There have been instances—and the discovery of penicillin was one—where a new and important remedy has been discovered and for a time was in very short supply. Those things cannot be helped, but I should like to know whether anyone can quote an instance where a cut-off has been made because we cannot provide the service, and where people have been turned down for treatment simply because they are above or below a certain age.

I wish to refer again to questions which others have raised and which I did not intend to mention because I have spoken on them in previous debates. I shall not bore noble Lords with all the details on the issue of foreign doctors. This problem exists at registrar level—that is, sub-consultant level—in other countries. In the United States of America 50 per cent. of those doctors come from overseas and only very few are from Britain; in Western Germany and all parts of the world where medicine has developed so rapidly that it needs a staff of people with this particular level of expertise. This is not simply due to a shortage of doctors, because if sufficient doctors were to qualify to fill all those posts, most of them would have nothing else to do for the rest of their lives.

We must remember that a consultant holds his post for an average of 30 years, during which time perhaps 20 or more young men will pass through his unit as registrars or in similar posts. When the consultant finally retires he leaves but one vacancy. The very simplest arithmetic will show that we must fill these posts in some other way. Many of these young men will, rightly and properly, go into general practice, where I am sure they will be very welcome. Nevertheless, there is this arithmetic gap which most people seem to pass over and say, "We do not have enough doctors because of all the foreign gentlemen around". That is largely, though not entirely a fallacy.

Noble Lords will be glad to know that I shall not repeat all that I have said on previous occasions. However, I must reiterate one or two remarks because there are certain principles of which we are in danger of losing sight. In this to a considerable extent I shall be drawing on personal evidence, which, I have given to the Royal Commission on the National Health Service. The Health Service has been a boon to millions of people; that is a truism or, as some noble Lords may prefer, a platitude. This is in danger of being forgotten, especially by those who did not know what the medical profession and the service to the patient was like before the introduction of the Health Service. In the old days we had the bankrupt voluntary hospital and a low standard of hospital service in a large number of provincial towns, with the exception, usually, of their teaching hospitals.

There are two reasons why people do not seem to bear in mind the boons of the Health Service. One is the constant denigration of the Service by the British Medical Association and similar organisations, and the fact that right from the beginning the then secretary to the BMA, who shall be nameless, told all the doctors to boycott the new Service and not join it.


My Lords, the noble Lord will go down in history as a distinguished diagnostician, but not as an accurate historian.


My Lords, I listened to some of the speeches myself. I do not want to dwell on that. These tactics are bound to have at least two effects. The first is that they build up a grievance, because one cannot get doctors to boycott a Service without building up a grievance. Then one is never quite sure how much of the discontent is due to the grievance and how much is real and due to the defects of the Service, of which, of course, there are plenty. This leads to a lowering of morale and the maximum of between the Government and the doctors, whereas the maximum amount of co-operation is the only solution to most of the problems facing the Health Service.

I think that I may now skip some of my notes, although not because of any interventions that have been made. We should bear in mind three important principles. One, which I have just enunciated, is that we shall never succeed without the maximum amount of co-operation between the Government and the doctors. I am not convinced that in the 30 years since the setting up of the Health Service we have had maximum co-operation on either side. I blame neither the doctors nor the Department.

The second principle is that, whatever may be the calls from the far Left for a wholly illusory egalitarianism, one just cannot mount a good Health Service without the willing participation of the doctors, even though one's political views may not always coincide with theirs. In that context the phasing out of pay beds has been an absolute disaster. Various speakers have said that it does not seem to have done anyone any good.

If the noble Baroness, Lady Lee of Asheridge, were present, she would remind us that when the Health Service was introduced it was decided that there should be amenity beds and that by paying a modest fee—which I believe was five guineas a week (which sounds like pocket money for a child nowadays)—one could have the benefit of privacy and so on, though it would not lead to better treatment or to jumping the waiting list. I should like to point out that, from a practical point of view, that is quite impossible. Presumably amenity beds are set aside for patients who want to pay to have amenity beds. Either we have enough or more to spare of those beds, in which case patients will jump the queue, or else we do not have enough, in which case those amenity beds will be filled by National Health Service patients who are not paying for amenity beds in any case. Even that does not solve the question of queue-jumping.

Certainly the phasing out of pay beds does not solve any of those questions. For the phasing out of pay beds to be introduced by a Socialist Government is quite surprising. One would think that it is almost a deliberate attempt to divide medicine into one kind for the rich and one kind for the less rich—one cannot say poor nowadays. It is the most dangerous development in medicine. You appoint the very best people, who build up tremendous reputations for themselves, sometimes for their hospital, for their patients, and you want them to work in the hospital to which they owe their loyalty. Let us suppose, for instance, it is St. Bartholomew's Hospital; do you say that if you see private patients you must see them in St. John's Wood, or something like that? The whole thing is so ridiculous that I cannot think how it ever came about. However, it did, but I am glad to hear that it is believed that it is not a success. I wished the noble Lord, Lord Wigoder, the very worst success for his committee the other day, which he took with very good grace.

On the doctors' side there has been a lack of co-operation among themselves. There are obvious ways of reducing waiting lists. I do not say that they can be done in every hospital or done in a matter of weeks, but wherever a deliberate challenge has been made and doctors and hospital staffs have got together to reduce waiting lists, they have always succeeded in doing so. What is more, a lot of the waiting lists are to some extent bogus. Large numbers of them are for children waiting for hospital beds for tonsils and adenoids, which, in most instances, would be better left where they are. I think the doctors have not collaborated even among themselves to try to abolish other abuses. This question of queue-jumping is in some hospitals, I am sure, quite serious and should be tackled within the profession, because I do not see how administrators are going to tackle it at all.

That leads me to another very important principle. It is absolutely naive to imagine that the faults of the Health Service can be put right by administrative action. They cannot. I think that the so-called reorganisation, which I often call the disorganisation, of the Health Service, is a good example of this. In that respect, I should like to read a short extract from one of the famous CIBA Foundation conferences on health care, which was held in 1976, in which one of the members of the conference, himself a hospital administrator, said about the reorganisation of the National Health Service: The main aims are presumably operational integration and better planning of services…The main problem was whether it could achieve these aims…without introducing a stultifying and expensive bureaucracy…on the evidence of the first 18 months the basic problem has not been overcome and an administrative bureaucracy, in the pejorative sense of the word, has been created". Another principle which I think we should embrace—perhaps that is the word—is that, if you are to judge any new venture in the Health Service, the best criterion on which to judge it is what effect it will have on the reputation of British medicine at home and abroad, because in the long run the benefit to the patient depends on that. The reputation of British medicine, in spite of all that you hear said about it almost every day, is still very high both at home and abroad. It is high for its honesty, its integrity, and the skill of the people who work in the hospitals.

If we were to forget about equal opportunities, which are impossible to achieve, and were to think now of what effect this will have on the reputation of British medicine, we might get a little further in the way of co-operation between the profession and the Department. One final point. The noble Lord, Lord Auckland, referred to strike action and picketing. I was not quite sure why he did not condemn what I call the strike action by junior doctors, and the work to rule—fancy having to use that expression about my profession!—of the consultants. I think that those were two big blots which the profession should never have allowed to materialise.

4.16 p.m.


My Lords, having no administrative experience of the National Health Service I feel some degree of temerity in getting up to talk about it. However, I am a user, and on the whole it has not done me too badly; but I admit that some of my more serious complaints have been dealt with in the private sector. Nobody can deny that some of the delays are rather horrible, and my medical friends say that the whole Service is going downhill. They blame first of all the Conservative Government for their passion for reorganisation, and the Labour Government for their passion for egalitarianism.

I am rather inclined to think that there may be deeper factors still at work, and they are that medical science is progressing at a far faster rate than the national product, and also that we are an ageing population. The net result of this is that the traditional proportion of the national wealth which has been devoted to health in the past is now proving quite inadequate. It has to go round a larger number of people, and if they are to have the best and most modern treatment it has to provide much more expensive treatment. Therefore, we have to find a lot more money. Of course on health the sky is the limit. I do not hold myself up to adjudge exactly how high the sky should be, but there has to be a lot more money. It cannot come out of the Budget because the British people are already grossly over-taxed in the Budget. There would be a revolt. We have to find new sources which would be acceptable to the British people.

The idea would be if people paid a considerable, or a definite, proportion for all the services they received, but great complications arise there. There are the exceptions. There is the splendid myth about the old age pensioners. We are all supposed to be paupers, and those hundreds of thousands, and perhaps even millions of us who are not paupers benefit greatly from this myth because we get a lot of things at the public expense which we do not in the least deserve. Nevertheless, this myth persists, that anybody who is on an old age pension cannot afford anything, and therefore they would have to be excused charges. Then of course the Left Wing would create a tremendous rumpus. Nye Bevan would be quoted and misquoted ad lib, notwithstanding the fact that, as regards incomes and wages, he lived in a completely different era from the present. Moreover, and perhaps most important of all, the doctors might create a fuss about collecting the money in their surgeries, and so on.

No, we might try something better. I suggest that we might have an accident levy. After all, the National Health Service spends a lot of money on rehabilitating people who half kill themselves on the roads. Why not put 1p on petrol as an accident levy? It spends a great deal of money easing the dying from lung cancer. Why not have a levy of 1p per packet on cigarettes, and call it the lung cancer levy?

I suggest that in addition we should have a national lottery in aid of hospitals. This has been done in Rhodesia and, I believe, in certain countries in Europe. If we are not prepared to stomach any of those sources of revenue, the next best I can think of is an increase in the employee's portion of the National Insurance stamp; the employer's portion is already much bigger than that of the employee's and, in any event, an increase in the employer's contribution goes straight on to prices and sends them up, so for this reason it should be an employee's levy.

As my noble friend Lady Young rightly said, all these things would have to be explained to the public. It would have to be made clear that the money was for doctors, nurses and other facilities, and not for spoiling a new brand of bureaucrats, which I am afraid is what the British people may suspect. We need more doctors, nurses and ancilliary services so that people may be given a better service generally; one gets a very quick examination from the doctor these days, and it is intolerable that hospital waiting lists for diseases which, in medical parlance, are called not dangerous but which may be hideously uncomfortable, are months' long. If the results are seen and if such matters are properly explained, the end will be considered to have justified the means and the British people will not grudge the extra they have paid by way of some additional levies.

4.22 p.m.


My Lords, I seek to speak briefly on two aspects of the National Health Service, a Service which has been, and even now should be, something of which we can be proud. Nevertheless, we should surely temper our pride with self-criticism, and we are grateful to the noble Lord, Lord Auckland, for giving us this opportunity to look at the present difficulties, of which there are many.

I wish to touch on two aspects, first the recruitment, training and morale of the nursing profession, and secondly an aspect of management as between hospitals and the Regional and Area Health Boards. Let me first, however, take up a point made by the noble Baroness, Lady Young, concerning the nursing profession. I also seek to know from the Minister why there are 3,821 trained nurses out of work on the one hand, and why, on the other, on 11th May 1977, at their congress in Bournemouth, members of the nursing profession posed certain difficulties of which I will mention a few. For example it was said by a nurse that it was ridiculous that untrained staff should still be left in charge of wards. Later somebody at the congress said that nurses knew that proper standards of care were not being met and that grave injustice was being done to patients and their relatives who did not realise the situation.

Although Lord Auckland spoke about hospitals, I wish to draw attention to community care and preventive work in the community. At that congress it was said by a community nurse that in 1975 his department made 147,000 visits with a staff of 61 and that last year they made 159,000 visits with a staff of 57. If the hospitals cannot cope with all the patients, then surely—in any case it would be right—we should carry out preventive medicine with community nurses in our areas.

There is a real difficulty here and I seek the Minister's views on the Briggs Report in which it was recommended that the age of entry for training should be reduced. Would that be wise? There are two channels of entry; the girl of 18 who has 0 and A levels, and the girl of 16 leaving school who, at the age of 17, wants to train as a nurse. The latter, if helped in the right way, has much to offer. However, in my view they should not start their training until 18, first doing two years in allied professions—working in a children's or old people's home or perhaps as nursing auxiliaries in specialised hospitals—thus experiencing gradual exposure to the responsibilities and emotional shocks of illness. Of the 18 year olds, I would say that they also need a time of adaptation to the rigours and joys of nursing.

The early achievement of qualification often places responsibility too soon on too young a nurse at too early a stage, and in her own interest this is perhaps not wise nor in the interest of the patient. Indeed, I would say that it is far better for a girl to feel she is working towards a career.

There seems to be a slight dilemma which I hope the Minister can explain. Have we in this country an adequate number of tutors in nursing qualified enough to teach, to inspire and have time to support each individual nurse in training, thus ultimately turning out nurses of the highest and best quality? If highly trainined nurses are removed from the wards to be tutors, what then happens in the wards when there are not enough adequately trained older women to supervise the patients? It seems from the figures that this is a very real dilemma, and I hope the Minister will explain how we are to overcome it.

I support the noble Lord, Lord Segal, because I, too, am not in the least worried at our having more nurses in training, and afterwards trained, than we can use. I am sure that throughout life the nursing qualification for any woman is a great asset. It is unlikely in this country, though not impossible, that we shall at any time have an epidemic, but how glad we should be of any trained nurses More important perhaps, the Third World needs the kind of skilled nurses whom we produce in this country

My Lords, I turn to an aspect of management. I should like to ask the Minister whether he would agree that there is too wide a gap between, on the one hand, those responsible for patients in a hospital and the day-to-day running of that hospital—and I include all members of staff—and, on the other hand, the budgeting of the needs of that hospital. Would it not make for flexibility, efficiency, and a sense of responsibility, for each hospital to receive an allocation of finance each year and leave it to the hospital board, which might consist of all staff across all areas, to use the money as they see the needs? At present they are allocated money from the Area and Regional Boards, which are not involved in the day-to-day needs of the hospital, and with the best will in the world, they cannot see exactly what are the needs of a hospital at any point in time.

The hierarchical structure is causing frustration, and diminishing a sense of responsibility. Of course there would need to be inbuilt safeguards. In my view the sector administrator should be in the hospital, and not at the Area Health Board. This may be a naive recommendation; it is a simple recommendation, but I believe that responsibility should be put where responsibility belongs.

Lastly, I should like to say that the hospitals have always belonged to the people—and they should belong to the people. We are short of money, and I do not recommend that there should be vast extra sums spent. But any community that has a hospital in its area, and which has a very good and committed hospital league of friends, will seek to raise money for areas where the National Health Service cannot meet the needs; and in this way the community are involved in the National Health Service, in the hospital in their area, and with the patients who are in that hospital.

4.32 p.m.


My Lords, I am very glad that we are having a Royal Commission on the National Health Service, because from all the very interesting speeches made this afternoon one realises how many very important aspects of the National Health Service require investigation. I have quite a number of points that I should like to talk about, and I will try to be as brief as I can; but I should warn the House that I could speak for two hours on this subject—not that I am in the least likely to do so. As I have, for a very long time, and very proudly, been a vice-president of the Royal College of Nursing, I have had sent to me—as I think my noble friend Lady Faithfull has, too—the evidence from the Royal College of Nursing that has been submitted to the Royal Commission. When one sees the size of that document, one realises that for a very long time the nursing profession has required many things to be done for it which no Government apparently have been able to do.

I should like to add one other point here. For a very long time when I was in another place I represented the physiotherapists who, very cleverly, I thought, had a special committee with a well-trained and highly respected secretary to deal with the requirements and needs of the physiotherapists. As a matter of fact, I do not think that anybody has mentioned the physiotherapists and their problem in the debate today. They are very important people in the Hospital Service. So I should like to ask the noble Lord who is to reply, whether the Royal Commission will have taken, as I am sure it will have done, evidence from the physiotherapists' organisation, because it is most important that when the Royal Commission reports it deals with all these very important matters which will, as I believe, make all the difference in the world—


My Lords, I hesitate to interrupt the noble Baroness, but in case she intended to put similar questions to me on other disciplines, I should like to say that it is for the Royal Commission to take evidence from any person, or from any source, and it is for any professional organisation, or for any individual, to submit written evidence, or even ask to give oral evidence. This is not a matter over which my Department or the Government have any jurisdiction at all.


My Lords, I am very grateful to the noble Lord for intervening. Having been in another place for 38 years, I know only too well that it is most important to get those who answer from the Front Bench to debates of this kind to take an interest in what those who contribute to the debates say. I have a great respect for noble Lords who answer from either Front Bench, because I know that if they take an interest, and if they interest the Cabinet also in all the points made, it makes a considerable difference. Although I am not expecting that the noble Lord will answer the point that I made, I should like him to know that at some time or other I may ask him to answer a question which may have been considered by the Royal Commission. I cannot ask the Royal Commission now to give me an answer, though I could write to it. However, I am not very keen on writing. I like to see things in print, which I can quote if I wish. I thank the noble Lord very much for intervening, but I shall hold him partly responsible, in any case, for the interests of the physiotherapists whom nobody has mentioned this afternoon.

I now want to turn to another point. I have quite a few points that I want to make, but I shall not be very long. I want to refer to the question of food in hospitals. Fortunately for me, I have been very healthy over the years, but I had an emergency operation for an appendix the other day, and I very nearly passed out. It struck me at the time that while some of the food which is provided in hospitals is very good indeed, it is a little worrying for people if, when they are feeling so ill that they can hardly read it, they are given a huge menu which suggests all kinds of things that can be ordered. So far as I was concerned, I could not eat any of it. So I had to have simpler things, such as scrambled eggs, fruit, and so forth, which I could enjoy.

There has been considerable criticism about hospital food. Much of it is probably unnecessary criticism because I think that the catering staffs in hospitals do their best to provide the nicest food that they can for the patients. But to have a choice of four or five main dishes every day seems to be going rather far from the point of view of Hospital Service expenditure. I wonder whether it would be possible to have simpler, more suitable, food which the patients would probably prefer if they are really ill. I hope that the noble Lord will not want to say in reply that it is somebody else's duty to raise this question; if nobody else has raised it, then at least I have raised it here, and I put it forward as a suggestion.

I turn to the next point that I want to raise, which I also believe is very important. I think it is fair to say (though, naturally, it does not rest on the noble Lord who is to reply) that the country is very grateful indeed to all those who serve in the National Health Service. We are very proud of them. Wherever they come from, they do their best; but there is no doubt that there is a great deal of criticism of the general administration at the top.

I want to go on to the next point, which is that, when the National Health Service was set up, it took over, so far as I can understand it, all the private hospitals and the private endowments, too. I should like to know whether we could have a list (I would not mind if the noble Lord had it printed, because he obviously could not provide it otherwise) showing how much money was taken over by way of endowments to private hospitals which came into the National Health Service. I should like it in detail; and I should like then to know, if we could be told, how that money has been spent. Because I may be wrong, my Lords, but my own view is that regional hospital services are sometimes so short of money that they spend endowments which have been made to private hospitals which they have taken over rather than maintain those private hospitals, many of which have done wonderful work for the people for whom they were provided. So perhaps in the Recess, when he has not quite so much work to do, the noble Lord will circulate in an appropriate manner a list of all the private hospitals and the endowments which were taken over, how much they amounted to and how the money was spent.

I ask the noble Lord that because, of course, upon that information I want to raise, as I always try to, a case in my own part of the world. I know that your Lordships sometimes get very tired of my referring to that part of the country from which I come, but I am a great believer in experience, and experience in my own part of the world has given me quite a lot of knowledge—and I now come to the point I want to raise about what was known as the Sanderson Home for Crippled Children. This home was built by a very well known family in the North, and was heavily endowed. It had lovely grounds and gardens. It is still there, but there has been a lot of controversy about it recently. There are still a large number of crippled children in that home, but, fortunately, with the improvements in medical science not quite so many homes especially for crippled children are perhaps so necessary.

However, although there are other beds in that hospital and there is a wonderful staff working in it, it was suddenly decided by the Regional Board that the crippled children should be transferred to the new Freeman Hospital, for which I may say we in the North of England have waited, waited and waited—your Lordships know what I mean: it is almost there, but not quite. Now it has been reported that these children are going to be transferred to rooms on the fifth floor of this hospital, where there are no balconies. There is no garden at this hospital, and the children do not want to go there. Certainly the people who were interested in the Sanderson Home do not want them to go there, because the Sanderson Home has a lovely garden; the children were always able to be pushed out into the garden, and they enjoy it. I think this is an absolutely immoral decision, and that is one of the reasons why I am asking about the endowment of private hospitals which have been taken over by the National Health Service.

In addition to that, when this matter was raised by me and other people in my part of the world—and I think my noble friend Lady Masham is also very interested in this hospital; she has done a great deal of work making inquiries about it—one of the reasons given to me was that the second floor in the Sanderson Home was not filled up by crippled children. I was told, in fact, that there were vacant beds. If there were vacant beds, why were those beds not filled by many of the people who have waited so long for beds in my part of the world? We have a very big waiting list indeed. Why could those beds not be filled? They have a very good nursing profession in the hospital, they have very good physiotherapists, and everything appears to be available. Yet that hospital is to be closed down, while those crippled children are going to be stuck in a new hospital, five floors up, I think, with no balconies and no ability to enjoy themselves in the garden. It seems to me to be a most regrettable position, and I should like to know the answer to it.

In addition to that, we had another big children's hospital in Newcastle-on-Tyne, the Fleming Hospital. Curiously enough, many years ago, when I was in the VAD, I did my first service as a VAD in the Fleming Hospital, so I have always taken a great interest in it. Then, suddenly, just like that, it was announced that it was going to be closed. I of course cannot tell whether that hospital is not really needed for children; but there it is. It is a perfect hospital, and it could have been used for housing people who want beds. I was up North last week-end, and I was told that it had been announced on the radio and in the paper that both the Fleming Hospital and the Sanderson Home were going to be pulled down. To me, that really seems a most unfortunate situation. Your Lordships know very well how outspoken people are up in the North, but their view of the National Health Service is anything but friendly, is perhaps even accurate, and certainly is not flattering.

My Lords, we in the North have a very good Regional Health Service Board. We have a very distinguished chairman indeed; and I am glad to say that on that Board in the last few years, for the first time, we have had a State-registered nurse from the Royal College of Nursing. We are very proud of this; and I think that a State-registered nurse on a Board of that kind can do a great deal of good and be very helpful indeed. What I am not sure about is this, because, of course, being only a Back-Bencher when I was in another place, I have not seen all the papers. Now we scramble around trying to get the facts and trying to see if anybody can give us a little bit of additional information about what is going on. Was it not realised by whoever it was who took the responsibility of announcing over the radio and in the Press that this action was going to be taken what effect that would have on the local people?

I think that whoever took that decision cannot be very much in tune with what local people feel about matters. We feel tremendously involved in what happens to people living in my part of the world; and I know that some of the officials, who are very good—and if one knows them very well they are kind enough to say, "How awful!"—feel the same. One never knows, of course, what representations they are able to make, to whom they make them and what action is taken. I think that communication in these great matters of the Health Service is very important, because these things matter tremendously to the local public. I should therefore like to know the answer to that.

I think I have covered everything although, as I say, I could go on talking for about two hours; but I should like to know about some of these matters. I hope the noble Lord who is to reply will not say anything about this not being his responsibility. I think that Cabinets of Governments of all Parties have a very real responsibility. Perhaps the noble Lord could tell me whether he will read all the evidence that has been given, because then perhaps he would know a little more than he does about all the problems that have cropped up in my part of the world. I am glad we have had this debate and I thank the noble Lord, Lord Auckland, for having thought of it. Perhaps we shall not have to wait too long before hearing from the noble Lord on the Front Bench about what has happened to all the important and interesting suggestions and recommendations that have been made.

I am glad to have been here today. I have a great admiration for the Royal College of Nursing and for the physiotherapists, for the consultants and for the doctors. I should like to say how sorry I am that the name of the noble Lord, Lord Hunt of Fawley, is not on the list. He is probably too busy to speak. That happens to a great many very important medical men; they have not the time to do all the work they are called upon to do. I should have liked to hear his contribution. Perhaps I shall go to see him. He sometimes gives me injections against flu. I will go to see him one day and ask why he was not able to be here and what he would have said had he been here.

I hope that the next time we have a debate on this important matter of the Royal Commission inquiring into all the necessities in the National Health Service, it will have gone forward a long way; so that we can continue to find out what the recommendations were and whether the Government have been able to implement them.


My Lords, if the noble Baroness is really in need of seeing her doctor, she will find that he is behind her.


My Lords, all I can say is he is a very nice doctor. I am delighted that he occasionally can look after me. His name was not on the list and I shall not forget to ask him all the questions that I said publicly that I would ask.

4.52 p.m.


My Lords, in 1959 my noble friend the late Lord Stonham initiated a debate to draw attention to the problems of the Hospital Service. He excluded the teaching hospitals from his survey knowing, as he said, that others with more intimate professional relationships with them would do so, and do it better. He preferred to confine himself to consideration of what are now called district general hospitals. His administrative talents and charitable attitudes served numberless of those hospital committees. He understood. He was a link between my profession and the public. May I join other noble Lords in thanking the noble Lord, Lord Auckland, for contriving today's debate. I hope that it will bear fruit for the matter is most urgent.

At the time of that debate, in 1959, I was consultant physician on the staff of one of our larger district general hospitals and had been so for ten years. I am proud that I retain such a position today. We realised that not only the welfare of patients but our whole reputation in the field of international medicine was increasingly dependent on those hospitals. They were acquitting themselves most admirably. We were all intensely proud. This pride and the high morale it engendered gradually became eroded over the years—increasingly after the reorganisation of the Health Service in 1971.

Your Lordships debated this reorganisation on a Motion by the noble Lord Lord Aberdare in 1971. If your Lordships will bear with me for a moment I should like to repeat what I said then. I said: Since the appointed day the status of district hospitals has been steadily rising. They have therefore been able to attact consultants of the highest calibre. This in turn has attracted correspondingly excellent junior medical staff. Success breeds success. Medical students have increasingly been seconded from their teaching schools to district hospitals for elective or longer periods. All in the present district hospital garden may not be lovely, but there is at least a garden. If, unhappily, my anxieties prove well-founded, and if, for administrative and financial reasons—or both—the status of district hospitals declines, the future will be grim indeed. In truth, my Lords, there will be no future, only a progressive slither of a vital part of this country's hospital services into mediocrity, and no chance then of recovery in any foreseeable future; for emigration of too many of our brightest young medical people will, I fear, have seen to that." [Official Report, 29/11/71; col. 117]. The noble Lord, Lord Aberdare, when winding up that debate, took me gently to ask for being, as he put it, a little too gloomy about the future of the district general hospital". I only wish that my anxieties had proved unfounded, but, alas! they have not. Administrative unwieldiness coupled with insufficient money to maintain existing services, far less expand them, generated a crisis of morale and a loss of pride in the Hospital Service particularly among those medically qualified in all seniority grades and in all specialities.

A most significant attribute of such a crisis of morale may be found in the consideration of numbers of applicants for vacant appointments. I shall do no more than to quote from the letter to The Times newspaper to which the noble Baroness, Lady Young, has already referred, from the President of the Hospital Consultants and Specialists Association. It was headed: No Britons apply for National Service posts". It went on: In 1964, a training post in general surgery at Wolverhampton attracted 26 applicants. These registrars were trained at the following medical schools; St. Thomas's Hospital, 15; Melbourne, 1; Saint Bartholomews Hospital, 1; Charing Cross Hospital, 1; Birmingham, 2; Newcastle, 1; University College Hospital, 1; St. George's Hospital, 1; Manchester, 1; Guy's Hospital, 1; and the Middlesex Hospital, 1". It went on: The latest advertisement for the identical post has attracted 21 applicants from the following countries: Iraq, 5; Afghanistan, 1; Sudan, 2; Pakistan, 1; India, 3; Egypt, 5"— and, rather quaintly— USSR, 4". Although, my Lords, this refers only to surgical registrars similar disastrous reports may be obtained from all specialities and the calamitous trend is mirrored in applications for consultant vacancies.

My Lords, the district general hospital service must be salvaged. It requires much more money. It requires more imaginative administration. It requires more representative administration. It especially requires more medically qualified members of administrative committees. But, above all, I plead with ferocious humility—I am sure these can co-exist—for the utmost harmony in a common endeavour to restore our district hospitals to their former happiness and stature. Nothing less will suffice. They deserve this from us, and if we succeed we shall be esteemed by people coming after us.

5 p.m.


My Lords, I join in congratulations to the noble Lord, Lord Auckland, on having introduced this debate, and, indeed, admire his persistence in sticking to a topic and raising it as he has on more than one occasion—a topic and a subject to which he and his family have devoted so much public service. It took a long period of years to produce the plans for the reorganisation of the Health Service, from which we now suffer. They were well advanced under the late Mr. Richard Crossman when he was in the Ministry and before Sir Keith Joseph set foot in the Ministry of Health. Both Governments share some responsibility for the bureaucratic colossus which, rightly or wrongly, has evolved from the revised Health Service.

I welcome very much the Royal Commission which can take a long hard look again at what has been the result in practice of the high hopes that we had for the reorganisation of the Health Service. First, I think it has destroyed the democratic and local participation which was so valuable under the old hospital management committees. Today, in control locally, there are district committees composed entirely of officials and medical staff within the Service. We have lost the devoted laymen with vast practical experience in finance and working relations, experience in community and social problems, who so ably served—as have so many Members of this House—Regional Boards and/or hospital management committees under the old régime. They knew their local community; they were a contact between the community and the officials. The current community health councils on which the laymen, the doctors and others are represented, are no substitute. They are without teeth. They are frustrated and just about as powerful in influencing policy as are the unfortunate users' associations attached to the nationalised industries.

As one who in six years in the Ministry of Health visited over 300 of our hospitals and met as many boards and hospital management committees, I deeply regret that the revamped Health Service, instead of being a vast human operation in touch with people, has become as remote and bureaucratically controlled as a nationalised industry. The Area Boards control vast catchment areas, from about the largest, around 2 million people, down to the smallest, about 150,000. They meet once a month; they have to deal with a colossal programme concerning dozens of hospitals, ambulance services, welfare services, all at a meeting which may take three hours. So more and more decision rests with those six officials on the district committee. The lay approach, had a vast field of experience. If the noble Lord who is to reply differs from me on other items, I am sure he will agree with all his experience of the Service about the enormous wealth, contribution and contact that the professional laymen brought to those committees. Today, trying to get hold of one of the god-like officials of the district committees is like trying to telephone the noble Lord who adorns the Woolsack at any given time. So we welcome the Royal Commission.

We want the Health Service to regain its human face; we want community contact through those public figures to represent us and speak for us, and bring their considerable expertise in varying forms to bear upon the use of the Service. Nowhere has there been a greater lowering of morale than among the medical professionals in the hospitals. The medical brain drain is a disaster, as was so ably detailed by the noble Viscount, Lord Waverley. The new proposals of the EEC for harmonisation will exacerbate the problem. I cannot see many highly-paid doctors on the Continent opting to come here. I fear that many of our doctors will opt to practice on the Continent and add to the brain drain which we already have to Canada, Australia, and, in particular, America.

When Mrs. Barbara Castle was Minister of Health, while she denied the consultants their legitimate increases, she yielded—not, I am suggesting, without justice—on the question of under-manning and the consequential abnormal hours worked by junior doctors. But instead of giving them increased salaries commensurate with their skill and training, she gave them overtime. I wonder whether she then envisaged what damage she was doing to the future of the consultants' service. What is happening now is that the junior doctors, experienced and qualified after several years, who are capable of being offered consultants' posts, are refusing them because it will mean a cut in pay. This is a disaster for the Service which has always prided itself on its highly skilled and professional consultants' service. I agree with the noble Lord, Lord Segal, that many of the waiting lists in many areas are not due to lack of beds, they are due to a shortage of specialists to perform the operations and treatments needed.

Then, how we treat our specialists! In one great London hospital the consultants are denied a private room where they can get together and discuss their cases, new methods and new treatments in privacy with their professional colleagues. Yet, the NUPE representative has asked, demanded and received a room to himself to conduct his union affairs. For a year he has claimed that his union duties take up 100 per cent. of his time. Ten hours a week—a quarter of his weekly time—would have been adequate to look after the needs of 200 members of his union in that hospital. The hospital pays his full wages for not performing any of his hospital duties. He also represents staff in other hospitals, where his employing board of governors have no jurisdiction and he claims overtime from that board for the visits and times that he spends at the other hospitals. If the union want a full-time official, they should pay his wages from their own funds and not from the hard-pressed funds of the teaching hospital.

This brings me to the cuts in expenditure. The same hospital has had a 10 per cent. cut imposed on it, but it has also decreed that there must be no redundancies whatsoever. Where do the cuts fall? They fall on patient treatment, on food, on cleaning, on vital repairs—all items which affect the patient. The patient is the most important person in the hospital.

Now I turn to the leagues of friends. Minister after Minister, radio programmes, television programmes galore on Sunday, exhort us to do voluntary service, to help the old, to help the handicapped and to fill in the gaps in the system that the National Health Service cannot provide. Just listen to how some of the friends are treated. I am a founder member of a league of friends and proudly we raised the money for telephone trolleys that could go round the hospital so that patients, early every evening, could keep in touch with their relatives at home and tell Johnny to be a good boy and go to bed when his father told him and, if he was a good boy, he might have a brother or sister in about 10 days' time. We had a team of 40 volunteers who took these trolleys round the wards in the evenings, at no expense whatsoever to the hospital.

Then NUPE step in and demand to take the trolleys round—on overtime, of course, from six to eight—a complete and utter waste of public money, when that money could have been far better spent on providing the additional nurses that we need. There were heartbroken members of the friends who had spent 15 years giving their services, keeping to their rotas, refusing to do anything else on their rota night and providing additional comforts particularly for the geriatric wards—for example, they would write a letter for the old lady with arthritic hands to keep her in touch with her son in Canada; they would bring in a card that she wanted to send to her grandson for his birthday. None of these services NUPE do, and if we really want the great fund and wealth of warm-hearted volunteers that we have in this country to contribute in this fashion, as I am sure we all do, then, please, see that when they have not only initiated but wholly financed and serviced a service like this, we do not kick them in the teeth in this way.

Medically, we still have great consultancy services and we rival the most advanced countries in most medical research, but we are seeing now the human face of the Health Service being steadily obliterated. It is no longer the people's service; it has become the bureaucrats' paradise. And until we restore the community contact the Service will continue to decline, and, tragically, I believe we shall continue to lose some of our finest doctors, and medical and professional technicians as well, to countries abroad. We are proud of our Health Service, but unless we restore public and professional confidence in it, we shall no longer be worthy of the Health Service.

5.13 p.m.


My Lords, when I took advice for this debate I asked what the problems were. The answer came in one single word—money. I thought, therefore, that savings would be a good theme to try to speak on, and the first saving it appears one ought to look at, to my mind, is whether or not there are too many tiers. With the Area Health Authority, someone has to co-ordinate the districts and there are too vast a number of districts for the region to co-ordinate, so that therefore the area is a necessity. But one must question the need for the Regional Health Authority.

As I understand it, the Regional Authorities do strategic planning, which increasingly can be and is being done by the DHSS, particularly if they were to be devolved round the country to a greater extent. The other thing, of course, is the consultants' contracts which they would like to be done by the region, but one wonders whether, if they were done by the areas, the world would stop for them and whether that would not be perfectly adequate. After speaking to various people, I seriously wonder whether the regions could not be disbanded. I should be most interested to see whether it is possible to get an answer as to what it would save if the regions were to be disbanded.

The value of the return, where possible, of the hospital management boards has been mentioned by the noble Lord, Lord Auckland, and the noble Baroness, Lady Hornsby-Smith. Hospitals will increasingly get bigger and bigger and so the hospital management boards will increasingly be missed. Unfortunately, one inevitably gets the staff upset by people applying for their old jobs again, as happened with reorganisation, and so politically (with a small "p") it may never be possible. As new hospitals are built, one wonders whether at least the bigger hospitals could not be administered by hospital management boards rather than the districts. There is certainly a great need for the tidying up of the tier system and at the moment there is quite a lot of overlap between the Area and the district authorities, particularly on the development of services.

The noble Lords, Lord Amulree, and Lord Auckland, mentioned cottage hospitals. Although these are technically uneconomic to keep going, they provide a most valuable service for old people and for people recovering. One finds remarkably good relations with the staff in many of these hospitals, where they are known by their Christian names by the people who live there and by the families, relatives and friends who call. The benefit of all that may well outweigh the disadvantages of the small hospitals.

One then goes to the community health councils, which were set up comparatively recently, with their paid secretaries, paid assistants, members' expenses, and so on. They go so far as to advertise for complaints of the Hospital Service. One wonders what is the area chairman for and what is the Area Authority for. There is a team of officers: the medical officer, the nursing officer, the administrator, the treasurer, and, in our particular case in the Northern Area, we have 38 local authority representatives on that Area Health Authority. What need is there for yet another council breathing down the necks of the Area Authority? If it is necessary to have publicity so that people may know where to ring up and to invite complaints, surely the Area Authority can do what is needed and can publicise the names of the elected local authority people who are on that Area Authority. The public view is becoming increasingly known on the Area Authorities, and surely it is just as easy for somebody to contact a councillor as to contact a member of the health council. Also, of course, all planning by the Area Health Authority has to go to these community health councils and that results in delays, with inevitable expense. What happens is that things tend not to get done as a result. I should be most interested to hear whether it is possible to be told the cost of all these community health councils. Are they really necessary?

The abolition of pay beds has been mentioned. I am afraid this is a political matter (with a capital "P"). Wherever one goes and whoever one talks to in the Health Service, all doctors say the same thing: that private beds never held up or delayed public patients. There really was no logic to the demolition of the private beds. It was purely a political demand by ancillary staff, porters, cooks and so on. Now, in our area we have only 22 private beds out of a total of 4,600, and there is a likelihood that these will be further cut down. The reason is that statistically the occupancy of these beds is under 50 per cent. But, of course, that is not quite correct, because that occupancy is calculated on the number of nights occupied. These private beds are more and more occupied for day surgery and therefore do not show up in the figures. So it will be a great pity if the figure of 50 per cent. occupancy is used to demolish yet more private beds.

Inevitably there is a value in cash to the Health Service through these private beds, and it would be most interesting to know, if possible, how much money is now being sacrificed by the Health Service through the loss of the beds which have already been taken away. They constituted no loss to the public's use of the Health Service, and indeed I think that there was a gain to it. The ancillary staff insisted that they should be reduced, but surely the views of the thousands of people who wanted to use the pay beds should have been listened to as well.

The next saving consideration that I should like to mention will, I am sure, be most unpopular. When people who pay for rent, rates, light, food and so on have to go into hospital, they continue to make most of those payments, and they still get their pension, their pay, their unemployment money or whatever it may be. But I see no logical reason why they should not make a contribution towards the food that they eat in hospital. I do not suggest that they should make a contribution towards their accommodation, in addition to their rent. But, after all, in old people's homes they have to pay for their board and lodging, so why should they not contribute towards their food in hospital? The Hospital Service is not meant to be a social service in order to provide people with more cash; it cannot afford that. It is a means for getting people right—although we all know that there is more to it than that, with welfare and so on—and if people contributed towards the cost of their food, not even up to the full rate, it could bring in something like £200,000 annually in many areas, which would no doubt be most welcome.

I was most interested to hear my noble friend Lady Young speak about insurance and, being of the same political persuasion, what she said appealed to me. I was interested to hear about the Swiss system. Switzerland is a very old democracy—I think it is fair to say that it is a classless democracy, and a rather egalitarian country—and everybody there has to insure and they have to pay for their hospitalisation. If they cannot pay, their sons or parents are asked for the money and, if they cannot pay, cousins, friends and so on are asked. But if nobody can pay, the bill is torn up. It is a rugged but efficient system, and it seems to work. I am not advocating it here, but it is interesting that, in a country which can by no means be called Right Wing, that is a system which seems to work well.

I should like to say a word on drugs, because we all know that they are extremely expensive. I heard of one bottle of pills which cost more than £100. While one can debate the profits of drug companies, one is also very aware of the cost of research and development which is extremely high for drug manufacturers. But I still wonder whether there is enormous wastage of drugs through over-supply. One puts a bottle of pills in the cupboard, takes out two or three, and leaves the rest. When I have something wrong with me, which is very seldom, I may go for some pills. I take one, I think that I have cured myself and am all right, and all the rest are not used.

I remember that I once went to a boxing match, and the doctor who was sitting next to me said that the Norwegian, who had just won a match, had been to see him that morning and asked for a pain killer, because he had hurt his wrist. So the doctor gave him a pill and told him that, if he took it exactly half an hour before the boxing match, he would be all right. After this Norwegian had completely felled his English opponent, the doctor went around to see him and the Norwegian thanked him and said that what he had given him was absolutely marvellous. The doctor told me that what he gave him was half of a vitamin D tablet, which was equivalent to an orange, but the Norwegian was convinced it was what he needed and it worked.

There is also the question of the cost of modern drugs. I am sure that many doctors, in particular young doctors, read the appealing literature and the rather attractive names of some of the modern drugs, and are rather inclined to prescribe them because they are most fashionable, although in many cases they could recommend much cheaper but equally effective drugs. However, this is a technical matter and I am not qualified to form a strong opinion on that.

Furthermore, there is a great waste of food in hospitals. I believe the noble Baroness, Lady Ward, said that she was offered an enormous banquet after just coming out of the operating theatre. I have also been told that a great deal of food is thrown away in hospitals, and this is obviously waste which can and should be avoided. I think that the reorganisation is not an unqualified success, and there is a great deal of tidying up that should be done in the tier system to avoid duplication of responsibilities.

5.26 p.m.

Baroness MASHAM of ILTON

My Lords, I should first like to apologise to the noble Lord, Lord Auckland, for being late for this debate, but I had an appointment with the National Health Service. While I was at the hospital a few hours ago, a young consultant went up to the receptionist's desk to collect a package and he said: "I no longer work here. I am now in Harley Street". Perhaps this is what is happening too much. It is most worrying to see the resentment and the barriers which have built up within some of our hospitals among the medical staff and the hospital administrators. The doctors I have met have complained of inflexibility, and of being bogged down with paperwork and endless committees, unable to find the necessary time to do clinical work. There is disappointment that no funding was available for the post-registration diploma course in remedial therapy at Southampton University. This would have been a way of raising standards and giving opportunities for in depth training, but standards seem to be dropping fast.

Today I want to concentrate on the striving for survival of some of our splendid hospitals, which have been saving life and allieviating suffering. It is extraordinary, appalling and frightening to contemplate this. A few weeks ago, BBC television showed a film about the proposed closure of a well-equipped maternity hospital in Liverpool, and the world-renowned Birmingham accident hospital. It also showed the appalling waiting lists at Northampton. If these closures take place, it will not be just the doctors who leave the country; it will be the complete teams. It is no good hiding behind the cover of the fact that the Royal Commission on the National Health Service will be reporting in a few years' time. By then, at this rate, the hospitals will house only ghosts.

I should like to bring to your Lordships' attention today the serious problems currently affecting the spinal units in our hospitals. There is an inadequate service for spinal cord injuries, because the number of beds has been reduced in the last few years and no new units have so far been established. At the moment, there are only 156 beds in the whole of the South of England from Norfolk to Land's End including London. These are all at Stoke Mandeville Hospital, which is a unit which as been over-burdened for years. The number of patients with spinal cord injuries is increasing all the time, due to road, industrial and sporting accidents, as well as soldiers shot in Northern Ireland and a few non-traumatic cases. Over 6,000 patients have passed through this unit, and it is thought that by now about 2,000 will have died. There are about 4,000 patients who need check-ups yearly or two-yearly, and it is impossible for this to be done with the staff available. This does not include newly injured patients.

In 1975–1976 a ward was closed through lack of staff and industrial disputes; 14 patients who were on the waiting list died. The year before the closing of that ward only four patients died. At the moment there are 31 patients on the waiting list to go to the spinal unit. Two years ago it was thought that there would be a spinal unit at the Royal National Orthopaedic Hospital in London. I should be very interested if the noble Lord could find out why this unit has not materialised and let me know.

We have now been told that the Government are to open another unit at Odstock in Wiltshire but that this will take three years to establish. The hospital at Odstock has still not had the go-ahead to advertise the post for a doctor to start the unit. Whoever it is will need training. Can the Minister give an assurance that no more wards at Stoke Mandeville Hospital will be closed until the new unit at Odstock is functional? I believe that there is a need for two new units.

It is surely logical that patients who are paralysed and do not feel below their injured cord should go to places where the medical and nursing staff are trained in caring for their many and varied problems. I have seen appalling cases of neglect through ignorance in general hospitals where moving a patient with an unstable spine is a danger, where the paralysed bladder is not understood and where the care of the skin is overlooked. The morale of the patient is of the utmost importance and support to shocked relatives is paramount. If the correct treatment is not available initially, extra time will be spent in hospital, so money is wasted.

The number of doctors with spinal experience now working in the National Health Service is diminishing. Two senior consultants have retired in the past year: Dr. Hardy from Sheffield last year and Dr. Walsh from Stoke Mandeville in the last few days. On behalf of their many grateful patients, I should like to take this opportunity to pay a tribute to the most humane service that these two fine consultants have given over the years. Had their last fews years in the National Health Service been less frustrating, they would not have chosen to retire early. So far, they have not been replaced. The reason may be that all the junior doctors who have been trained have gone back to their countries of origin.

Just before Dr. Hardy retired from his unit in Sheffield he invited me to spend a day at his hospital. He took me to a window and showed me a large new administrative block, carpeted throughout, which had sprung up since reorganisation. For 21 years he had been waiting for a day room for his patients, for which the money had been raised by the WRVS. They are still waiting for that day room.

Three years ago, a group of us started an association for spinal injuries. We are working with the Department of Health and Social Security to bring out helpful information. We shall go on trying to help and support patients and their families, but when the problem is serious, such as a blocked kidney or an acute abdominal emergency, an experienced doctor is needed to understand, diagnose and treat the ailment. At the present time, there is an acute shortage of spinal doctors and there are a great many worried patients.

It seems hard on a health region like Oxford to have to support a national unit like Stoke Mandeville which serves people from far and wide. If the National Health Service is truly national, then surely some national money ought to be given to hospitals which serve a national need and have an international reputation.

I should like to mention one last point of concern which has recently been brought to my notice. There are some unfortunate people who, because of extreme disability and lack of family support, have to live in hospital units attached to hospitals. There seems to be a move to insist that people should go to a unit near their place of origin, without any choice. Most people may want to be near home, but there may be some who would like to go to a place of a particular religious denomination or to be in a home with a friend. I hope that there will continue to be flexibility and a humane choice rather than mere administrative tidiness.

5.36 p.m.


My Lords, before speaking for only a very few minutes I, too, should like to apologise to my noble friend Lord Auckland for not being here at the start of the debate. Several of my patients could not be persuaded that their appointments were less important than our debate this afternoon.

It is not unusual for concern to be expressed in this House and elsewhere about the state of the country's health services but now, as several noble Lords have said, the problems are of almost unprecedented proportions. As a dentist, I have about 1,300 colleagues in the Hospital Service. The problems they face in trying to prevent standards of patient care falling are the same as those which are faced throughout our hospitals—financial cutbacks and uncertainty, administrative delays, distorted pay structures, the inevitable inefficiency brought about by the separation of the National Health Service and private hospital practice.

I should like to mention two areas of particular difficulty. The first concerns the financing of Britain's 17 dental teaching hospitals. These hospitals exist primarily to train dentists rather than to meet the treatment needs of their surrounding communities, yet although they have a national training function there is no national machinery to ensure that they are adequately financed. The DHSS allocates funds to the health regions in a way which takes approximate account of the presence and size of teaching hospitals, but subsequent decisions on how these funds should be spent are made locally to meet local needs. At any level—region, area or district—the funds needed by dental hospitals can be diverted to other purposes in a way which is perfectly legitimate in terms of local patient need but which can nevertheless place dental education at serious risk.

A cut in the National Health Service funds to dental hospitals inevitably means less clinical experience for dental students and a lowering of dental educational standards. There may in general be good arguments against the central earmarking of National Health Service funds for specific purposes, but the way in which dental hospital finance must filter through the National Health Service administrative structure, tier by tier, has created severe uncertainty for the schools and made it difficult for them to function normally or to plan ahead. The problem has been aggravated recently by the recommendations of the Resource Allocation Working Party. The Working Party's intention is to direct funds to the regions on the basis of need, a principle with which it is difficult to argue, but their treatment of dental hospital financing has been ill-researched and arbitrary and has made it even more difficult for the schools to secure the funds that they need. I ask the Minister for an assurance that his Department recognises the special problems of dental hospital financing. Also, I ask him to consider introducing more centralised financing arrangements.

Finally, I should like to draw attention to the pay problems of doctors and dentists. The House will be familiar with the anomalies which the last two years of pay policy have created at the higher levels of income in the public sector. Nowhere are they worse than in the National Health Service. As the independent review body on doctors and dentists remuneration said a few weeks ago in their seventh report: We doubt whether so many and varied anomalies can have been created in any other single field … in our experience no organisation can be expected to function effectively if the pay structure itself is so wracked with anomalies that injustice is manifest within it". My Lords, the patience of the medical and dental professions is almost exhausted. If steps are not taken soon to restore normal pay structures, incentives and differentials the damage done to the Health Service may be irreversible. I ask the Minister to state what action the Government propose to take to remedy the problems described so clearly by the Woodroofe review body.

5.41 p.m.


My Lords, I should like with noble Lords' permission to intervene at this late stage of the debate. I apologise to your Lordships and, accordingly, I feel that it is my duty to be brief. I declare an interest because as many of you know I am a practising general practitioner. However, having listened to all the speeches made during the debate, I am more than surprised that most of the substance of the previous speeches has revolved around the hospital, the hospital administration and the social and nursing services. Nothing much has been said about the general practitioners who are an integral part of the medical services. Indeed, there has been only one mention of general practitioners, and I did not think much of that.

A little earlier in the afternoon my son could be seen listening to the debate from the steps of the Throne. He, too, is a doctor in general practice. He, with his partner, and I with mine, have a daily—and I emphasise daily—responsibility for about 10,000 patients. However, there has been no mention of all these people who are afflicted with one sort of illness or another. The vast majority of these patients requiring treatment are to be seen by the general practitioner in his surgery each and every day almost on demand. I believe that the general practitioners are deserving of much more praise and much more comment than I have heard in the speeches made this afternoon.

5.43 p.m.


My Lords, I open my remarks by congratulating my noble friend Lord Auckland on securing this very important day for debate on the Hospital Service. In emphasising this, I should like most respectfully to remind the noble Lord, Lord Stone, that this debate is, of course, on the Hospital Service rather than on the National Health Service as a whole.


My Lords, I must point out that the general practitioner feeds the hospitals and, accordingly, has to be taken into consideration as to who, out of the 10,000 people for whom my son and myself are responsible, is selected to receive the hospital services, or to be seen or reported on if necesary. It is only fair that the general practitioners for whom I am speaking this afternoon should have fair comment as to their role.


My Lords, I am quite sure that the debate has been enhanced by yet another general practitioner who has stated his views, as, of course, on this side of the House we have had the advantage of my noble friend Lord Colwyn speaking as a practising dentist. I am grateful to all my noble friends and all those who have taken part in this debate, because I believe it has come at a particularly apt time and, having listened to all the speeches in the debate, there have been two very noticeable factors; namely, the great knowledge of all those who have spoken and their deep concern that things are not well within the Hospital Service.

My Lords, I think that one of the consistent themes mentioned by my noble friend Lord Auckland and many others in the debate, is the fact that the communications within the present system are not satisfactory. My noble friend mentioned that the old system of the hospital management committee and complaints and suggestions flowing from patients, doctors and all those involved in the Hospital Service, was easy to administer. This view was strongly emphasised by the noble Lord, Lord Amulree, as regards the need for good communications and my noble friend Lady Young further underlined the need for better relationships between patients and all those concerned including the doctors, nurses and ancillary staff. My noble friend Lady Ward of North Tyneside also mentioned communications. My noble friend Lady Hornsby-Smith in a particularly interesting speech, touched upon a matter of the greatest consequence; namely, that the present bureaucratic colossus has obliterated the human face within the Health Service. My noble friend Lord Gisborough mentioned the problems of the community health council and I should like to emphasise these a little later.

I now come to the heart of my speech. I believe that one of the most significant documents which we have not yet debated in this House is the report of the Davies Committee. The Davies Committee was set up to deal with complaints from those in hospital. It reported on the procedure and suggested that a draft code of practice should be adopted. I ask your Lordships to be indulgent with me if I go into some detail, because the report which I hold in my hand was the last document with which I was particularly concerned when I occupied the same place as the noble Lord, Lord Wells-Pestell, now occupies.

My Lords, I believe that the code of practice recommended by the Davies Committee is a matter of great concern because, of course, it touches on the whole area of communications within the Hospital Service. My Lords, what has happened? A draft circular has been published following the acknowledgment by the Secretary of State of the Davies Committee's report. The code of practice was issued for comment on 15th June 1976—a full 12 months ago. I ask the noble Lord, Lord Wells-Pestell, what has happened since then. I have given the noble Lord notice of this particular issue, because I believe that he may be able to advise us.

Let us compare the draft which was produced by the Department of Health and Social Security with the model in the Davies Report. We find certain very notable omissions. At page 125 of the Davies Report under the heading, "Making a suggestion or complaint" at paragraph 2.5, it states very clearly: The Community Health Council will help and advise patients". When we turn to the draft code of practice, there is no reference to this important body, the community health council. That, in my view, is a matter for regret and one which was pointed out by my noble friend Lord Gisborough when he asked what the community health councils were for. Certainly they are not, so far as I can see, being engaged in the machinery of complaints.

When we had the last debate on the National Health Service on 3rd December 1975 the then Minister Dr. David Owen, had recently made the comment: Community Health Councils give the NHS a public lobby and a public voice". Clearly the Minister at that time welcomed the public role of the community health councils in affairs, and I wonder why the Government have apparently dropped their capability in this particular area and whether they perhaps wish to reintroduce it.

However, my Lords, the heart of a complaint is something very much more important; that is, the fear which patients and others have of victimisation. It is a very real worry, for the patient is surely a captive in a hospital and is subject to the whims of circumstances in which he or she is placed. Therefore patients may not wish to lodge complaints for that very reason. Sections 2 and 4 of the Davies Report contain no fewer than three references to victimisation.

We then turn to what the Department say about this important issue. They have neatly telescoped the two sections together with only one passing reference to a subject which must occupy the minds of many people when in hospital. I should say in parenthesis that what we are aiming at is good communications. I think all those who have spoken from all parts of the House have recognised the need for this, and surely it is a matter which will increase rather than diminish morale if all working within the Health Service knows exactly how they stand and there is a fair and open look at the whole problem of complaints.

So what are we offered? We are offered a code which in tone and impact is very different from the Davies Report. The wording is subtly different and leaves an impression of rather a defensive stance being adopted. I regret that I must press this a little further because I believe it to be very important. For example, one must go a little further, to that essential tool in the whole process of complaints, the record book. On page 129 of the Davies Report it is said quite categorically: The record book will be kept easily accessible to all members of staff and will not normally be removed from the ward or department". However, we turn once again to the draft code and we find there is no such obligation. The nurse or ward sister is required to record suggestions and complaints and to look at the book regularly, but it is therefore entirely up to those responsible to decide where it is to be kept; and it is probably in a locked drawer in an office.

I turn to the vital matter in communications, that of suggestions and complaints. Surely suggestions and complaints are very much a matter of a constant dialogue both among the patients and the staff themselves. Therefore, I was glad that so many of your Lordships have stressed this particular issue and I feel that our time is well spent if we consider this problem. Many people are very satisfied indeed when they leave National Health Service hospitals. The figures that I have show the number of those people to be over 75 per cent., but there is ark area of perhaps 25 per cent. of those who might have made complaints, who have made complaints, and who are dissatisfied with the replies they have received.

To turn to another matter touched upon by my noble friend Lady Young, that of resources, I was very glad when my noble friend Lord Colwyn mentioned the Resource Allocation Working Party. Here I should like to thank the Department for sending over from their office at the Elephant and Castle a special copy of the document, because the Library does not hold it at the present moment. I believe that this report of the Working Party, which was appointed in May 1975, and issued an interim report in August 1976, has the greatest consequence upon the whole of the Hospital Service. Their terms of reference were: To review the arrangements for distributing NHS capital and revenue to RHAs, AHAs and districts respectively with a view to establishing a method of securing as soon as practicable a pattern of distribution responsive objectively, equitably and efficiently to relative need and to make recommendations". A weighty task indeed, but they have discharged it particularly well, although they have produced many problems in so doing.

Perhaps one of the most interesting facts which is thrown up by the report is that of current costs. I expect your Lordships are better informed than I was when I looked at page 120 of the report to see what was the capital cost of an acute bed at the present moment. I understand that at the moment an acute bed is reckoned to cost £24,000 inclusive of on costs, fees and equipment, while a non-acute bed is reckoned to cost £12,000. This is a capital cost and when we consider the pay beds which have been phased out, and those which are going to be phased out, within the NHS it surely must give us cause to consider what will be set aside if they are not going to be brought into service within the National Health Service, as your Lordships recommended in your important Amendment to the pay beds Bill last year.

I turn to the report of the Central Policy Review Staff, because here surely is one of the most important factors. The Resource Allocation Working Party and the Central Policy Review Staff look at the picture with the same eyes in the sense that it is a population problem and it is on the population element that the distribution of revenue will be geared. This may be a seemingly straightforward statement until we look at the deep complication which arises from the weighting of numbers. To recognise how complicated this is one must look at the algebra of the formula in Table C6 of the report, but I think there is light at the end of the tunnel.

I was much encouraged to read in the report of the Resources Allocation Working Party the following recommendation which I believe is well worth recording in this debate because it is a matter of great consequence for those authorities concerned with the allocation of money. It reads: We therefore recommend that RHAs should be allowed to seek augmentation of their future capital allocations at the expense of their future revenue allocations and vice versa over and above the permitted level of flexibility within the year". The point is that it is not a case of borrowing from Peter to pay Paul. It is a matter of permitted flexibility within a very strict system of rules, and I believe, as indeed my noble friend Lady Faithfull believes, that it would be very much better to consider the problems of allocation of funds on a hospital basis, if that is possible, and to allocate funds to a hospital and allow that hospital to work out its own priorities. This is foreshadowed in our Party's policy document, The Right Approach. We believe there is a need for flexibility in managing affairs in this respect. We have not finally drawn up our policy in this regard; nevertheless, I am quite sure that this will be one of the matters to which great attention will be given.

To turn to a matter raised by both my noble friend Lord Auckland and the noble Lord, Lord Amulree, the question of the three-year allocation of revenue arises and I think both noble Lords referred to the problem of unspent money on account. The resolution to which I referred answers the problem to a certain extent, but it raises the question of whether a three-year allocation period is a wise one, whether it is one which should be curtailed or increased or whether it should be allocated on a rather different basis. My Lords, we have had a very interesting debate this afternoon and I feel certain that the noble Lord, Lord Wells-Pestell, has been asked a large number of questions, so I shall draw my speech to an end by thanking all those who have taken part.

6 p.m.


My Lords, yesterday I spent some time in the Library, thinking that I would work out how much time your Lordships' House had spent since March 1974 on talking about National Health Service matters or the hospital service. In fact I did not have time to count the columns of Questions and debates that had taken place in your Lordships' House. I derive one comfort from it: it is quite clear that, with all the criticism that is levelled against Her Majesty's Government in your Lordships' House, the only thing that noble Lords apparently have to complain about is the Hospital Service and the National Health Service. Your Lordships seem to me—though I may be wrong about this—to have spent more time on this matter than on anything else, but I take some comfort from the fact that your Lordships have nothing else to criticise us for. But, after these occasions, I find myself like somebody sitting on the ground at the foot of the rich man's table, waiting for crumbs of approval or appreciation of the Hospital Service to fall. They do fall, but they are quite inedible, hard and useless. This is no new experience for me, as your Lordships know.

Noble Lords have outlined a number of important issues which give real cause for concern, and may I say quite frankly that their concern is no less our concern; we are much more concerned about these matters than noble Lords sitting on the opposite side of this Chamber. It is our Service; it never was yours.


My Lords—


No, my Lords, I am not going to give way. I have a lot to say. The Health Service is a national service that noble Lords opposite did not support, did not want and have criticised ever since 1948. After it has established itself and, with all its shortcomings, proved its worth, noble Lords opposite cannot say one word of approval or of comfort.


My Lords, with all due respect to the noble Lord, I did say that over 75 per cent. of patients in the hospital service or who had visited a hospital were full of approval. I did make that comment. Further, I think the noble Lord is unaware that only two of his noble friends have taken part in this debate, whereas a very large number of my noble friends on this side have shown concern.


My Lords, the noble Lord, Lord Sandys, said that 75 per cent. of people who receive treatment in National Health Service hospitals were satisfied. The noble Lord has never once said that he is satisfied; he did not do so today, and to my knowledge, he has not said so during three and a half years. If noble Lords are talking about the number of people who participate on this side as against that side, this House has about 10 times as many noble Lords on that side as we have on this side, and I think that the proportion speaking today is much the same. I do not want to quarrel with noble Lords. It is so easy to be destructive.


My Lords—


No, my Lords, I am not going to give way. I am sorry. I have a lot to say. There have been 16 speakers and I want to try to answer them. There is always this feeling among noble Lords opposite that the National Health Service is on the verge of collapse, that it is bankrupt, that it is disintegrating, that it is on its last legs. Of course, it is none of those things. Some reports would have it so, but the facts, as noble Lords opposite know if they are honest—and most of them are smiling, so I think they agree with me—belie the charges. Like any other service, the National Health Service has to live within a tight budget.

Noble Lords opposite—and I have heard them so many times—have been loud in their demands for drastic cuts in expenditure. It has been almost a battle cry with noble Lords opposite for months and months, and they all know that it is perfectly true. There has been this great demand for cutting of expenditure—for reduction, reduction, reduction. But noble Lords do not take their arguments to the logical conclusion. The logical conclusion is that, if there must be a reduction in expenditure, that reduction must be spread over all the services that are provided by any Government that is in power. We spend £3,500 million a year—and I repeat that—on the Hospital Service. That is a pretty good amount. I agree that we spend about three times more on pensions and benefits and so on, but it is all part of it. An enormous chunk of the cake is taken by the Hospital Service, the National Health Service generally, pensions and so on.

What is often forgotten—probably noble Lords do not know it—when we talk about waiting lists and the long queues of people waiting to be attended to in our hospitals is that, in the last three years, our hospitals have dealt with nearly 140,000 more inpatients. That is an increase of nearly 50,000 a year which I do not believe anybody has taken into account at all. Our hospitals have also dealt with 130,000 additional new out-patients. Those are tremendous additions to in-patient and out-patient treatment. But, in spite of all the prophecies of doom, the Health Service is very much alive, and providing, I believe, a magnificent service to our people.

Let me be the first to say that we believe this to be due to the energy, the commitment and the skills of doctors, nurses and other professionals, even administrators—who have come in for a certain amount of criticism this afternoon—and also the ancillary workers in our hospitals. I will read what I was going to say—and not just because my noble friend Lord Stone has spoken. It is that, in the tributes, I include the general practitioners and others involved in primary care. In my view, no other country in the world can boast a family doctor service comparable to our own. Let us bear that in mind; the service is making a tremendous contribution, as those of us know who have spent many, many months in hospitals as National Health patients without any privilege and without jumping the queue.

There are noble Lords who have spoken this afternoon about pay beds and said what a disgraceful business it is. Let me say this, my Lords; that issue is settled. It was a political issue and Parliament has pronounced on it. That is the end of the matter as far as I am concerned. The separation of the private sector from the public sector is, I admit, a political issue, because we object to people who can pay being able to get privilege and special help. We say that, if they want that, that is fine and we do not object to it; but it must be outside the National Health Service. I shall say no more about pay beds, although a number of noble Lords referred to it—the noble Lord, Lord Auckland, the noble Baroness, Lady Young, my noble friend Lord Segal, the noble Lord, Lord Platt, and the noble Lord, Lord Gisborough.


I shall do so again, my Lords.


My Lords, I am sure that the noble Lord will do so again, but let him do it on information that is accurate. He said that this was done at the demand of the unions. It was not done at the demand of the unions. It has appeared in Manifestoes of the Labour Party for many years. I sat on a committee years ago which was designed to separate the private sector from the public sector. It had nothing to do with the unions, except in so far as they are members of the Labour Party. So let us make no mistake about it; it has been our intention for years. We may be wrong, but as far as we are concerned it is a principle. People may talk about the amount of money that we shall lose as a result of it, but money cannot replace principle. Time and time again I have heard noble Lords argue in this House that we are concerned too much with the material things—which in the main is money—and not enough with principle. We may be wrong but we do not think we are.

I want to try to answer some of the questions that have been asked today. I shall deal with the shorter issues. The noble Lord, Lord Auckland, referred to a dispute which is taking place at the London Hospital at present. I can give him literally the latest information which is that the Advisory Conciliation and Arbitration Service will be arbitrating in this matter. I am sure the noble Lord will be glad to know that at present arbitrators are being appointed. We hope that the matter will go to arbitration within a day or so. Because of his knowledge I know that the noble Lord will not expect me to make any other comment. The noble Lord asked me a number of questions, some of which he was good enough to inform me of in advance. I have them here. However, the replies are rather lengthy and I wonder whether he would agree to my writing to him and giving him the detailed replies. They relate to hospital building plans, British born doctors and nurses, knowledge of English, fire hazards and so on.

The noble Lord, Lord Auckland and Lord Amulree, wanted information on nursing as a career. Information on nursing as a career is available to young people through the career guidance service of all local authorities and also from a number of other sources, including the Nursing and Hospitals Careers Information Service. I am able to reassure both noble Lords that difficulties in recruiting young people into nursing, both as student nurses and as pupil nurses, are not now a problem which is causing any concern. They may like to read that in Hansard and if they wish to make any comments I should obviously be glad to have them.

The noble Lord, Lord Auckland, asked whether the kidney unit at the Hammersmith Hospital was to be phased out. I am advised that the Ealing, Hammersmith and Hounslow Area Health Authority (Teaching) have reviewed a number of the specialist units at Hammersmith to see whether any economies could be made. The AHA has decided that savings will be made elsewhere and therefore there is no question of phasing out the kidney unit.

The noble Baroness, Lady Young, raised the question, which I think was raised by another noble Lord, about health insurance. Group schemes which are financed by employers are an allowable business expense and employees who are paid more than £5,000 per annum, who benefit from their employers paying health insurance premiums on their behalf, have to pay income tax on the value of the premium. But it means that for every £100 they derive in benefit from the premium they pay only about £35 in income tax, so the net benefit is something like £65 in every £100.

The noble Baronesses, Lady Young and Lady Faithfull, drew attention to the unemployment of nurses in this country. One of them—I am not sure who—tabled a Question on this subject some time ago. My reply now is what it was then, and we should bear it in mind. There is so much unnecessary comment and criticism which does the Health Service no good at all. If you want to "knock" it, then let us go on doing things of that kind. First, through, let us get the matter into its right perspective. The number of qualified nurses and midwives registered as unemployed in England has been rising and in March 1977 amounted to 3,821. The increase comprises, to a very large extent, nurses who are unwilling to move to localities where posts are available or who are prepared to work for only restricted hours. We understand that there are many vacant posts with no one applying for them even where the number unemployed appears to be high.

This is a pattern of unemployment all over the country. We get pools of people who are unemployed who could get work elsewhere, but some of them are married and have young children and the result is that they cannot afford to travel. They may be living in council property and the chances of getting council property in the area to which they would go is, if not impossible, highly remote. So they stay where they are and continue to register—quite properly—as being unemployed. That is the situation in our view as far as it affects the majority of the 3,821 nurses who were unemployed at the end of March 1977.

The noble Baroness, Lady Young, referred to the recent report by the Review Body on Doctors' Pay. At this stage I do not think that I can say anything constructive or useful other than that the Government have accepted the report and have noted the criticisms of the anomalies caused by the pay policy. The fact that the report has been accepted probably speaks for itself.

The noble Lord, Lord Platt, asked about the standard of provision for long-stay patients. Let me be quite frank about this. Apart from being of supreme importance—and we accept that it is a matter of supreme importance—this is a matter that causes us a good deal of anxiety because, as I think all doctors in your Lordships' House know, it is not easy to deal with. At this stage I do not think that I can say anything more than that we went into the matter in fair detail in the Consultative Document, Priorities for the Health and Social Services in England, which we published in May of last year. But we realise that that is not a wholly comforting answer. I can only say that we are alive to the problem; we know what it means to the long-stay patients and to the hospital, and what it means in terms of money.

The noble Baroness, Lady Faithfull, raised the question of a hospital having a sum of money with which to do as it pleases. I believe that the noble Lord, Lord Sandys, also referred to this. This is not on. When a Government work through a Department and have to provide a sum of money to maintain a hospital service and a National Health Service—albeit that it fits only where it touches—there must be some fairly rigid control. We, the Department of Health and Social Security, cannot exercise that rigid control. That must be done by the Area Health Authorities. If we gave money to individual hospitals there would be nothing to prevent their going off on frolics of their own, costing an enormous sum of money. I am sure that in principle the idea is sound and it is one which ought to be tried, if we had the means to do it. But I think that when an allocation from the DHSS goes to the Regional Health Authority who, in turn, have to make allocations to the Area Health Authorities, they must know what the money is wanted for and be able to say, as the system is at present, whether it can be spent in a certain way.


My Lords, would the noble Lord allow me to intervene? Would it not be possible to try the suggestion in one or two hospitals? After all, we are casting aspersions at the hospital staff if we think that they are going to fritter the money away, and say that we think that they are not going to spend it wisely on patient care.


My Lords, we are not being critical at all, human nature being what it is. The noble Baroness knows better than anyone else how emotional and soft-hearted some social workers can be. She had to control her social workers when she was director. I am not having an argument with the noble Baroness. I have been speaking for 21 minutes. I am always generous to her, and she takes advantage of it too. I do not think that in the present climate or, for that matter, perhaps for some time, this is "on". I do not think it would be, or could be, just yet.

The noble Baroness, Lady Ward, obviously did not appreciate what I was saying, and I thought I put it clearly. When a Royal Commission is appointed it is the responsibility of the Royal Commission to invite people to give written evidence or oral evidence, and the Royal Commission that we are talking about, on the National Health Service, did precisely that. There is nothing to prevent Government Departments from speaking as a Government Department, but outside bodies must submit their own evidence, either in writing or as oral evidence, and it is for them to take the initiative.

The noble Baroness raised the whole question of endowments, going back something like 30 years. I hope she will not misunderstand this, but I really cannot give an undertaking that we shall be able to ascertain the exact sums of money that all the hospitals that have endowment funds had in 1948, and what they have done with them. I would suspect that the work involved would cost thousands of pounds. One noble Lord wrote to me at the beginning of the year asking me what appeared to be a simple question, and I replied to him. That brought forth another letter, and we went on until finally the point that he raised concerned a person who had spent—there is no harm in my saying this—the greater part of her life in a whole series of National Health hospitals, and it was suggested that she was entitled to certain rights; and it was finally dealt with not only in London but at Blackpool and two other areas involving 25 separate civil servants. I hesitate to think what that cost, and I do not think it would be fair in this particular instance for me to give some undertaking. What I would say to the noble Baroness—and I hope she takes me up on it—is that if she likes to put down a Question in respect of any particular hospital about which she is concerned in the area that she still keeps both eyes on—I may say and two ears, too—we shall do what we can to get the information for her.

The noble Lord, Lord Platt, raised the important issue of renal dialysis. The renal dialysis of children presents special problems and needs to be provided at centres where the special skills needed can be made available. My Department is aware of the shortcomings of the special facilities for children, and we are looking into ways to see whether we can improve them. So far as the elderly are concerned, I am afraid I have to say that it must be recognised that there may be clinical considerations which preclude elderly people from being considered for long-term dialysis. I do not know whether the noble Lord really wants me to go beyond that, or whether perhaps that does not really answer his question.


My Lords, I do not want to prolong this. I know what the situation is. The question I asked was whether it was not unique in the whole history of the Health Service that people are turned down simply because a deadline is drawn and they are too old or too young. I do not expect an answer to that.


My Lords, the noble Baroness, Lady Faithfull, raised the question of Briggs and nursing tutors. My honourable friend the Minister of State for Health has indicated to the nursing profession that he hopes to find a place in the legislative programme of the next Session for the enabling legislation necessary for the implementation of the Briggs Report. A coordinating committee of the nursing profession has been set up to assist in its preparation, and to ensure a smooth handover from the existing bodies to the proposed new bodies. Noble Lords may be interested to know that the Department has increased the funds available to the General Nursing Council for the employment and training of nurse tutors. A further expansion will be necessary—and we recognise this—if the Briggs Report is to be implemented.

The noble Lord, Lord Gisborough, questioned the value and use of community health councils. I hope he will not mind my saying this because he is not alone in this: I do not think that the function of the community health councils is really understood. We had this reorganisation—I am trusting entirely to memory, but I believe it was the last Government which included community health councils; I do not think it was something we did but it was part of their reorganisation—and we thought it was extremely good. The only credit that I would take on behalf of this Government is that I think we gave it a few more teeth: that is not to imply that it did not have any.

It represents the patient. It is where patients go if they have complaints to make. It is the voice of the patients. The patients have no other voice, but if they have any grievance, legitimate or otherwise, they take it to the community health council and the community health council then takes the matter up either with the hospital or the AHA, and, if it is not satisfied, with the RHA. It also means that it is impossible to consider closing a hospital without the approval of the community health council. If they agree then the hospital can be closed, but if there is a difference of opinion and the CHC does not agree, then my right honourable friend the Secretary of State is then brought in and he has to make the decision. I think that on reflection, if the noble Lord went into this matter more carefully, he would find that it is important from the point of view of the ordinary patient.

The noble Lord said something about a drug costing £100 a bottle. I am sure it was a statement of fact. I am not questioning that for one moment. However, I do not know whether the implication was that this was quite disgraceful and that we ought not to prescribe drugs costing that amount a bottle. There is a lot of loose talk about over-spending on drugs, and I think much of it—and I am speaking personally here and not as the Government spokesman—is justified. But one has to remember that there are some drugs that are extremely costly. I wonder how many noble Lords who had a small son or small daughter that had leukaemia and were told, "This child needs three weeks' concentrated treatment", would ask: "Well, how much is this going to cost?" Let me tell your Lordships the cost. It would cost £4,500, but if it is going to save the life of that child, what is £4,500? If it were my child, money would not matter at all; I would not be able to afford it, but the National Health Service can. As I say, some of these drugs are extremely costly, but compared with saving a life, they are worth it.

I cannot answer the questions put by the noble Baroness, Lady Masham of Ilton, about Stoke Mandeville, but I suggest she accepts the advice I gave the noble Baroness, Lady Ward of North Tyneside, and tables a Question. The noble Baroness, Lady Masham, said that people from the part of the country she comes from are outspoken. I, too, am outspoken, although I try not to be offensive, and I am not implying that she is. When she reported the dig, of somebody having told her, "I am up in Harley Street now," what does that mean? Harley Street can take only a certain number of people. If the implication is that they are leaving the NHS to go to Harley Street, then I do not mind them doing that because my knowledge of the medical and dental profession in Harley Street, Welbeck Street and Wimpole Street is that a large percentage of them also work in the NHS, so there is no reason why they should not go there.

Baroness MASHAM of ILTON

My Lords, it was not meant to be a dig. I repeated what I had heard him say, which was that he had left the NHS and I thought that was rather sad because he was a young and exceedingly active consultant.


Why say it, my Lords?

Baroness MASHAM of ILTON

Because the NHS is not attracting young consultants who want to stay working in it, my Lords.


That statement is not true, my Lords; it is not true to say that young consultants will not come into the NHS or, if they are in it, stay in it. I could give the figures and if any noble Lord cares to table a Question I will do so. The noble Lord, Lord Colwyn, raised the question of the Department's advice to health authorities in respect of a report. The Department's advice to health authorities drew particular attention to the special requirements of dental hospitals for finance and I can give the noble Lord my assurance that we are keeping a special watch on the way in which allocations have been made. I remember that when the noble Lord last took part in one of these debates I wrote to him at great length. We were grateful for the issues he raised then and I hope he felt that my replies on that occasion were helpful to him, too.

Lord Sandys raised the question of the Davies Committee and I wish to dot his i's, cross his t's and underline what he said. We are not unmindful of its importance. It is true that from a thick report—it is a fair size—one cannot cull everything and put it into a consultative document or a kind of draft proposal. However, as the noble Lord said, we have got out a draft code of practice based, I believe, on the Committee's recommendations and this was widely circulated in June of last year as a Consultative Document.

We are back with the old problem with which we are continually faced in Government—noble Lords opposite were faced with it when they were in office—and that is how to send such a document over such a wide field. In this case it has gone to all the health authorities (the noble Lord will know the exact number of those), to all the professional bodies, to all staff bodies and to all the CHC's, and there are about 210 community health councils. We are in duty bound to give them adequate time to consider the matter, We have received a great many comments on the document and we are currently studying them. I hope Lord Sandys will not ask me, as he is entitled to ask, when we are likely to report on it; we do not let things lie on the table unnecessarily.




The answer, so far as the Department is concerned, is, No, my Lords. I wish to conclude on a happier note and to remind your Lordships that it was not a member of the Government but a spokesman for the Opposition, the right honourable Mr. Patrick Jenkin, who said this to an American audience; but before quoting him let me say that I have known him personally for a good many years. There is no harm in my saying that I respect his competence and ability and I hope, if he reads this, he will not think I am being patronising; that is not intended. We lived quite near each other for some years and, as I say, I have great respect for him as a person as well as for his ability. However, it was only a few weeks ago that he, the shadow spokesman in another place, said to an American audience: Experience suggests that … if health care is organised nationally … this is a system which, for all its frustrations, does help to ensure reasonable value for money … For these reasons I believe we will retain, and will be right to retain, a National Health Service".


My Lords, before the Minister resumes his seat, may I ask him to confirm that he will be writing to noble Lords who asked particular questions which he has been unable to include in his speech? May I further ask him to confirm some calculations? He quoted a case in regard to medical insurance premiums in which he suggested that a married man with two children with a taxed income of between £5,000 and £6,000 a year would be charged income tax at 35 per cent. It is, in fact, 45 per cent. and I think the noble Lord would probably wish to correct what he said.


My Lords, I did not make any mention whatever of a married man with two children; I referred to an employee earning £5,000 a year. I did not say whether he was married or single, with or without children. I will, of course, look at the matter. I shall, as is my usual practice, read Hansard—I will not promise to do so for a day or two—and if I have not answered adequately any questions put to me I shall be happy to write to the noble Lords concerned.

6.38 p.m.


My Lords, I should like before formally withdrawing the Motion to thank most warmly all noble Lords who have taken part in this debate. It has been gratifying that so many and varied members of the medical profession have participated. I would say to the noble Lord, Lord Stone, at the outset that because of the exigencies of time I did not mention general practitioners, though I would just comment, in so far as cottage and smaller hospitals are concerned, at any rate in my area, that the general practitioners do a marvellous job.

The debate has brought out a number of interesting and, to some extent, disturbing factors regarding hospitals and the National Health Service as a whole. Perhaps the speech of the noble Lord, Lord Wells-Pestell, was a little of the Jekyll and Hyde type. Beginning with the latter, he made a rather sanguine attack on this side of the House about the lack of support we had given the NHS. I recently re-read the Second Reading of the 1946 debate in the other place; of course I was not a Member of either House at that time, so I can take no personal responsibility for any vituperative attacks that were made on the NHS. So far as the noble Lord's researches are concerned, I can only say that when the Party on these Benches were in office the noble Lord, then in Opposition, had quite a number of slings and arrows hurled at him, some from me.

I would only make this point. The object which I had in putting down the Motion was to keep things in a low key. I believe that, on the whole, the debate has been in a low key. The National Health Service today is never, and will never be, free from criticism, and much of the criticism of it comes not only from these Benches, but from all parts of the country, from all political Parties. All that I seek to do—and I think my noble friends seek to do—is to make whatever criticism there is constructive. The fact that we have made criticisms—lack of finance and so on—is not, let us face it, entirely the fault of Her Majesty's Government. I have tried to make this point myself, and so have my noble friends.

I would end by once again thanking all those who have taken part, whether they have been critical or otherwise, and saying that there is no service in the world which, if somebody gets knocked down at three o'clock in the morning, will not deal as quickly as possible with the victim concerned. In most instances if something dreadful happens at three o'clock in the morning, the matter can wait until office hours—but not in any hospital service, be it private or National Health. In withdrawing my Motion, I would say that the vast majority of people in this country recognise that there are problems, perhaps deficiencies, within the National Health Service, but they have a very great respect for it, and an even greater respect for those in all grades who administer it. With the leave of the House, I beg to withdraw my Motion.

Motion for Papers, by leave, withdrawn.