Lords Sitting of 14 November 1979

Preamble
The House met at a quarter-past two of the clock: The LORD CHANCELLOR on the Woolsack.
Prayers—Read by the Lord Bishop of Peterborough.

LORD HOLDERNESS
The Right Honourable Richard Frederick Wood, having been created Baron Holderness, of Bishop Wilton in the County of Humberside, for life—Was, in his robes, introduced between the Lord Saye and Sele and the Lord Carrington.
LORD DACRE OF GLANTON
Hugh Redwald Trevor-Roper, Esquire, having been created Baron Dacre of Glanton, of Glanton in the County of Northumberland, for life—Was, in his robes, introduced between the Lord Astor of Hever and the Lord Blake.

MESSAGE FROM THE QUEEN
2.38 p.m.
Lord MACLEAN: My Lords, I have the honour to present to your Lordships a Message from Her Majesty the Queen, signed by her own hand. The Message is as follows:
"I have received your Address praying that the Ministry of Overseas Development (Dissolution) Order 1979 be made in the form of the draft laid before your House.
"I will comply with your request."

ROYAL ASSENT
The LORD CHANCELLOR (Lord Hailsham of Saint Marylebone): My Lords, I have to notify the House, in accordance with the Royal Assent Act 1967, that the Queen has signified her Royal Assent to the following Acts:
Southern Rhodesia Act.
Van Diemen's Land Company Act.

IMMIGRATION: EQUALITY
2.40p.m.
Lord AVEBURY: My Lords, on behalf of my noble friend Lady Seear, I beg leave to ask the first Question which stands in her name on the Order Paper.
The Question was as follows:
To ask Her Majesty's Government whether they will give an assurance that they will not retreat from their commitment to full equality before the law for all citizens including women, and that they will embody in the new Nationality Bill the right of all British women to reside in Britain with their non-EEC spouses.
The PARLIAMENTARY UNDERSECRETARY of STATE, HOME OFFICE (Lord Belstead): My Lords, we are not retreating from the general spirit of that commitment but it was also made plain in the Conservative Party's Manifesto that there would be changes in the law governing the entry of husbands and male fiancés. This inevitably means some difference in treatment as regards the right of a woman to be joined here by her husband or fiancé. We believe that this is justified to prevent abuse of the present system by men using marriage as a means of immigration to this country. These are matters for the Immigration Rules, and we shall not wait for our Nationality Bill to implement our proposals on them.
Lord AVEBURY: My Lords, we can deal with the Immigration Rules in a moment; but does the noble Lord recall that in paragraph 50 of the previous Government's Green Paper on British nationality law there were four options set out on the acquisition of citizenship by virtue of marriage to a person who was himself or herself a citizen of the United Kingdom and Colonies, and that all these four options were nondiscriminatory in regard to the two sexes? Are the Government in their forthcoming proposals intending to confine themselves within the limits of one or other of these four options, or to introduce some new proposal which will in itself be discriminatory?
Lord BELSTEAD: My Lords, the Government are not responsible for the previous Government's Green Paper. I seem to remember, however, that the previous Government felt that it was right—indeed, necessary—only two years ago, in 1977, to take a hard look at the question of arranged marriages, and to do something about them. In fact the rules, if I remember rightly, were changed. As regards the line which my right honourable friend will be taking, I shall be making a Statement to your Lordships' House, if the House will agree, at a convenient moment after half-past three.
Lord MURRAY of GRAVESEND: My Lords, have the Government received any representations from any other Governments saying that they may well refuse the rights of British men who marry their female citizens? Also, have any other countries applied or are they expected to apply, reciprocal treatment to our citizens?
Lord BELSTEAD: My Lords, I am not aware of any representations of the kind.
Lord DAVIES of LEEK: My Lords, is the noble Lord aware what would have happened to the Royal Family through the centuries if this medieval concept of this Tory Government had been put into effect?
Lord BELSTEAD: My Lords, I am not aware that previous Royal Families have indulged in arranged marriages.
The Lord Bishop of SOUTHWARK: My Lords, while welcoming the Government's statement of their commitment to the equality of all British citizens before the law, may I ask that the sensitivities of the Asian community in this country are not bruised by any suggestions that arranged marriages are necessarily to be presumed to be marriages of convenience?
Lord BELSTEAD: My Lords, I unhesitatingly give the right reverend Prelate an assurance to that effect. It is no part of the intention of Her Majesty's Government to discourage the traditional practice of the arranged marriage. But we are fully entitled, we believe, to take steps to prevent further primary immigration through marriages which are arranged for this purpose.
Lord INGLEWOOD: My Lords, referring to the question from the noble Lord, Lord Davies of Leek, will my noble friend confirm that His Majesty King George I never did succeed in getting his wife into this country?
Lord BELSTEAD: My Lords, if I am quick I can reply just before my former tutor at university, who was introduced into your Lordships' House today, takes his seat, and say that honestly I cannot answer that question.
Baroness BIRK: My Lords, when I asked the Minister a similar question last week as to whether he could produce evidence of the abuse, he said this was a fair point and he proposed to deal with it, as I understand it, in the White Paper. Has he not again in his first Answer referred to the exploitation of the present system? So far as I can see, however, we have had no evidence of what this abuse is and how far it has gone. Is the noble Lord going to produce this evidence?
Lord BELSTEAD: My Lords, it is a fair point and I thought I gave a fair answer. Indeed, pressed by the noble Lord, Lord Avebury, I then wearied your Lordships with specific statistics. I do not think the House would want me to do that again. I think I should say to the noble Baroness on this occasion that the statistics for husbands coming into the country have shown a very marked increase since the concession which was made by the noble Baroness's Government after, I know, very mature thought and considerable hesitation in 1974. Similarly, the numbers of male fiancés coming into this country have also shown a very marked increase.
Lord AVEBURY: My Lords, is the noble Lord aware that his former tutor has a lot to answer for if he taught him that the Royal Family have not entered into arranged marriages in the past, or that indeed it was not the custom for persons of Royal blood to enter into marriage with persons they had never seen? Can the noble Lord separate in his mind for a moment the concept of immigration from that of citizenship and address himself to the question of how a person acquires citizenship by virtue of a marriage to a person who is a citizen of the United Kingdom? Does he recall that the

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Green Paper, whether or not the present Government are committed to it, contained four non-discriminatory options with regard to the acquisition of citizenship by marriage to a British citizen? Will he answer my original question: Do the Government therefore in their forthcoming proposals on nationality, which are not going to be dealt with in the Statement after 3.30, intend to adhere to the principle of non-discrimination?
Lord BELSTEAD: My Lords, what would be needed to reply to the noble Lord's question is a nationality Act and I do not think there is anything between the two sides of your Lordships' House that this is desirable; but I am afraid we have not got to the moment when we are able to introduce such legislation.

CITIZENSHIP: BRITISH WOMEN
2.52 p.m.
Lord AVEBURY: My Lords, I beg leave to ask the second Question which stands in the name of my noble friend Lady Seear on the Order Paper.
The Question was as follows:
To ask Her Majesty's Government whether they will assure the House that they will not create two classes of citizenship for British women by allowing British women born in Britain to live with their non-EEC spouses whilst insisting that those British women who happen by chance to be born overseas must live abroad if they marry a non-EEC man.
Lord BELSTEAD: My Lords, my right honourable friend the Home Secretary has today published a White Paper on our proposals for revision of the Immigration Rules, and I shall be repeating his Statement to your Lordships later this afternoon. Under these proposals a husband or fiancé will not be allowed to settle in the United Kingdom if the primary purpose of the marriage is to obtain admission to this country or if one of the parties does not intend that the couple should live together permanently as man and wife or if the parties
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have not met. In other cases the man will have no claim to settle here but may be allowed to do so if the woman is a citizen of the United Kingdom and Colonies by birth in the United Kingdom.
We have not, however, overlooked the fact that girls will have been born abroad because their parents happened to be out of the country (for example, on Crown service or on business) at the time of their birth. It is my right honourable friend's intention to consider such cases sympathetically outside the rules.
Baroness WOOTTON of ABINGER: My Lords, may I ask by what authority the Home Secretary can consider cases outside the rules and, if he can, what is the purpose of having rules?
Lord BELSTEAD: My Lords, for precisely the reason to which I admit I have only alluded at the end of my reply to the noble Lord, Lord Avebury—because it may be that girls may have been born outside the United Kingdom but in circumstances in which I think any fair-minded person would feel that such girls would fall within the rules as they are being made. I have mentioned that parents might have had to be abroad on Crown service or on business, and it also occurs to me that they might have been abroad as missionaries or in certain other guises. It is such cases that my right honourable friend would be looking at sympathetically.
Lord AVEBURY: My Lords, if I understood the noble Lord correctly, he is repeating a Statement made by his right honourable friend the Home Secretary, at a convenient time after 3.30. Might it therefore be for the convenience of the House if we dealt with these matters comprehensively in the course of dealing with that Statement later on?
Lord BELSTEAD: I would have thought so, my Lords.
The Earl of SELKIRK: My Lords, do I understand the noble Lord correctly, that anyone who goes through a form of legal marriage without the slightest intention of pursuing it will in future not receive a passport?
Lord BELSTEAD: Yes, my Lords. We are, of course, talking in the context

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of marriage to girls who are not born in the United Kingdom; otherwise what the noble Earl has said is correct.
The Lord Bishop of SOUTHWARK: My Lords, may I ask the noble Lord if he would give an undertaking that in the Government's forthcoming changes in Immigration Rules and nationality law no provision will be made regarding British subjects born overseas which in fact amounts to a distinction between white women and those who are coloured?
Lord BELSTEAD: My Lords, when your Lordships will allow me to make the Statement, I think the right reverend Prelate will find that in that way the new rules are not racially discriminatory. Girls of any race, colour or creed born in this country will, under the rules which my right honourable friend is putting to the House in the form of a White Paper, have the same rights.
The LORD PRESIDENT of the COUNCIL (Lord Soames): My Lords, I venture to suggest that, in view of the suggestion made by the noble Lord, Lord Avebury, with which I think we all agree, perhaps further questions should wait until the Statement is made.

RHODESIA: ACTIONS AGAINST ZAMBIA
2.57 p.m.
Lord HATCH of LUSBY: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
The Question was as follows:
To ask Her Majesty's Government whether they have made any protest to Bishop Muzorewa's régime about the invasion of Zambia and the attack on the Tanzam railway.
Lord TREFGARNE: My Lords, my noble friend the Foreign and Commonwealth Secretary answered a similar Question from the noble Lord yesterday and I have nothing to add to the reply he gave then.
Lord HATCH of LUSBY: My Lords, is the noble Lord aware that, while his noble friend the Foreign Secretary may
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have answered a similar Question yesterday, he did not answer this Question yesterday? This Question refers to a separate and quite different incident. Would he agree that this incident of an attack on a bridge on the Tanzam railway, many hundreds of miles from where any guerrillas could have been, is an act of international aggression perpetrated by a régime for which the present Government claim to be responsible, against a friendly Commonwealth country?
Lord TREFGARNE: My Lords, the noble Lord's supplementary contains a number of assertions with which I would disagree, but I would remind the noble Lord and the House that a war is going on in that part of the world. We certainly deplore that fact. Noble Lords will recall that when the conference began at Lancaster House some 10 weeks ago we invited all the parties to that war to enter into a cease-fire. The bishop's parties in Salisbury agreed to that ceasefire but the other parties did not.
Lord PITT of HAMPSTEAD: My Lords, am I to understand the noble Lord properly? Is he saying that, because there is at this moment the war between the forces of Zimbabwe-Rhodesia and people from Zimbabwe-Rhodesia who are in fact trying to overthrow the Government of the country of which they were members—in other words, the forces of Mr. Nkomo and Mr. Mugabe—it is right for the forces from Zimbabwe-Rhodesia to take action such as the bombing of the Tanzam railway, which in fact invites retaliation from the Zambian forces? Is that what the noble Lord is suggesting?
Lord TREFGARNE: My Lords, of course we deeply regret that the war continues, but I can only repeat that we invited all the parties to enter into a cease-fire at the beginning of the conference. The Muzorewa party did agree to a cease-fire but the Patriotic Front did not.
Lord PITT of HAMPSTEAD: My Lords, I am sorry; the noble Lord is not answering the question.
The Earl of KIMBERLEY: My Lords, does my noble friend not agree that, while these very delicate and important negotiations are going on, the less these

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matters are brought up (which we on certain sides of the House consider as irritations), the more smoothly the conference might go?
Lord TREFGARNE: My Lords, I could not agree to condemn the actions of one side only. We regret all the military operations that are occurring in the war in that part of the world, and I can only say yet again, for the third time, that we have invited all the parties to enter into a cease-fire. If only they would.
Lord PITT of HAMPSTEAD: My Lords, the noble Lord has not answered my question, because what I am asking him is: is he aware that the bombing of the Tanzam railway invites retaliation from the forces of Zambia, and therefore, in fact, could cause an escalation and an enlargement of the war?
Lord TREFGARNE: Yes, of course, my Lords. All military operations invite retaliation.
Lord DERWENT: My Lords, does the pursuit of this question really help matters at this particular moment?
Lord TREFGARNE: Not particularly.
Lord HATCH of LUSBY: My Lords, I must ask the noble Lord to answer my original Question. This has nothing to do with the Lancaster House Conference. This is an attack on a friendly Commonwealth country which is our friend, and which has been trying to assist the British Government in their mediations. Is this the attitude which the present Government take to the Commonwealth: that they will allow and excuse an attack from another country on a friendly Commonwealth country, and call it nothing more than an incident?
Lord TREFGARNE: My Lords, I do not think that the noble Lord can have listened to what I said. Yes, of course, we regret that the Rhodesian authorities mounted this attack into Zambia, but we also regret the attacks mounted from Zambia into Rhodesia.

THE INDO-CHINESE REFUGEE PROBLEM
3.2 p.m.
Lord SHEPHERD: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
The Question was as follows:
To ask Her Majesty's Government what steps are being taken to fulfil their commitment to take and resettle the remaining Vietnamese refugees in Hong Kong within the next nine months.
Lord BELSTEAD: My Lords, the announcement by my noble friend the Foreign Secretary on 18th July of the Government's decision to take a further 10,000 Indo-Chinese refugees from Hong Kong indicated that the timetable of admission would be agreed with the governor, and fixed no particular period. In view of the situation in Hong Kong, the Government are anxious to admit these refugees as quickly as possible. The total received in October was well over 1,000. The future rate of intake will, however, be largely determined by the speed with which the refugees can be resettled in permanent accommodation. The machinery for handling the reception and resettlement of these refugees has recently been strengthened by the formation of the Joint Committee for Refugees from Vietnam, to which my right honourable friend the Home Secretary has appointed Sir Arthur Peterson as chair- man.
Lord SHEPHERD: My Lords, I am very appreciative of the full reply which the noble Lord has just given. May I ask the noble Lord whether his department, in particular, will consider with sympathy the suggestions which I believe are being made by the Hong Kong Government; that the officials who are looking into the credit of the refugees who wish to come to the United Kingdom should be strengthened, and should be able to remain in Hong Kong for longer periods than they have during 1979? Secondly, recognising that many of the refugees have very little knowledge of the United Kingdom—in the main, it is knowledge of the United States that they have—is there not a case, in order to

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fulfil our commitment to the colony of Hong Kong, for some form of counselling and advisory service to be set up to inform the Vietnamese refugees in Hong Kong of the possibilities and the openings in this country?
Lord BELSTEAD: Yes, my Lords. I am most grateful to the noble Lord. I think that his second question in particular is something which officials in the Government, especially in my right honourable friend's department, would want to look at very carefully. May I just say in reply to the noble Lord's first question that, as I think he will be aware, the selection is carried out by officials of the Home Office and the British Council for Aid to Refugees, and they have indeed recently returned from their third visit to Hong Kong. I think it is fair for me just to say that arrivals here have at no time been limited by a lack of refugees already selected, and we do not think there is at present a need to maintain a permanent selection team in Hong Kong. But, in the light of the noble Lord's question, we will certainly keep this matter under very close review. As I said, so far as the second question is concerned, I think the noble Lord will forgive me if I say that I should like to take it away and draw my right honourable friend's attention to it and, if need be, write to the noble Lord.
Lord SHEPHERD: I thank the noble Lord.

IMMIGRATION RULES
Lord DENHAM: My Lords, as my noble friend Lord Belstead has already told your Lordships, with the leave of the House my noble friend will be repeating a Statement on the Immigration Rules at a convenient moment after 3.30 p.m.

RESERVE FORCES BILL [H.L.]
The LORD CHANCELLOR: My Lords, I beg to introduce a Bill to consolidate certain enactments relating to the reserve and auxiliary forces, and the lieutenancies, with amendments to give effect to a recommendation of the Law
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Commission; and to repeal certain obsolete enactments relating to those forces. I beg to move that this Bill be now read a first time.
Moved, That the Bill be now read 1a.—(The Lord Chancellor.)
On Question, Bill read 1a, and to be printed.

GREATER LONDON COUNCIL (GENERAL POWERS) BILL
Read 2a, and committed to an Unopposed Bill Committee.
GREATER LONDON COUNCIL (MONEY) BILL
Read 2a, and committed to an Unopposed Bill Committee.

THE NATIONAL HEALTH SERVICE
3.6 p.m.
Lord WINSTANLEY Lord WINSTANLEY rose to call attention to the increasing inability of the National Health Service to meet the needs of patients, and to the necessity for the more efficient use of existing resources and the improvement of industrial relations within the service, and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. As noble Lords are aware, this is one of those rare occasions—some, though by no means all, might say too rare occasions—on which the privilege of selecting the topic for debate in your Lordships' House is bestowed upon noble Lords sitting on the Liberal Benches. I hope that in focusing attention on the National Health Service and its present problems and inadequacies, we are not merely pursuing a long-standing interest and preoccupation of our own, which dates back to the National Insurance Act 1911—a Liberal measure. This gave birth to the beginnings of the National Health Service, with the old panel doctor and so on for insured persons, though, unhappily, not for the dependants of insured persons; a measure taken further by a notable document, the Beveridge Report, whose author was a distinguished Liberal

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Member of your Lordships' House. I hope that we are also serving the interests of this House as a whole.
We have among us noble Lords and Baronesses with immense knowledge and experience of this subject, whose collective wisdom, at a time when Government must be devoting their thoughts to the National Health Service, should surely not be allowed to go to waste. And, after all, whether we are experts or not, we are all patients or potential patients. In discussing these matters before the Government make up their mind about the report of the Royal Commission and other pressing matters, it is surely appropriate that your Lordships' House should have an opportunity to make the kind of constructive contribution to the formulative stage of policy-making of which we all know it is so very capable.
I must begin by saying at once that I, as a doctor with more than 30 years of experience working in the National Health Service, and as spokesman for my Party on this subject, have brought with me no magic instantaneous cure, no revolutionary therapeutic measure which, at a stroke, could shorten waiting lists for in-patient or for out-patient hospital treatment; empty GPs' waiting rooms or reduce their visiting lists: conjure up skilled and necessary workers, not just doctors and nurses, but speech therapists, chiropodists and many others of the same kind who, in some areas, are conspicuous at the moment by their absence; halt the closure of pharmacies, which is now proceeding at a rate of something like nine per week and causing immense inconvenience to many patients in many areas; bring back to our shores some of those anaesthetists, radiologists and other consultants whose disciplines do not require linguistic ability, but who have left our shores to work for higher remunerations in the EEC; provide a dental service in districts where none now exists; make kidney transplants readily available to all who need them; restore the situation when GPs had time not only to talk to their patients but to listen to them as well; or, indeed, restore a sense of harmony, commitment and partnership between all those different groups who work within the National Health Service, and a commitment to the needs of patients
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rather than, perhaps, to their own needs as individual groups working in the service. No, my Lords; neither I nor anyone else has a magic wand with which to do any of those things. Things are not like that. All we can do is to accept that all problems do not necessarily have solutions, but we must look for those solutions none the less.
Having looked at the long list of distinguished speakers in today's debate, I am sure that suggestions will be made from all parts of your Lordships' House from which a Government that is willing to listen and able to learn could derive much benefit and assistance. In that connection, I must say that fate appears to have exercised a nice discrimination in timing by striking down with ill-health certain noble Lords on these Benches who were to have supported me. Furthermore, the noble Baroness, Lady Robson of Kiddington, who is so experienced in hospital matters and administration, has been summoned to grass roots to deal with a crisis and will not be able to be here to support me.
Let us consider some basic facts. First, we must all get rid of the notion that we in this country spend an unusually large percentage of our resources on health. We do not. If we examine the facts critically, as I am sure many noble Lords have done, we find that in fact we spend on health less per head of our population than many other of our European partners and, indeed, many nations beyond the Iron Curtain and in other parts of the world. I should like this country to spend a great deal more on health but I must reluctantly accept that at the moment it is unlikely that we shall. Also I have to accept that there are other functions which are desperately in need of money—matters like housing, education, food—which are relevant to the health of our community. So we have to accept that at the moment the amount which can be spent on health is necessarily limited.
We must also accept that we shall never be able to spend enough money to do everything for everybody. The cost of modern methods of treatment, diagnosis and investigation in one way or another is now so large that if every single thing which could conceivably be of benefit to the patient was at once to be made readily available to every man, woman

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and child, the Health Service—and, indeed, almost everything else—would come grinding to a halt. Let me give your Lordships a tiny example; namely, the immense progress which has been made in recent years in the transplantation of human organs and human tissue. Immense strides have properly been made in heart transplants, liver transplants and so on and they must be commended, but if we were to accept that any man, woman or child who could conceivably benefit from a human organ transplant must immediately have a right to that human organ transplant, then we should realise that we just could not cope.
Next we must accept that the workload, already large, is growing and that it will grow further. On 5th July 1948 when our National Health Service originally began, I think many people were under certain delusions; namely, that if we removed the financial barrier which existed at that time between the patient and his doctor, somehow or other ill health would be banished from the face of the earth and the need for doctors and resources in health would diminish steadily and remorselessly as we made the service available. Regrettably and unhappily, the reverse is the case.
We have to accept that our very success has added and still is adding to the total workload. Every time we learn to treat a disease which formerly was not treatable, so we increase the total workload. Every time we prolong the life of a person who formerly would no longer be with us but who continues to live and who now requires regular treatment, regular care and maintenance therapy of one kind and another, we increase the workload. In our country there are today thousands, indeed millions of people alive who in past years would have been no burden to anybody at all. They are alive and they are consuming resources; and they are requiring increasing resources. That is a fact with which we must all grapple. The workload is growing and it will continue to grow.
There seems also to be some kind of melancholy law of medical science that as we get rid of old diseases like diphtheria and the old nutritional diseases—and we have got rid of a great many, to our very great credit: to the credit of the professions and also to the credit of those who
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have been responsible for hygiene, sanitation, better housing and things of that kind—so it appears that new diseases arise to take their place. Let us think, if we can call them diseases, of the immense burden caused by accidents on the road, in the home, and at work and also of the growth of cancer and cardiovascular disease which in part may be related to the way in which we now live—to our modern life style. We have to accept that the workload will grow and that it is continuing to grow and that the more successful we are in medicine the more that load will grow. So the problem facing us is how to cope with an increasing volume of work when resources are finite and limited and when those resources are going to grow only at a minimal rate in the immediately foreseeable future.
First, we must look at legitimate ways to reduce the workload—not by stopping doing necessary things but by seeking ways by which we could possibly reduce the total burden of ill health and the total burden at the moment bearing down upon our resources. Next, surely, we must look very carefully at ways of using those resources which we have very much more efficiently and very much more effectively than we now do.
In trying to answer those two immense questions, what can I do? In a short debate I can merely try to drop one or two pebbles in the pond, if I may so describe this august House, in the hope of producing a few ripples. There are minor aspects of this subject. One could talk about the whole problem of coping with, dealing with and caring for the psychiatric-geriatric patient. That would be a day's debate, yet it is a tiny part of the whole subject; so I hope noble Lords will forgive me if I generalise and merely make a few pointers which I hope will promote and provoke observations from other speakers.
Let me deal with the question of reducing the workload. First, surely we must direct more and more of our attention to the environment in which we live—the environment at work, at home, on the roads, the air we breathe and so on. I do not think I need to elaborate on that. I am quite sure that many noble Lords are aware of small things which can be done with our environment that would very rapidly indeed reduce the

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total volume of ill health and of illness in the community in which we live. Let me take as a tiny example something to do with our environment. Surely in the long run it is going to be very much more profitable to dissuade people from smoking rather than to set up more and more complex and expensive thoracic units in different parts of the country. That would be a simple and short way to cut down the workload and reduce the overall burden.
Next we must look more closely at the question of health education. As a doctor speaking about health education, I do not mean cultivating somehow or another a new generation of amateur doctors—the kind of people who used to walk into my surgery every day to blind me with science out of the Readers' Digest. I do not mean that for a moment. I mean cultivating a greater understanding among our people of what health really is and how to achieve and maintain it. I mean, also, cultivating a greater understanding of those conditions and symptoms which require attention and the work provided by highly trained people, by resources which are in very short supply, and those which in point of fact can be left to get better on their own.
I used to get a little tired of the sort of patient who came to me at the end of a long surgery and said: Isn't it awful, all these people here wasting your time?". He was never the one who was wasting my time; it was all the other people. What I am endeavouring to say is that the vast number of people who come to doctors' surgeries come for reassurance; they come merely because they wish to know about this symptom, that symptom or the other symptom—does it matter? Provided you can convince them that it does not matter, they can go away happily. They do not necessarily need treatment or further investigation, but it is a little unfortunate that the general practitioner finds it easier to give a patient a prescription rather than to explain to that patient that he does not really need a , prescription. I am sorry to labour that point, but it is a fact that if colleagues who are general practitioners could see their way to spend a little more time in explaining to patients that something will get better on its own and they should not
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worry about it, I think in the long term we should reap considerable rewards. Whereas in a minute and a half one can dish out a bottle of inert medicine or harmless pills, it might take half an hour to explain that the patient does not really need the medicine or the pills.
Health education has to be started in the schools. There are many old dogs who can no longer learn new tricks—I am not addressing my remarks to anybody in particular, but I think that if we were to start with the younger generation there is surely hope that in the future we may have people who, first, understand the way in which to recognise danger signals which indicate an immediate need for advice and perhaps further investigation and who can also understand that certain things may be safely left to get better on their own.
Of course, if we had a more sensible approach to the whole question of certification, not only from Government but perhaps from many firms who insist on a doctor's note being produced when a person has been off for two days with a bad cold, that might cut down some of the unnecessary work. I am merely saying that health education is extremely important, and I say most earnestly to the Government that they will not save money in the long run by saving money in the short run. It is possible that health education could be better done; greater use could be made of the media, not to teach people to be amateur doctors or to teach them about elaborate scientific techniques which are nothing to do with them, but to teach them to recognise that many things can be left to get better on their own so that skilled manpower can be devoted to things that really matter, and to recognise in fact that many things do not require the use either of the doctors or of the hospitals.
I will now move on to the whole question of preventive medicine. Immediately one mentions that people tend to give three loud cheers and to say, "That is the way to proceed". Certainly it is, but even in that field we must have some kind of study of cost effectiveness. We have to start thinking about the elaborate schemes into which we enter, such as cervical cytology schemes, cervical smears—a campaign which I supported for many years—and from time to time

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we have to examine the way in which we are using the resources which are in extremely short supply, and assess whether or not we are getting a return for our investment in terms of real relief from human illness and suffering. So we have to look at them very carefully. Some things are obvious and have brought immediate benefits, like the immunisation programme for diphtheria. Before that was introduced we had some 80,000 cases a year of that very serious disease; within a matter of years the total number was down to single figures, and it remains down. That is the kind of preventive medicine which really brings immediate results.
Perhaps I might not be straying from our rules of order (if we have any rules) if I say something to anticipate a debate which is to take place tomorrow, to be introduced by the noble Lord, Lord Campbell of Croy. Let us take the matter of fluoridation of water supplies. I do not want to start that debate here and now: I merely say that in my honest opinion—and I say this now so that your Lordships will not have to listen to me tomorrow on the same subject—no public health measure has ever been so exhaustively studied and found so free of undesirable side effects or consequences, and demonstrated to be so capable of making a substantial contribution to the public health. If something of that kind can be done and can bring an immediate return in terms of an improvement in the public health, surely that is the way to bridge the present gap between work load and resources.
We must even look at things which perhaps sound a little exotic, like genetic counselling. In many ways modern medicine has taken evolution by the scruff of the neck. No longer does the principle of the survival of the fittest endure. I am not saying that it should. We now make absolutely certain that the least fit not only survive—as indeed they should—but survive and reproduce and multiply; and again so they should. But we will disregard what we have learned about the transmission of genetically transmitted diseases at our peril. If we expand the kind of genetic counselling services which have come into being, then again we can do something to reduce the growing number of genetically transmitted diseases from which people in our country are suffering.
Many minor matters contribute to this in a wholly innocent fashion. If we take societies like the British Diabetic Association—a remarkable society doing wonderful work for diabetics—the kind of disadvantage is that this kind of society, which works for people who suffer from a particular ailment, tends also to become a social gathering, so that the diabetic meets only people who are diabetics and it then happens (not surprisingly) that an increasing number of people suffering from diabetes marry diabetics, with the result that we slowly increase the total amount of diabetes within the community. That does not greatly matter, my Lords, because here we have a disease which can now be controlled, but controlled at a price. It would surely be better to give some thought to those procedures. I merely say that in passing. I repeat, we ignore what we have learned about genetically transmitted diseases at our peril. We are not doing enough to explain what we have learned to people and to advise them about it.
I wish now to say something briefly about making better use of our limited resources. The efficiency of the National Health Service depends on four factors: the number and quality of the people doing the work; the adequacy or otherwise of the premises within which they work—such as the hospitals, the clinics, the doctors' surgeries, and so on; the tools with which they work—the X-ray appliances, the kidney machines, surgical instruments, the drugs and medicines and, finally, the administration by which those other three are welded together and given to the patient. In each of those four areas there are deficiencies, but there is also waste and duplication. So far as the number and quality of the people doing the work are concerned, over and over again we come across examples of people duplicating other people's work. For example, we get duplication as between the school medical service and the family doctor; as between the occupational medical service and family doctors, and indeed hospital doctors.
In short, so far as people are concerned we are not really spending time on the things which bring the maximum return and we are often duplicating the work of others. Many of my colleagues in your Lordships' House who are doctors and who practice medicine, either in hospitals

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or outside, if they pause and think I am sure they will tell us that they often spend time doing work which really could be done by somebody with much less expensive training and could be done in a very different way. We make nothing like enough use of ancillaries of one kind or another; nor do we make enough use of volunteers and of voluntary organisations, which are only too willing, ready and able, as they have demonstrated over and over again, to save the National Health Service enormous amounts of money by providing services themselves.
On premises, it is a waste of resources to persist with old and dilapidated buildings which consume resources and waste them. It is a waste of resources, as other noble Lords will explain, I am sure, to have in hospital at a very high daily cost people who frankly ought to be looked after outside hospital, at home or in ways which are very much less consumptive of resources which are in very short supply.
I move on to the tools with which we work. How many patients are referred regularly for unnecessary X-rays merely because it has been the habit to send the patient for X-rays, or merely because it is a wise precaution in case there should be some medico-legal inquiry crop up at a later stage and some learned counsel asks, "Did you not send the patient for an X-ray?"? People are sent daily to casualty departments for X-rays which nobody wants to look at, merely for the sake of some kind of medico-legal necessity which might possibly arise in the future.
What about drugs? I have no wish to see a nationalised drug industry. The nationalised pharmaceutical industry of the Soviet Union has produced no new therapeutic substance of any significance at all, whereas our own industry has produced an enormous number of new products which have revolutionised people's lives. But while we keep on producing new products, I do not see much enthusiasm for getting rid of old ones. Because doctors are conservative people and some doctors greatly object to anybody telling them what to prescribe or not to prescribe, it is now necessary for the average pharmacist to have on his shelves perhaps 80 or 90 different kinds
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of antihistamines, 40 or 50 different kinds of iron preparations, just in case some obstinate and conservative old general practitioner insists on going on prescribing them. All of us who work in this field in any way must be prepared to start doing something about variety reduction so far as the use of instruments are concerned and so far as drugs are concerned, and we must also be prepared to start doing something in the way of cost-effective studies with regard to what we are actually doing.
On administration I do not wish to say very much. A lot will be said in the course of this debate. I agree that we should phase out one tier. I am not sure that I would like to discuss which tier, but whichever tier is phased out I hope it will be recognised that there is a real need to establish and preserve some kind of health service unit which has substantial local involvement, local commitment, and is capable of generating local pride in the health services within a locality. Let us not move away from that, whatever else we do.
On industrial relations I will say little. My noble friend Lord Rochester will deal with that aspect of the subject from our point of view. It is a very important aspect and one to which some answer will have to be found. I have no magic wand and I greatly doubt whether my noble friend Lord Rochester has.
Finally, may I say a word about finance and charges. I should like to refer noble Lords in particular to Recommendation 112 of the Royal Commission report, which substantially turns the Commission's back on the idea of charges at the time of need and recommends the gradual phasing out of charges. I am under no delusion that the National Health Service is free. It has to be paid for. I take the view, and my noble friends take the view, that it is better that it should be paid for throughout life on a taxation or insurance basis rather than at the time of need by the patient.
Here I must say a final word about the rumours with regard to a massive increase in prescription charges. With regard to prescription charges I merely say this, that a whole system of elaborate exceptions and exemptions, with season

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tickets or certificates of pre-payment, exceptions for this category of diseases or that, cannot make right in the end something which is wrong and a muddle to start with. If the present Government decide that they wish to make a charge, so be it. I would not agree with them. I believe payment should be spread throughout life and not levied at the time of need when the patient is least able to pay.
But surely that charge should be related to the actual demand made on the service. A prescription charge does not do that. The patient who spends three-quarters of an hour of a general practitioner's time for matrimonial advice, often very necessary advice, needs no prescription, pays nothing. The patient with diabetes who may want some insulin, cotton wool, surgical spirit, needles or whatever, might pay £2 or £3 and take only half a minute of the doctor's time. There is no relation to the cost of the drug. An individual drug might cost £50 a tablet and the patient will pay 70p. A prescription for iron and vitamins might cost a few pence a bucketful, but the patient may pay £2 or £3. Let us remember that the patient who costs the State money by having his pneumonia in hospital not only gets his drugs free but he gets his laundry and food and everything else free. The patient who has his pneumonia at home and saves us money has to pay a prescription charge on his drugs which could add up to £4 or £5 or even more.
Let us remember the consequences of prescription charges and what happened before. They lead first of all to poly-pharmacy; that is, an enthusiastic effort by the drug firms to save patients money by including in one tablet nine or ten ingredients which would formerly have been prescribed separately. It is not very good pharmacy, not very good therapeutics; but it is very attractive to the GP who wishes to save his patient money, so he prescribes that which in the end may cost the service a good deal more. This tendency to prescribe blunderbuss preparations, everything in one tablet rather than in several, could cost money in the long run. One other consequence of prescription charges is bulk prescribing. General practitioners will, as prices go up, prescribe in larger and larger amounts, particularly for elderly patients, in the hope that it will save them money. It
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will not save the Government money; it will in the long run cost money.
My Lords, I have gone on speaking for longer than I meant to. To conclude I would merely say this. I hope, and I feel sure, that in the course of our discussions on this Motion we will realise that what matters in the National Health Service is the patient. I would say that when those who work in the National Health Service and those who legislate about it in this House or in another place come to consider the Health Service entirely from the point of view of the patient, rather than from the point of view of their own wellbeing in their own work, whatever it is, then I think we shall make progress at long last.
My Lords, I beg to move for Papers.

IMMIGRATION RULES
3.38 p.m.
Lord BELSTEAD: My Lords, with the leave of the House, I will now repeat a Statement being made in another place by my right honourable friend the Home Secretary. The Statement is as follows:
"I am today publishing a White Paper setting out the Government's proposals for revising the Immigration Rules. The Immigration Act 1971 requires the Home Secretary to lay before Parliament a statement of any changes in the Immigration Rules, and the statement may be disapproved by a Resolution of either House. My purpose in publishing our proposals as a White Paper is to enable them to be debated before I lay that statement of the new rules. The White Paper is the result of a comprehensive review. The new rules will be clearer, easier to operate and firmer in a number of critical areas.
"We shall end the automatic rights of entry of the husband or fiancé of a woman settled in this country. But it is not my intention to keep out the husband or fiancé of a woman who was born in the United Kingdom and whose marriage is not contracted for immigration purposes. The object of the new rules is to prevent the exploitation of marriage as an instrument of primary immigration. We cannot permit that

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to continue. I have not overlooked the fact that some girls will have been born abroad because their parents happened to be out of the country (for example, in Crown service or business) at the time of their birth. It is my intention to consider such cases sympathetically for favourable treatment outside the rules.
"We undertook to end the practice of allowing permanent settlement for those who come here for a temporary stay. The new rules will provide that visitors and students will not be able to remain for another temporary purpose if this carries with it the prospect of eventual settlement. Visitors will be prohibited from taking employment. People who wish to set up in business or stay here as self-employed persons or as persons of independent means will have to meet stricter requirements and will need first to obtain entry clearance.
"We undertook to limit the entry of parents, grandparents and children over 18 to a small number of urgent compassionate cases. Children aged 18 or over will qualify for settlement only where the circumstances are of the most strongly compassionate nature, though special consideration will be given to daughters under 21 who formed part of the family unit overseas and have no other relative to whom they can turn. Parents and grandparents aged 65 or over and widowed mothers already have to show that they are wholly or mainly dependent on children in this country who can support and accommodate them. In future they will also have to show that they are without other relatives in their own country to whom they can turn and that they have a standard of living substantially below that of their own country. Parents and grandparents under 65 will not qualify for entry, save in the most exceptional compassionate circumstances.
"We also said we would severely restrict the issue of work permits. This is not a matter for the Immigration Rules, but my honourable and learned friend the Under-Secretary of State for Employment is answering a Written Question on the subject today.
"The White Paper explains that the Government will consider on the basis
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of the present rules all applications made before today.
"The other changes in the White Paper are the result of the comprehensive review which I have mentioned. Obscurities have been cleared up, anomalies have been removed, and the scope for abuse and evasion of the control has been reduced.
"The Government believe that firm immigration control is essential in order to achieve good community relations. The new rules will not affect our commitment to certain United Kingdom passport holders being admitted under the special voucher scheme, nor to men lawfully settled here who wish to be joined by their wives and young children. We shall continue to welcome the genuine visitor and the genuine student. What we are determined to do is to deal strictly with those who seek to evade or manipulate the control."
My Lords, that concludes the Statement.
3.42 p.m.
Baroness STEDMAN: My Lords, the House will be grateful to the noble Lord, Lord Belstead, for repeating the Statement. There are one or two comments that I should like to make. First, quite early on in the Statement, he says, in effect, that the White Paper gives the details of all the proposed controls and that he will enable them to be debated before the new rules are laid. I hope that the noble Lord when replying will give us an assurance that time will be given for debate on those rules to take place in this House as well as in another place.
A year ago the present Prime Minister spoke about the country being swamped with immigrants. It was not true then and we said so; and it is not true today. At the election the Conservatives said three things. First, that they would maintain a register—that seems to have been dropped. They said that they would establish a quota—that seems to have gone by the board. They said that there would be restrictions on husbands and fiancés—half of that appears to have been dropped because the only restrictions left are those which affect Asian women. At one stage it would seem that the argument was about numbers and now, when we come down to it, it is about the abuse of the regulations.

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I remind the noble Lord that in 1977 we introduced measures to deal with marriages of convenience, and for the most part they seem to have worked. So two and a half out of the three election proposals have now been dropped and I contend that what we are left with is both racist and reactionary. The attack is on an arranged marriage system. I contend that it is not for Governments to attack minority cultures. The practice will change with time, but such a practice must change at the pace which can be set by the ethnic minorities themselves and not by regulations of Governments.
Before we have the proposed debate we need more facts. For example, prior to the election we held an inquiry into overstaying. I believe that the results of that inquiry showed that it was not the coloured people who were overstaying. Will the Government now publish the results of that inquiry and will they make those facts available to both Houses? I believe that the major primary immigration is over, and has been for some time.
As regards the other proposed changes, what of the children who have been left behind to go to university or to look after elderly grandparents and who will now no longer be able to join their families? Many of them will be entirely alone. What about the parents and the grandparents who cannot join their children? It is inhuman to try to prevent a family from looking after its elderly people. That is entirely lacking in compassion. It will make little difference to the total number of black people in Britain, but it will cause the utmost pain to the families affected. I contend that it is being done solely to satisfy racial prejudice.
The Statement says that the new rules will be applied from today. Is that so, my Lords?—before either House has debated the proposals or the rules have been laid? Does that statement tie up with paragraph 13 of the White Paper which seems to imply something slightly different? The developing countries have moved towards equal treatment on nationality law for the men and women citizens of their countries. Now we are creating three categories of citizenship: men and women born in Britain and women who were born overseas. The White Paper begins by saying that:
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"Immigration officers will carry out their duties without regard to the race, colour or religion of the people seeking to enter the United Kingdom".
That is as may be, but our contention is that these proposals are sex discriminatory and are quite unworthy of a British Government.
3.47 p.m.
Lord AVEBURY: My Lords, I should like to ask the noble Lord about three matters. As regards refugees, is he aware that, in two of the places where they are referred to, only the convention and not the protocol is mentioned and therefore they are technically deficient? Moreover, is he aware that the immigration officer is given a very wide discretion as to when he should refer applications for refugee status to the Home Office; that the immigration officer is not instructed to inform the passenger of his right to contact the United Nations High Commissioner or the United Kingdom Immigrants Advisory Service; that there is no objective machinery for determining claims to refugee status; and that, as regards all those matters, the requests made by the UNHCR representative here have not been satisfied?
As regards parents and grandparents, is he aware that very few are permitted to enter under the existing rules, that they are not even separately distinguished in the statistics, and that the few parents and grandparents who will be denied entry as a result of the harsher provisions now contained in these draft proposals will be caused very serious hardship? It is incompatible with the Tory Party's claim to be the party of the family to deny entry to those few parents and grandparents and children between 18 and 21.
If it is the intention of the Home Secretary invariably to use his discretion to admit, outside the rules, the husband of a United Kingdom citizen—a woman herself born outside the United Kingdom, although the child of a United Kingdom-born citizen—why could that not have been embodied in the rules themselves? Is he aware that the provisions regarding husbands are retroactive, in that they apply to the husbands of women who were not born in the United Kingdom, although they have hitherto had that right up to the time that these rules were published?

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How could the Minister claim, as he did in answer to the Question that I put to him on 7th November, that the number of husbands entering Britain under the previous rules, is evidence of abuse when, if one looks at the immigration statistics themselves, in each of the last six years the number of wives entering the United Kingdom has exceeded the number of husbands?
Finally, these changes will not satisfy the commitment in the Tory Manifesto to an immediate and substantial reduction in net immigration. But it will have the effect of causing grave hardship and anxiety to a few families, and of undermining community relations by creating needless anxieties among the ethnic minorities.
Lord BELSTEAD: My Lords, the noble Baroness, Lady Stedman, and the noble Lord, Lord Avebury, have asked me a series of questions which persuades me—indeed, that is the intention, as indicated in the Statement—that some further discussion in your Lordships' House would be desirable. Of course, this would be arranged through the usual channels. I say to the noble Baroness that this has nothing to do with attacking minority cultures. About three-quarters of an hour ago I specifically gave an assurance on this point to the right reverend Prelate the Bishop of Southwark. I shall certainly look into the question asked by the noble Baroness about the project within the Home Office on "over-stayers".
I come to the points which the noble Lord, Lord Avebury, raised with me about refugees. In order to get the matter straight I shall say this to the noble Lord. The paragraphs with regard to those claiming refugee status under the 1951 convention relating to the status of refugees and its 1967 protocol, and to those seeking asylum in the United Kingdom, are being revised to make it clear that a refugee or an asylum claim has precedence over other parts of the rules, and that where such an application is well-founded the person is not to be removed to the country in which he has a well-founded fear of persecution. This is already our practice, but the drafting of the current provision of the rules has been criticised, and we want to make it
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clear. I am very pleased that I have this opportunity to make the point absolutely clear.
At this stage it might be the wish of the House that I do not burden your Lordships with any other remarks, except on one matter. Several times this afternoon I have been asked for statistics. The statistics show something without a peradventure. It is that after long and earnest consideration by political parties on both sides of the House; after one Home Secretary, in the shape of the right honourable gentleman, Mr. Callaghan, in 1969 had brought down a bar on many forms of immigration; after deep thought in 1974 and debate in your Lordships' House in which the noble Lord, Lord Harris of Greenwich, warned your Lordships of the dangers of a wave of immigration if something was not done about the particular problem of husbands and fiancés; after the Home Secretary of the day, Mr. Roy Jenkins, took the view that he would make a concession in this matter, and bearing in mind the fact that clearly this is a very difficult problem, it is absolutely certain that the numbers of both husbands and wives coming into this country have enormously increased, and increased in particular from the Indian sub-continent.
It is for that reason, and because we are certain that many of these partnerships are arranged to the detriment of girls living in this country, that we felt it right to make the Statement to your Lordships today.
Lord BARNBY: My Lords, I welcome the Statement which my noble friend has just made and congratulate him on its detail. It is a fairly balanced solution to what undoubtedly is a complicated question. Over the past 15 years in this House we have had many discussions on immigration. At times the discussion has centred on the matters which the noble Lord, Lord Avebury, so often raises, and which have been effectively dealt with in the Statement. But over the years there have certainly been anxieties on this side of the House and I think on the Cross-Benches about the whole question of immigration. Admittedly it is a very sensitive matter which has habitually raised great emotions. I ask my noble friend to bear in mind, and to reassure his right honourable friend the Home

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Secretary, that there remains in this country widespread anxiety that, under the guise of emotion such as we have heard today and at other times, increases in immigration may occur. There is undoubtedly great anxiety that the scale on which immigration has occurred in this country in the last 15 years has imperilled the rights and privileges of native citizens. This has manifested itself in housing, health and education. It is on those grounds that I hope my noble friend will remind his right honourable friend of the strength of feeling there is that emotion may cause an excess and a bending of the rules of immigration.
Baroness FISHER of REDNAL: My Lords, I recognise that the Government are committed to equality between the sexes, although that might not go down very well with the noble Lord, Lord Barnby. Perhaps he does not even believe in equality between the sexes. Will the Government consider changing the legislation, because that is what will be necessary—not changing the rules—so that the right of British men born overseas to marry and to settle in Britain with foreign wives is taken away from British men? I ask this question bearing in mind the equality between the sexes which the Government are supposed to support.
Lord HATCH of LUSBY: My Lords—
Lord DENHAM: My Lords, I do not want to interrupt the noble Lord, but it is usual on these matters, after the two initial statements, for each question to be answered separately. If my noble friend can do that and then turn to the noble Lord, Lord Hatch, it will be easier for the House.
Lord BELSTEAD: My Lords, I am grateful to my noble friend Lord Barnby for his intervention. In essence, my noble friend was saying something which was in the manifesto of his political party and mine at the last election—at least, I think it was in the manifesto—namely, that firm immigration policy leads to good race relations. I believe that that is right and I know that that is what my noble friend believes.
In answer to the noble Baroness, no, we are not at present, as I made clear
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when I answered Questions earlier this afternoon, considering the introduction of a nationality Bill, not because it is something that we do not want—indeed, we do and I believe that there is common ground on this—but because I am afraid I must say to the House that we are simply not ready to introduce that particular legislation at present.
Lord HATCH of LUSBY: My Lords, in answer to a supplementary question from me last week, I understood the noble Lord to admit that there was some dichotomy within the Conservative Party manifesto at the election. If he has read beyond what he has just quoted, he will find that the Conservative Party put itself forward as a party which was going to control immigration in the interests of better community relations in this country, but it then went on to insist that the rights of all British citizens today should be equal. Does this White Paper not contradict that pledge? Is it, therefore, not the case that the Government are introducing legislation which is completely opposed to the mandate on which they were elected?
Lord BELSTEAD: My Lords, it is a great pleasure to answer questions from the noble Lord. He asks me the same questions from week to week and I give him the same answers. The answer to the noble Lord is, no. I give that answer because we made it clear in our manifesto that we believe that a firm immigration policy is the necessary precursor to good race relations. We also made it quite plain in our election manifesto that we would change the rules governing the entry of husbands and male finacés in order to deal with the exploitation of marriage as a means of primary immigration of men for work. I must say that I cannot think of a practice which is more likely to lead to worsened race relations. That is why I have no hesitation at all in following my right honourable friend the Home Secretary and making this Statement to your Lordships today.
Lord PITT of HAMPSTEAD: My Lords, the noble Lord and all Members of your Lordships' House will know that I do not agree that firm immigration controls in fact are an aid to good race relations. You have often heard me say hat they do the direct opposite. How

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ever, that is not my reason for rising. My reason for rising is to ask the noble Lord to beg his right honourable friend to look at this again. With regard to the statistics he is quoting, there is evidence that in fact there are more wives coming than husbands, which merely indicates that people want to marry in that particular way. What he is in fact doing is to penalise people who have obeyed the law because certain people are breaking the law.
Would it not be better for his right honourable friend to look for a tighter way of making sure that there is not evasion, rather than this blanket refusal to allow people to exercise a right they already have? The analogy to what he is doing would be if my noble friend Lord Sainsbury were to close his supermarkets in order to stop shoplifting. This is the analogy to what is being done. Will the noble Lord ask his right honourable friend to look at this matter much more seriously, because all that is happening as a consequence is that there will be more unpleasantness—and we have too much already.
Lord BELSTEAD: My Lords, I am grateful to the noble Lord for the way in which he has put his question. I must say that in the time that I have been in your Lordships' House together with the noble Lord I have learned to listen carefully to what he says. Certainly I shall draw the attention of my right honourable friend to what the noble Lord has said. That is not just a form of words. Deliberately these proposals, which are of course much wider than the specific point about the entry of husbands and fiancés, have been put to Parliament in the form of a White Paper so that it would be possible for both Houses of Parliament, if the Members of both Houses wish to do so, to debate these matters before the order for the rules is actually laid.
I should add that from time to time I get the opportunity to see individual cases, and there is no doubt in my mind that the exploitation of immigration control in the way we have been talking about in the last few minutes does in fact occur. If one attaches that to the statistics concerning the increase in husbands and fiancés one can only be led to the conclusion that exploitation is occurring
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more and more. I would just say to your Lordships that if this is the case and it is not ended, then it brings into disrepute the system of an arranged marriage arranged within the country not for the purpose of primary immigration, and that is yet another reason why I believe it has been right to make this Statement today.
Lord ELWYN-JONES: My Lords, may I ask two short questions. First, has consideration been given to the question whether the new rules are in compliance with the provisions of the European Convention of Human Rights, and in particular Articles 8, 12 and 14? I do not expect the noble Lord to have those immediately in his mind. Perhaps we can be informed in due course whether that question has been examined and what conclusion has been reached, because I greatly fear that the Government and this country may be in grave difficulty under the terms of the convention.
Secondly, in relation to girls who will have been born abroad because their parents happen to have been out of the country and for whom consideration should be given, the Statement says:
"It is my intention to consider such cases sympathetically for favourable treatment outside the Rules".
Does that mean that in any given case a wide discretion will be given to the Minister whether to apply the rules or not? Is this a customary way of dealing with rules? Should there not be an attempt at any rate to spell out in the rules the exceptions that are contemplated? Otherwise the purpose of having rules at all seems to be minimal.
Lord BELSTEAD: My Lords, if I may reply to the first question which the noble and learned Lord has put to me, consideration has been given by my right honourable friend as to whether the changes proposed in this White Paper are consonant with the provisions of the European Convention, particularly the articles that the noble and learned Lord mentioned. My right honourable friend believes that the Government have a perfectly respectable argument for doing what we are proposing. The answer to the noble and learned Lord's first question, therefore, is, Yes, we have taken this seriously into account.

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So far as the second point is concerned, if I may say so, the noble and learned Lord has, with his customary accuracy, hit the nail on the head. The matter which he raises is something which has concerned my right honourable friend in trying to decide how to present the White Paper to your Lordships' House, as to whether or not the exceptions outside the rules for girls born abroad could be framed in the White Paper. It is true that at the moment we simply refer to exceptions and give an indication of the sort of exceptions the Home Secretary would have in mind. Your Lordships might like to go into this in more detail if the House comes to debate these matters further.
Baroness DAVID: My Lords, in the light of the Statement, may I ask whether the Minister is going to advise British women who are abroad, that if they become pregnant they had better come back for their confinement.?
Lord BELSTEAD: My Lords, there is not the slightest need to do anything of the sort, precisely because the White Paper refers to the discretion of the Home Secretary.
Baroness LOCKWOOD: My Lords, I wonder whether I may first declare an interest, and secondly therefore seek the approval of the House to put a further question to the Minister. It seems, in looking at paragraph 50 of the White Paper, that even British women born here are going to have no automatic right to bring a spouse into this country. What they have is the right to seek permission to do so.
They have a number of obstacles to overcome. In the first place, they will have to establish that they were born in this country. Having established that they were born in the country, then there may be a clearance permit issued for their spouse, or their fiancé, to enter the country. It is only "may", it is not automatic. One has to look at the three clauses contained in paragraph 50. Therefore it seems that not only are British women who were born abroad going to have great difficulty in coming back into the country with their spouses, and it will be dependent on the Home Secretary's discretion; it
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also seems as though the Home Secretary is going to have to exercise discretion in relation to those British women who are born here in this country.
May I link this with the provisions in relation to EEC citizens. A woman, a member of certainly those EEC countries—and there are a number of them—which provide equal rights for citizenship to men and women, such as France, Italy, Germany and Denmark, would be able to marry outside the EEC. Would the Minister confirm that they would then be able to bring into this country a spouse from South-East Asia or from any other part of the world, and that that would place them at a very great advantage compared to British women?
Lord BELSTEAD: My Lords, I appreciate the concern which the noble Baroness, as chairman of the Equal Opportunities Commission, has about this aspect of the White Paper but, if she will forgive me saying so, I think she is disregarding the reason why paragraph 50 appears in the White Paper. It appears there because the Government believe, and I think many of your Lordships would agree, that we are entitled in this country to take steps to prevent primary immigration through marriages which are arranged for that purpose and for that purpose only.
Regarding the noble Baroness's question about the EEC, it is technically correct to say that a woman who is an EEC national, if I may put it that way, and who comes here to work, may bring her husband and dependants with her. But there is no evidence to show that many are seeking to do that, and, when such women are wanting to do it, those marriages are not being used for the purpose of primary immigration. Therefore although there appears to be a contradiction between the effects so far as EEC nationals are concerned and the effects so far as other men and women are concerned, it is only an appearance; the fact of the matter is that those EEC cases have nothing to do with using marriage for the purpose of primary immigration.
Lord MURRAY of GRAVESEND: My Lords, one point which the Minister—-
Lord DENHAM: My Lords, it is of course for the House to decide, but noble Lords may feel that, having spent 33 minutes on this subject and having a long list of speakers wishing to take part in today's debate, we might leave this matter until we come to debate it later on.

THE NATIONAL HEALTH SERVICE
Debate resumed.
4.12 p.m.
Lord WELLS-PESTELL: My Lords, by the time we come to the end of this debate I have no doubt that many of your Lordships will be glad that we had two maiden speeches this afternoon because at least they are required by the custom of the House not to speak too long and to be non-controversial. I am sure I can say with the approval of the House how delighted we all are to have two maiden speakers in the noble Earl, Lord Erne, and the noble Baroness, Lady Ryder of Warsaw, and how much we look forward to hearing them.
I suspect that by the time I sit down noble Lords will have come to the conclusion that I have been both disagreeable and controversial. One fact we must recognise, namely that, when it comes to what should be done in the National Health Service, there is a wide gulf separating noble Lords opposite from those of us on this side as to what we believe is absolutely essential and necessary. Let me say at the outset that in our view the Government plans affecting the NHS which have been set out recently can only be described as absolutely disgraceful.
The noble Lord, Lord Winstanley, when talking about the NHS—and I thought he presented a very fair and impartial view of what needs to be done—said, "We are all patients or potential patients". I very much doubt whether that applies to most noble Lords opposite, who are more likely to be private patients and, when necessary, occupants of private beds.
Several noble Lords: Nonsense!
Lord WELLS-PESTELL: It is not nonsense, my Lords, because I happen
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to know the private doctor of a good many of them. It is not nonsense and they know it.
Baroness FAITHFULL: What about confidentiality, my Lords?
Lord WELLS-PESTELL: My Lords, if noble Lords in the Chamber say, "My doctor is sitting behind me", there is nothing confidential about it. In the five years when I was a Minister in the Labour Government I was subjected by noble Lords opposite to a good deal of criticism about the NHS and all I wish to say about the achievements of the last Government is that capital spending did not suffer in any one year under us; under Labour the NHS did well out of the total public expenditure. We managed to increase its share each year and in those five years there was a tremendous increase in medical staff—4,000 more hospital doctors, 1,300 more general practitioners, 1,000 more midwives and 45,000 more nurses. The number of patients who became in-patients in the last year exceeded 6 million, a figure never before reached, and there were over 3 million more dental treatments in 1978 than in 1973; in 1978 there were 27·1 million dental treatments as against 23·7 million in 1973. I mention those figures for no other reason than to show that the NHS, in spite of all the difficulties the Labour Government had to face, was not static.
I wish to refer to the Conservatives Election Manifesto of April 1979, in which they said:
"In our National Health Service standards are falling; there is a crisis of morale; too often patients' needs do not come first. It is not our intention to reduce spending on the Health Service; indeed, we intend to make better use of what resources are available".
On 12th June 1979, after the election, they said:
"As we have repeatedly made clear, it is not our intention to reduce spending on the National Health Service".
Then we had the Secretary of State for Social Services saying in the House of Commons on 17th July 1979, about five weeks after the Statement made by the Chancellor of the Exchequer:
"We anticipate that the total amount to be squeezed [from the NHS] will be of the order of £90 to £100 million in this year. Of this only £35 to £40 million is a result of the increase in

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VAT … I concede at once that some health authorities, especially some of those in London, are faced with the need to make real cuts this year in order to remain within their cash limits. It is not for me or my Department to tell them where or how to make their savings. As responsible authorities, it is up to them to look at their priorities carefully and make savings where they will do least harm to patients' care".
"Least harm"—not no harm. It may be argued by the noble Baroness, Lady Young, "But we did not know the state of the country's finances when we came to power." I am sure that that may well be true, but what a stupid remark to make: that one will not do something if one does not know what the circumstances are; far better to have made no promises at all. In fact the Government ordered health authorities to cut £125 million from their budgets before 31st March next. The Secretary of State expressed confidence that the cuts could be restricted to the administrative service. He knows very different now—that they cannot be confined to the administrative service. My Lords—
Lord WOLVERTON: My Lords, I hate to interrupt the noble Lord in an important debate like this, but the Government's White Paper on expenditure, issued in November, stated:
"The Government plans to maintain spending on the National Health Service in 1980–81 at the level proposed by the late Administration".
That has only recently been stated in the Government's expenditure plans for 1980–81, yet we have just been told by the noble Lord that the Government are going to make cuts. They may be making cuts on the administration side, but they have said that they are not going to cut spending on the National Health Service. So I should like to know what the noble Lord thinks about this.
Lord WELLS-PESTELL: My Lords, I have just said that the Government have ordered the health authorities to cut £125 million from their budgets before 31st March, 1980. Cuts of that magnitude cannot be imposed without affecting patient care; and in a matter of a few minutes I shall enumerate the way in which this is being done. What is really happening is that health authorities are proposing the temporary or permanent closure of dozens of hospitals and clinics—that cannot be denied—the closure of
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hundreds of wards and special units; leaving vacancies for doctors and nurses unfilled; cutting out holiday cover for doctors; reducing staffing levels in laboratory services; postponing all new developments to improve services.
Let us make no mistake about it, my Lords; it means a real deterioration in the service that the National Health Service can offer. None of this is surprising to us on this side of the House. I am sure that this will be denied by the noble Baroness: the Conservative Party has never whole-heartedly accepted the National Health Service, either in principle or in practice. It is doubtful whether noble Lords opposite know much, if anything, about it—certainly not, I believe, from personal experience, because it is common knowledge that many of them use the private sector. I am not quarrelling about that, but I am saying that one is in a far better position to make judgments if one really knows what is going on.
The Secretary of State's room in the Department of Health and Social Security contained a portrait of Aneurin Bevan—at least in my day. I read recently that,
"A large square of unfaded wallpaper above the Secretary of State's desk at the Elephant and Castle is symbolic. For years a portrait of Aneurin Bevan, founding father of the National Health Service, hung there. Patrick Jenkin, the new Social Services Secretary, has had it removed. Instead on the sideboard is a framed photograph of Iain Macleod".
May I say that I am very glad that he has removed the portrait because, bearing in mind what goes on in that room at present, it would be an insult to have it there. I am not so sure that the photograph of the late Iain Macleod is appropriate because if there was one thing that the late Iain Macleod stood for above everything else, it was his belief in one nation, and this Government, let us make no mistake about it, believe in two nations: the "haves", the richest 7 per cent., to whom they gave 34 per cent. of the tax cuts, so that they could go off and buy private medicine and private education; and the "have nots", the 10 per cent., to whom they gave 2 per cent., and who have to suffer deteriorating health and education services.
The growth of separate private medicine, approved and encouraged by the present Government, can be accomplished only at the expense of the National Health Service. I ask noble Lords opposite to

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take note of this: that the growth of separate private medicine, approved and encouraged as I believe it is by the present Government, can be accomplished only at the expense of the National Health Service. Private medicine can in many ways make tempting offers to doctors, nurses and other medical personnel who in the end will not be treating citizens of the United Kingdom. The vast growth of private medicine in this country is a growing concern; it is also a cause of growing anxiety to all of us on this side of the House. As I said on a previous occasion, one can go into Wellington Hospital and it will not cost more than just over £900 a week—I emphasise a week—using doctors who have been trained in this country at public expense, drawing on nurses whom we badly need in our National Health Service hospitals, and as I said a few moments ago, to a very large extent they are treating anybody but citizens of the United Kingdom.
We know that the Government want to encourage medical insurance schemes by introducing tax relief on contributions, in order to shift the cost of the Health Service from taxes to insurance. But what of the future for the National Health Service for those who cannot afford an insurance scheme? Are we going to fall back on the kind of situation, which I can remember vividly, that existed before 1948, in which we had voluntary hospitals that could not pay their way and had to have Government help and in which the service left much to be desired? Are we going back to the kind of situation in which hospitals have to be maintained by charitable institutions, lotteries, and the like?—because this has been suggested; make no mistake about it, my Lords.
I want to refer for a few moments to the Royal Commission Report. I do not ask for answers to these points. I may well put them in question form, but that is simply because I want to emphasise to the Government the importance of these matters. The Royal Commission made a number of proposals: there must be removal of queue jumping through private medicine—so the Royal Commission was aware of it; there should be no change in the method of financing the National Health Service; and the National Health Service should provide equality of entitlement to health services. It said that the
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National Health Service should provide equality of access to all the services and a service free at the time of use, satisfy the reasonable expectations of its users and remain a national service to local needs.
I should like to emphasise a number of things that the noble Lord, Lord Winstanley, said and, if he does not mind, cross the proverbial "t"s and dot the proverbial "i"s. I think it would be helpful if the Secretary of State looked carefully at a number of things; for example, the cost of agency medical staff, which is phenomenal, and the saving which could be made in the cost of drugs. A pilot scheme could be started in this country in a defined area to find out what drugs were really necessary, and there could then be drawn up an approved list of inexpensive drugs, because I am sure the noble Lord, Lord Winstanley, will agree that there is more than one drug available which will do a certain thing, some of them three or four times more expensive. I think we also need to look at the secretaries employed through agencies for administrative work. With agency secretaries there is no continuity, and they never get to know the staff, they never get to know the system, because they come and go through an agency. The amount of money that has to be paid to employ agency secretaries would warrant paying shorthand-typists in the National Health Service a bit more, so cutting out the need for secretaries from agencies.
My final point is this—and to this I should like an answer, but not necessarily today if the noble Lord or the noble Baroness feels that it is a flatter that cannot be dealt with today, as I am inclined to believe. I think we ought to look very carefully at the scope and function of the community health councils. It came to my notice only a few days ago that one community health council were so enraged at the cuts being imposed upon the area health authority through the regional health authority that they wanted to take legal action to see whether they could be stopped. Not surprisingly, they were told by the regional health authority that the money which the regional health authority gave the community health council was not for litigation—anything but. T have some sympathy with this view, but as I see it—and I

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may be quite wrong about this—the community health council is a public body, and public bodies are not prevented from taking some action. I think that this is an area which needs looking at, and I would be grateful if at some suitable time the noble Baroness or the noble Lord would look at it and let me know.
As I say, my Lords, I am sorry, in some respects, that I could not have sounded more cheerful; but after a good many years in politics, going back to the time when I sat on a committee, albeit a very humble committee, a very small committee, that was planning the National Health Service, I have yet to be convinced that, whether or not we have the money, from the present Government we are going to get a sincere and sustained attempt to give us the kind of National Health Service we should have, unless there is a conviction on their part that this is of supreme importance to the community.
Lord SOMERS: My Lords, before the noble Lord sits down, I must take issue with him on one or two things that he has said—and the noble Baroness has kindly allowed me to intervene at this stage. I hesitate to do this because the noble Lord is a personal friend, and when he represented the Health Department in your Lordships' House nobody could have worked harder or been more conscientious, and we all admired him. But I must press him to believe that the old theory that all noble Lords who sit on this side of the House are wealthy landowners and all who sit on his side are poverty-stricken citizens is absolutely exploded by now.
Although I sit on these Cross-Benches I am a potential Conservative Peer, and, what is more, I am one of that obnoxious breed which I know is really allowed only on tolerance by that side of the House—an hereditary Peer. But I can assure the noble Lord that I have enjoyed the services of the National Health Service ever since they were founded, and I am thankful to say that if it were not for the services I received from them I would not be sitting in your Lordships' House today. I am a constant patient, and I have the very greatest admiration for the doctors who work in it. Naturally I know nothing about the private affairs of noble Lords who sit on the Government side of the House, but I think that if a secret ballot
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was taken the noble Lord would find that only about half a dozen enjoy the services of private doctors and private beds.
Lord WELLS-PESTELL: My Lords, I do not think the noble Lord need apologise for intervening in any debate in this House. We can hold our friendhisps very sincerely and very dearly, but we can also take our politics very seriously, as well. I think it is one of the great joys of this House that we can say what we think, although I hope we always say it nicely. But I think the noble Lord is mistaken when he thinks that there are only about half a dozen Peers on the other side of the House who use private practice.
4.37 p.m.
The MINISTER of STATE, DEPARTMENT of EDUCATION and SCIENCE (Baroness Young): My Lords, I am sure we are all very grateful to the noble Lord, Lord Winstanley, for initiating and introducing this debate today. He has made a most perceptive and stimulating speech, and I was very glad to hear the constructive and realistic contribution that he made. It is appropriate that we should at this stage, at the start of the new Government's life, debate the National Health Service, and do so as we move into the 1980s. I should also like to wish the two maiden speakers good fortune in their speeches. I am sure they will go well, and we shall look forward to hearing both noble Lords on very many occasions.
My Lords, I would take as my starting point this afternoon what members of the Royal Commission have recently said about the National Health Service:
"In the course of our work we have seen things we have liked and admired, and things we have not liked at all. But our general view is that we need not feel ashamed of our health service and that there are many aspects of it of which we can be justly proud".
I think that this, in a very real and balanced way, sums up the position we find ourselves in today.
It is very easy to be critical and to say critical things about the state of the Health Service, and I shall be turning to some of those detailed points in a moment; but before doing so I should like to place on record my party's support of the National Health Service, and certainly our pledge, which we gave in Opposition

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and which we reiterate now, that it is our determination that in what we do we shall put the patients first. Many points will come up in the course of this debate today, and if they cannot be answered either by myself or by my noble friend Lord Cullen I give an assurance to the House that we will follow them up, that the proceedings will be read by my right honourable friend the Secrtary of State for Health and Social Services, and that we will of course write on matters which we cannot answer.
The noble Lord, Lord Winstanley, said that Britain spends less of its gross domestic product on health than many other countries in Europe. He is, of course, quite right. The truth is that the National Health Service is no longer the envy of the world, and the Royal Commission in fact showed that for every £100 spent on health care per head of population in Britain, the Netherlands, for example, spends £147, and West Germany, £158. The consequences are what we might expect, as for example in perinatal mortality, which is higher in England and Wales than in Norway, the Netherlands and France. Nobody can be pleased by this state of affairs, and all of us agree that we want to do something about it.
We on this side of the House would like not only to spend more on the Health Service, but we can only do so once we have succeeded in restoring the nation's prosperity. Really, our fundamental difficulty is the fact that, even today, our factories produce barely more than they did five years ago under the three-day week. Because we have not had the economic growth the National Health Service, as other public services, has suffered greatly. I do not believe that in these circumstance it is a very valuable contribution to have an interminable debate about whether or not we should or should not have private medicine.
I have spent enough time queueing up in hospitals to know quite well how some of the more difficult features of the National Health Service work. Having said all that, it is, I believe, a fact that only this year the Electrical, Electronic, Tele-communication, and Plumbing Union agreed with the electrical employers to provide private medical cover for 40,000 employees—and why not in a free society, if that
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is what they want to do! Really and truly, I do not think that debating who does or who does not have private medicine is a profitable use of our time. The fact is that we want to improve the National Health Service, and it is to that end that we should be addressing ourselves.
May I now turn to the economic situation facing the hospital service. The position is that health authorities are having to keep their expenditure about £125 mllion to £130 million below what they had planned to spend in order to keep within their cash limits. The reason for this is that we inherited a whole series of commitments on NHS pay but not alas! the wherewithal to meet them. We have agreed to honour the arrangements made by the previous Government and to increase health authority cash limits by most of the excess cost over the inadequate cover they had provided. This has already cost £250 million and with more to come. The previous Government had already told health authorities they could expect no increase in their cash limit to cover excess price inflation over the amount that had been provided. Faced by the need to foot the substantial increase in the NHS pay bill, and by the equally urgent need to reduce the borrowing requirement and the burden of direct taxation, we felt unable to go further than our predecessors. This has meant in consequence hard decisions by many health authorities, and I recognise that there have had to be reductions in services in some places. London has faced particular difficulties. In general, however, health authorities have responded very well to my right honourable friend's request to achieve economies with the minimum impact on patient services; they have done this by cutting back on new developments as well as by stringent housekeeping economies, and focusing any cuts as far as possible on expenditure not concerned with patient care.
The noble Lord, Lord Wells-Pestell, quoted our Manifesto. He said—and I accept this—that in our Manifesto we said that it was not our intention to reduce spending on the Health Service. I have just given the figures, and I accept that there has been a tight squeeze this year because of cash limits and the economic situation. However, as my noble friend said—and it is in the White

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Paper—the fact is that planned spending on the Health Service in 1980–81 will give an increase of about 3 per cent. in real terms for the two-year period since 1978–79. This increase will restore this year's squeeze and add the further ½ per cent. real growth previously planned for health authorities. The net cost of the NHS will rise to £7,904 million, about 11 per cent. of the total of Government expenditure. We believe that it is not right that users should not bear a reasonable share of the cost where they are able to pay. We have therefore made two further proposals. The limits on hospital costs for road traffic accident victims which can be recovered from vehicle insurers involved will go up from 1st April.
I think at this point I should answer the points made by the noble Lord, Lord Winstanley, about prescription charges. We have accepted that prescription charges will be raised to 70p from 1st April 1980—representing roughly the same proportion of the total cost of a prescription as 20p did when that charge was introduced in 1971. There will continue to be arrangements for exempting the elderly, who will not have to pay; those under 16; those on supplementary benefits and other groups, such as expectant and nursing mothers. The prepayment certificates—which are colloquially called "season tickets"—for those needing frequent prescriptions, will continue on favourable rates. We recognise that many believe that treatment should be absolutely free at the time it is received. But we do not believe that the savings from increased charges—nearly £33 million next year—can be lost. Still less do we believe that we can afford to abandon charges altogether for those who are able to pay
As I have already indicated, we judge that the country cannot at present afford to devote more resources to the NHS if we are to restore the country to its economic prosperity. But we believe, as already indicated, that there is very considerable potential for making more efficient use of the resources that are available. The Government are seeking to reduce waste, bureaucracy and over-government across the whole range of public services including the NHS. I was particularly interested to hear what the noble Lord, Lord Winstanley, had to say on health
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education for all of us, preventive medicine and generally his remarks on sensible living.
Before Christmas the Government will issue a consultative paper setting out their proposals to simplify and decentralise the Health Service, and reduce bureaucracy. This will pick up and respond to the Royal Commission's recommendations on these matters. I believe that the Government's general approach is well known. We shall propose a simplification of the existing structure; in some places there are in effect six tiers—the department, region, area, district, sector and unit. We shall also propose greater delegation of responsibility to those at the level at which services to patients are provided. I hope that when the noble Lord, Lord Winstanley, sees the consultative document, it will help him on some of the points that he made about the importance of involving people at the level of the community.
We shall be making our proposals in order to achieve a more effective and responsive service. We also believe that if our proposals are implemented, the service will be less costly. My right honourable friend the Minister of State at the Department of Health has said, in answer to a question in another place, that the long term aim should be to save 10 per cent. of the present cost of managing the service—that is, £30 million of the £300 million per year spent on management Some have dismissed this aim as wholly unrealistic. I would simply reply that some authorities have already shown that substantial savings are possible by simplifying their structure. Somerset, for example, expects to save over £200,000 a year as the result of changes implemented earlier this year.
However, we are not simply limited to the question of making structure and management more efficient. We are also reviewing a wide range of possibilities for making better use of resources, some of which—for example, the use of incentive budgeting—have been highlighted in the Royal Commission's report. If I may, I will give two examples of initiatives taken by the Department of Health over the past few months.
First, a research project is being undertaken in several health districts which is designed in part to help clinicians be

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more aware of the economic consequences of their clinical decisions. There is certainly no intention to infringe the tradition of clinical autonomy, but there is no denying that within a finite budget the use of unnecessarily expensive drugs or procedures in diagnosing and treating one patient means there is less to be spent on others. Experience so far shows that if given by management well presented information about the costs of procedures, drugs, et cetera, clinicians are sometimes able to save quite considerable sums without in any way reducing the quality of care they give their patients.
The second project is one designed to help relieve consultants of part of their burden of paperwork and administration generally, by giving administrative support to groups of consultants working as a clinical unit. Experience in one or two cases has shown that a relatively junior administrator can relieve consultants of much of the chores of scheduling their work, arranging admissions, and similar matters, giving them more time for clinical work. If the experiment now being undertaken in several districts proves valuable to the consultants concerned, this is one area of administration in which we shall want to encourage growth. Noble Lords may be assured that my right honourable friend the Secretary of State will encourage initiatives to cut out waste and improve efficiency—and I shall of course draw the suggestions that will undoubtedly be made today to his attention.
I should now like to turn to another area in which concern has been expressed: that it the very important matter of industrial relations in the National Health Service. Not everybody realises that there are about one million employees in the National Health Service and that in fact it is the largest employer in the country. Of course, industrial relations in the National Health Service attract publicity. When they go wrong, industrial action threatens to harm people already vulnerable because of illness. Until relatively recently industrial action was almost unthinkable in the Health Service, with its traditions of service inherited from voluntary hospitals and other institutions. However, over the last 10 years there have been problems resulting primarily, I think, from two causes: first, as a pressure
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stemming from our relative national economic failure coupled with the application of rigid national pay policies. I think these cumulative facts have indeed had a very unhappy effect. Secondly, I believe it to be true that there has been a change of attitude in the National Health workforces and that management has found it very difficult to come to terms with this.
The present Government are most anxious to restore responsible collective bargaining within cash limits, so that settlements reached are, and can be seen to be, fair to the staff involved, to the service as a whole and to the taxpayer who foots the bill. Staff will not accept as fair public sector pay settlements markedly out of line with the private sector. Almost inevitably there must be some system of comparability, but the Government have not yet decided its shape in the long term. For the present the Clegg Commission continues to deal with references to it. Its recommendations on ancillaries and ambulance men have already been received and accepted. Its recommendations on nurses and midwives are expected early in the New Year. We hope that, through comparabilities and with the developing system of cash limits, reasonable settlements will be reached within the Whitley Council machinery, because the Government believe they can help by standing back from pay negotiations.
There is above all the clear need to foster good personnel and industrial relations at the local level. The Royal Commission made a number of pertinent recommendations. We believe the proposals for changes to the structure and management arrangements of the service, to which I referred earlier, will help and we shall be encouraging health authorities to develop ways of avoiding disruption of the normal flow of work in the National Health Service by avoiding disagreements through consultation and resolving those that arise through negotiation.
Finally, I should like to conclude by saying something about the importance we attach to volunteers and the whole of the voluntary movement in the hospital service. The noble Lord, Lord Winstanley, drew our attention to this and I think we are all very grateful not only to the Leagues of Hospital Friends but to the

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many people who do voluntary work in connection with hospitals.
A particular point has arisen, and that is the use of volunteers during industrial disputes. It is during industrial disputes in the National Health Service that the general public can have a role to play. Unlike the management of an industrial concern, NHS management cannot contemplate a shut down during a strike and basic essential clinical services must be maintained. Where these services are threatened by industrial action, National Health Service management must take other measures; and last winter saw heroic measures made by other groups of staff to cover for absent strikers. Nurses were cleaning wards, administrators were stoking boilers and doctors were acting as porters. However, the Government believe it is unfair to the other groups of staff to expect them to pick up all the pieces. We made our position clear when in Opposition last winter and we now believe, and we say again today, that National Health Service management must be and are free to make whatever use of volunteers from the general public they can. Perhaps alone among public services, the NHS always gets a spontaneous response from the public at times of crisis. We believe that the NHS management should be able to tap this fund of goodwill. But, of course, it is not only at times of crisis that volunteers have an important role to play and we support what they can do to complement the National Health Service.
There are many speakers today and many experts will be speaking. My noble friend Lord Cullen will be winding up for the Government and will be answering many of the points that are raised; but I should like to say finally that we believe in the importance of getting the best use of resources for the National Health Service. We accept—and I understand there are between 78 and 80 different professions involved in the National Health Service—how much we depend on all these people. I should like to pay my tribute to the many thousands of people who work in the National Health Service, who give to so many of us of their time, of their skills and of their efforts. All of them are needed to make the Service a success and each one is dependent upon the other. I hope we shall have this sense of belonging to a great service which we all want to
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support. It is for these reasons that I and my colleagues welcome this debate today, the interest of your Lordships, and the expert knowledge which you can bring to this debate.
4.57 p.m.
The Earl of ERNE: My Lords, I hope your Lordships will give me the indulgence of the House during my maiden speech. I should like to thank the noble Lord, Lord Winstanley, for having raised this important question and for giving me the opportunity of addressing your Lordships for the first time.
My interest in the question stems from my being a member of the Western Health and Social Services Board in Northern Ireland. The geographical area for which the Board is responsible includes my home county of Fermanagh, which is the most western county in the United Kingdom. It is an extremely remote county, consisting of small farms, forests, moors and lakes. It has a scattered population of 50,000, with some modest industrial development in three major towns.
We read with interest about developments in medical science in such fields as heart surgery, brain surgery, and radio-therapy; and we are pleased that these services are available to us at our regional hospitals in Belfast. However, we are much more concerned about our local services and we wonder whether those who plan in the National Health Service and in particular those who influence professional training, may be rather too obsessed by the views expressed in the cities and in the "centres of excellence" and whether perhaps they tend to overlook the somewhat different needs of those of us who live in rural areas.
I am informed, for example, that pharmacists and opticians are now required to undertake a university degree course rather than attending a local part-time course as they used to do. One wonders whether they may be more inclined to seek employment in the hospital service in research or in industry rather than to engage in retail pharmacy or eye-testing in small country towns and villages. It is certainly becoming more difficult to attract graduates into retail pharmacies, with the result that many chemists' shops are closing and smaller communities are losing this essential part of our Health Service. Similarly, I believe that the

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entry of doctors to general practice is seen to be the subject of regulations imposing compulsory vocational training, which in itself is most desirable so long as that training is not concentrated in the teaching hospitals and the larger centres.
I view with some concern the move towards group practices and financial incentives available to those who work in them. I should hope that some corresponding incentive would be made available to those doctors who undertake the much more demanding duties of providing single-handed medical care to village practices—practices which are still common and which are so much more appreciated in my part of the country.
Finally, I should like to speak with some feeling about two local matters. First, as has been mentioned before, the overall death rate in the West is similar to that of the rest of the Province although the birth rate is appreciably higher. However, the infant mortality rate and the perinatal mortality rate is the highest in the whole of the British Isles. This is due partly to social and economic reasons—high unemployment; a high proportion of families receiving social security benefits, combined with relatively poor housing—and partly to the lack of sufficient paediatric services.
The second local matter to which I should like to refer concerns our county hospital, the Erne Hospital in Enniskillen. This is a modern acute hospital with 215 beds, providing an excellent service to our isolated community. In common with many hospitals of this size, it has been experiencing difficulties in attracting medical staff and in providing acute services. The Western Health and Social Services Board has recently carried out a comprehensive study of our hospitals, under the chairmanship of Dr. Gordon, and has now issued a report in the form of a consultative document. This recommends that the Erne Hospital should be extended to take a larger population and thereby justify increased staffing levels, which should ensure a more reliable service. I feel that it is essential for County Fermanagh to retain and develop this acute hospital, and I fully endorse this recommendation. I hasten to add that my support for this recommendation is not due to the fact that this hospital
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shares my name, but is because it is so geographically situated as to meet the needs of the majority of our scattered community. I should like to end by saying that I sincerely hope that adequate hospital services will be retained in neighbouring areas until such time as communications have been considerably improved.
5.3 p.m.
Lord PITT of HAMPSTEAD: My Lords, may I be the first to congratulate the noble Earl on his maiden speech, which I found very interesting, and also to thank him for what he said because his speech will fit in very well with mine. I say that because he was speaking for a rural area, while I, of course, am speaking as a GP in a very deprived inner city area, but I am a single-handed practitioner. I started this practice in 1950 and saw it grow. I saw the first patient come in. Before that, I worked as an assistant in a general practice in Chiswick, and prior to that I was locum in Sydenham and in Newcastle. I was in at the inception of the National Health Service, though at that time I was only a locum. So I have seen the service grow.
I want to start by talking about general practice and then move on to other things. My practice was built by my wife and myself, she being my unpaid secretary as most doctors' wives are. But, of course, the stage has now been reached where a doctor in my position is allowed to employ up to two people, for which the State pays 70 per cent. of the cost of employing them. So we have moved a long way there. We have also moved to the stage where there is no question of my not being able to get pathology services from the hospitals around me. There is no question of my needing to send my patient to a consultant before he is X-rayed. I can get radiological services from the hospitals around me. I can also get physiotherapy services from the hospitals around me. So we are moving well forward there, too. In any general practice at the moment one can get an attachment to a health visitor and one works closely with social workers, because it is always possible to be in touch with those people in the area. Therefore, over the period that I have practised in this deprived area I have seen the benefits of the Health Service improve consider-

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ably, so far as primary health care is concerned
The area has changed out of all recognition during my period there, and of course, as in all such areas, I have the usual problems of drug addicts, alcoholics and the like. There is also the continuous problem of homelessness. Perhaps that explains to your Lordships why I so often speak on housing in this House. We could move further in improving primary health care if we improved housing, because a lot of the patients who go to hospital do so because it is not possible to nurse them at hime, as their home conditions do not allow it. Again, we could improve to a tremendous extent the turnover in our hospitals if people could be sent home earlier. There could be more day surgeries and things of that sort. But those matters are tied up with improving the housing in areas such as the one in which I practise. In addition to that, I represented another deprived area at County Hall for 16 years. So I hope that your Lordships will forgive me if most of my speech this afternoon is probably critical. It is because I am really talking about what has been happening to these deprived areas in London, so far as Health Service matters are concerned.
When I started my practice, one of the attractions of the area was that there were a large number of teaching hospitals around me. That is one of the reasons why I started there, even though it was a very congested area and other doctors were there. I was taking a big chance when I put my name on the door and waited. When I knew that we were having this debate today, I made contact with those teaching hospitals and found that they had terrific problems, most of which are the result of the resource allocation scheme which has been followed. As I listened to them, I thought that I was back in County Hall, because the way in which London has been treated in the resource allocation scheme is very much like the way in which London is treated in the rate support grant.
London never gets its fair share of the rate support grant. What happens is that it is agreed that the rate support grant should be 61 per cent. but then there is a claw-back. The theory is that London has more resources than the rest of the country and can therefore meet its
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problems more easily. To some extent that is true; both the City of London and the City of Westminster are quite rich. But poor people live in the City of Westminster. In fact quite a lot of poor people live in Paddington and they have to bear the consequences of those sort of decisions. What is worse is that the East End of London, which is a poor area, usually has to pay these high rates because of the decision that other parts of the country—which are, in fact, much wealthier than these areas of London—ought to receive more of the resources, since London is better able to take care of itself. That is the basis of this iniquitous way in which the rate support grant is usually distributed.
I get the feeling that the same sort of thing happens with the resource allocation scheme and that, as a consequence, London is having a rough time. London does have more teaching hospitals than most parts of the country, but London also has problems which are greater than those in many other parts of the country. Teaching hospitals develop special units, special services. Those services usually serve not just the area, district or region in which the hospital is situated. More often than not, those hospital services serve large areas—areas well outside London. This is one point which nobody seems to bear in mind when it comes to the total allocation of resources for London. Nobody has a clear conception of the cost of these special referral units which exist in London but which serve people who do not live in London. What happens is that the regional health authorities nominate regional specialties and they allocate funds for them. Since, however, as I said earlier, they are not too clear about their exact cost, the allocation is never adequate.
One of the suggestions I want to make to the Government is that in looking at the National Health Service—as, obviously they are doing at the moment—the question of more central funding of some of these special units should be seriously considered. May I give your Lordships an example of something that bears out the point in a very clear way. The Royal Free Hospital has a haemophilia unit which costs £10,000 per patient per day. That unit does not serve merely Hampstead; it serves a very much larger area than even the North-West Thames

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area. Such a unit should be centrally funded because I was told that to treat one individual has cost that hospital £100,000. Now £100,000 paid from central funds may not be too heavy a burden, but £100,000 paid by the North Camden district is a terrific sum. Even if, as happened, the region meets a large part of that sum, a great deal of expenditure still falls on North Camden, expenditure which it ought not to be made to bear.
I am using this example to illustrate the point that one needs to look a little more closely at the degree to which there can be central funding. I know that there is a certain amount of central funding. For example, Coppetts Wood is a Lassa fever specialist unit, and that is being centrally funded. This is the same sort of thing as the haemophilia unit when it comes to expense. However, there are many other units besides Coppetts Wood which need to be centrally funded and not left to be funded by the local or the regional authority.
Another point about London is the cost of the nurses. I am always hearing that we must not have agency nurses, but the truth of the matter is that most London hospitals have trouble getting nurses because of the accommodation problem and because of the cost of living in London. Although there is London weighting, it does not really meet the cost of living in London. Therefore, many of these hospitals can maintain their services only by using agency nurses. When, frequently, I hear that we must reduce the incidence of the use of agency nurses, I have to say, "Think again", for sometimes this is the only way to meet the needs of a particular hospital.
I said earlier that I would concentrate on some criticisms. The other side of my story is the question of the area: which I represented in County Hall. I am referring now to the London Borough of Hackney. Recently, the Hackney Borough Council took the decision to withdraw its representatives from the area health authority. I am sure the noble Lord knows that. It was a very serious decision for a borough council to take. In fact, they discussed their action with the other borough councils involved, who were sympathetic but who were not prepared to take the same action.
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I have spent some time today trying to get at the facts behind their decision to withdraw from the area health authority. The borough council told me that they withdrew from the area health authority because Hackney's interests were not being safeguarded. They told me that 250 acute beds have been closed in Hackney since 1976. The Metropolitan Hospital has been closed; the acute functioning of the German Hospital has been closed. Hackney and St. Leonards are the only hospitals left in Hackney. When they retired from the area health authority it was because there was a proposal to close St. Leonards Hospital. In fact, St. Leonards Hospital has not been closed, although the performance of its accident and emergency wards has been reduced. They function only from 8 a.m. to 8 p.m., which means that St. Leonards is not so useful to the people of Hackney as it once was or was expected to be.
The borough council also found that although Barts was expected to take the extra work as a result of the closure of these other hospitals, Barts itself was having to close beds. In 1976, Barts closed 40 beds which have never been reopened, and recently the hospital has been made to close a further 78 beds. They found, too, that the Prince of Wales and the Royal Northern Hospitals—which are not in their area but just on the border and which can therefore be used—were under the threat of having their accident and emergency services closed. They gave me a number of other details but I will not weary your Lordships with those because time is passing. When the suggestion was made that we should also close St. Leonards they decided that they had had enough and Hackney withdrew from the area health authority.
This is a serious matter and I have used it to illustrate the point I was making. It is quite easy to say that London has a surfeit of hospital beds. The truth of the matter is that the hospital beds in London serve more than merely the people of London. What is more significant, however, is that the reductions in the allocation to London are in the poor areas of London. Therefore although as a consequence it may well have helped some other poor area in the rest of the country it will certainly have done harm to one of the poorer areas of London.

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I have made this case at length because I want the Minister, when he is thinking in terms of next year's extra 3 per cent. to think more carefully of how much of that can go to areas such as the East End of London, because what is really required—and Merrison actually said it—is an improvement in the resource allocation scheme. It is not—certainly so far as London is concerned and it is London that I know about—doing the good that one hoped it would in the long term. In fact, it is doing a lot of harm.
I do not want to burden your Lordships for longer than I need to. There are many other things that I wanted to say but I want to draw the attention of the Minister to two threatened closures, one of which in fact is not taking place—that is, the closure of the Elizabeth Garrett Anderson hospital, which I now know will not take place. The other is the threatened closure of St. Columba's Hospital which is the hospital for terminal cancer up in Spaniards Road in Hampstead, which I gather the area authority of Kensington, Chelsea and Westminster are threatening to close because they cannot see why they should be spending money on people who in fact do not come from their area. That was one of the points that I was making earlier.
In the case of the EGA, I know that it is to be reopened but it is to be reopened as a gynaecological hospital, with day patients, 12 beds, a proper out-patient department and an early diagnostic unit, which will be useful for screening for cancer of the cervix, the breast, and so on, and possibly screening as a means of preventive medicine and some health education. All this is quite good but I think the Department misses the point. The EGA was a hospital where women who were sensitive about being treated by men were able to go to be treated by women and it is not only for gynaecological treatment that women feel they need to go to women doctors. The whole ethic behind the agreement to reopen the EGA as a gynaecological hospital suggests that that is the only reason why women want to go to women doctors. That is not true. There are a lot of women who prefer to have women doctors—just as, of course, there are a lot of women who prefer to have men doctors. I would not have said, for example, that it was necessary to
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build a new EGA, but you have the EGA and therefore you should keep it.
What is more, we are now turning out more women doctors than we did before and we need to know how best to use them. I should have thought that what the Government would be interested in doing is using the EGA to enable them to see how best to use women doctors. I am referring to such things as where part-time working can fit in, and so on, because one could do that with a hospital like the EGA which is served by women doctors for women patients. That could give a very good idea of how to fit women generally into the other hospitals in the country.
I have spoken for far too long so I will conclude by just making two points. First, my own view, having given some time to studying what is happening, is that there is more need for local influence on decisions. That is my firm conviction. I intended to take a few minutes to comment on Dr. Owen's suggestion that we should elect the health authority. I will not do that at the moment because already I have spoken for too long, but I think it is something that ought to be taken on board. Obviously it could not be done now—and here I come back to my local authority theme, which I to not like to do so often—unless one had local income tax. It could not be done on the rates. Therefore it is long and not short term, but it is worth thinking about.
The second point concerns the community health councils. One should strengthen them—and I notice again that Merrison suggests that—because they ought to be, and what is more they can be, a good thermometer of what the public want and, since they will know what resources are available, they would be useful vehicles for enabling the viewpoint of the public to be taken into account when decisions are being made. Therefore I hope that more use will be made of community health councils, and I hope the Minister will not pursue the line that he has taken, for example, when he told one of the regional hospital authorities that the statutory provision that there should be three months' delay before the services were withdrawn, in order to have consultation, can be waived because there is an emergency. I hope that emergency excuse will not he used for too long because I do not think it would be a

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good thing for us to start making changes and ignoring the local pressures which can come from community health councils and which can be for good.
I had intended to make some remarks on industrial relations, but I will only say one thing. What one needs is sensible machinery, but in the end what one needs are arbitration situations and arbitration which can be accepted. The doctors have a review body, and so do the dentists, for their pay. It is worth giving serious thought to having a similar set-up for the rest of the Health Service. That said, I may add that if that is going to be done there must not be an arbitrary rejection of the report by the Government of the day, as we have had sometimes with the doctors' review body. What we must have is arbitration machinery which, as employers, the Government would be willing to accept; and if the Government accept the machinery and its awards I think it will be found that the employees will also accept the machinery and the awards.
I am sorry that I have spoken for much longer than I had intended to, but there are many things in connection with the Health Service about which I feel strongly. On this occasion I felt that I had to put the case for Hackney. When I was told of the action they had taken, which I regarded as very strong action for any borough council to take, I thought I ought to find out what it was and why they did it, and that your Lordships ought to know.
5.30 p.m.
Baroness RYDER of WARSAW: My Lords, I crave the indulgence of your Lordships in addressing your Lordships' House for the first time. Also I am a newcomer, but I am moved, especially on this occasion today, to speak, if I may, for the silent sufferers in society whom I feel so deeply about. From the very wide spectrum of the problems among the handicapped and disabled I wish to confine myself to adults and children with cancer. Their lack of care constitutes one of the biggest gaps in our society. I refer in particular to people who receive, when possible, surgery and treatment. While some return to a full life, others realise with some alarm that they have entered a twilight world.
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The real problem arises when they must be discharged from hospital because they are blocking an acute bed needed for many others. Then these people for whom I speak are often left to their own devices. So long as patients need medical nursing care in hospital they are the responsibility of the National Health Service. It is not unknown that a general practitioner has neither the time nor the facilities in his busy practice to visit as frequently needed. Many patients are often in great distress, in need of constant support, full nursing care for 24 hours, and on pain killers. How can the average person with no nursing experience and with a family, perhaps with young children, when the husband or wife must go out to work, cope? Equally, how can a single person alone, often lonely, also cope? Whatever the patients' condition they fully deserve compassion, hope, love and dignity in death.
What is to be done? The average cost in my own foundation homes in Britain is between £90 and £120 per week per person, substantially less than the cost of a National Health Service bed. Is it fair, therefore, that we must raise funds both for capital and running costs? The one positive and clear point which emerges while these financial difficulties continue for the Government is that the public at large should be better informed, and from an early age in schools, too. We may rally them. In this way we give the public the opportunity of responding in a far greater and more effective way, based on our long tradition in Britain of giving voluntary service. Any discouragement of such voluntary efforts, of which my own is one, must be a most important factor to the Government as to when they make their cuts and where.
Is this help going to be sufficient? I can only say to your Lordships that it is daily a long hard struggle, but we cannot and will not turn our backs upon these needs, which are growing. To illustrate these needs, may I mention the boy Timothy, aged 11, whose illness was prolonged and painful. His parents were devoted to him. He had a great fear of hospitals and needles. He finally had to be admitted to hospital at Christmas time. The staff there were marvellous and gave him a tree and presents. But he would have benefited so much more in a more

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homely place and environment, out of the hospital atmosphere. He died, and later his mother died too.
Mr. N., aged 62, has had carcinoma of the bowel. This patient had constant discharge because of his malignant condition and lived in a house where there was no sanitation and no drainage, not uncommon in his part of the country. His wife was near to a nervous breakdown. Mrs. H., aged 49, had a spinal tumour and lived in a terraced house. She slept in a bed in the kitchen. Both her lodgers and neighbours tried to look after her. Conditions became deplorable and she needed long-term nursing care.
The four London regions are especially hit by the lack of resources. Successive Secretaries of State, including David Ennals and Patrick Jenkin, wrote to regional and area health authorities to encourage them wherever possible to help voluntary organisations, including the Sue Ryder Foundation, but, alas! the financial situation has, with very few exceptions, precluded this help. The warning lights came on early in the 1970s. The axe is falling upon social services, too, because there is no guarantee, due to cuts in public spending, that an individual in great need will be sponsored for his maintenance.
I am deeply aware of the financial crisis facing the Government. Moreover, every aspect of medicine has a huge priority; the field is so wide and the gaps so great. So, alas! we can but plug a few to meet the many. Charitable foundations here should always work, as abroad, together in harness with the Government. For three years the Foundation has benefited from the job creation programme, enabling us to use good unemployed tradesmen and labourers and thus provide the Foundation with an extra 134 beds for short and long-term treatment and nursing care. Now this scheme, too, referred to as STEP, is apparently denied us at the end of 1979.
My Lords, I am not here only to complain, but to speak for those who are hidden and sick in society. I have tried to stress the urgency for more assistance from the public and ordinary individuals to meet these tragic needs. I am reminded of the lines written by an Irish poet:
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"Who would once more relight creation's flame
Turn back to sanity a world that goes insane
To bridge this awful chasm of despair
The faint small voice of hope calls out
Do you answer, will you dare?"
5.37 p.m.
Lord GISBOROUGH: My Lords, I feel it a special privilege to be in a position to congratulate the noble Baroness, Lady Ryder. A maiden speech is a formidable task, and I know she spoke at short notice; but she has accomplished it with exceptional excellence and commendable brevity. She speaks with a formidable and long record of public service, exceptional service to the sick and disabled, and her name is known worldwide. This House is richer for having her with us, and I know we would all wish to hear her often on health and other matters. I should like to add my congratulations also the the noble Earl, Lord Erne, whose personal expertise and experience will be of great value to this House, particularly as he comes from Northern Ireland. I should like to apologise personally that I will not be able to stay to the end of the debate as I have to go to another appointment. I can only excuse myself by saying that I have not had to do that before.
My Lords, before criticising the Health Service one must first accept that many hospitals run very smoothly, efficiently, have flexible working by all, have good will and good management, and in spite of all the difficulties they are thoroughly appreciated by the patients, whom it is all about. But, because that is so, it is no reason for not looking at some of those other hospitals where those conditions do not apply. Whatever I may say does not reflect on those hospitals that are run well and are a credit to the nation.
There is a great deal wrong with the service. Over the past five years the waiting-list for admission to hospital rose from half a million to three-quarters of a million, which is surprising considering the huge increase of staff and resources categorised by the noble Lord, Lord Wells-Pestell. In his speech—which I am sorry to say I considered to be a bit of class war-fare—he mentioned his hatred of private medicine. For one thing, he does not seem to be aware of the machines which were provided by private medicine and which then became available to National

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Health Service patients. He also seemed to forget that whether for Peers, people, or for the union man, private health is paid for by insurance policies for which premiums have been paid. Others may have preferred to spend those premiums on beer. It is a question of choice.
The morale of the service dropped, so that a combination of lack of discipline and weak management, caused by over-protective conditions of employment, led to the situation where the ancillary workers were almost able to bring the service to a halt last winter. The situation of ancillary workers trying to dictate terms by which the service will operate continues to this day.
We now have the cuts and the great question is where they should fall. The Government have suggested several areas for economies—for example, raising prescriptions to realistic figures; charging for traffic casualties; the abolition of the Health Services Board and general good housekeeping. But after that eventually comes jobs, and how will that affect the service? NUPE says: No cuts or the patient will suffer—no cuts, above all, to ancillary staff. Yet, who are these ancillary workers who are now complaining about cuts and insisting that patients will suffer? How have many of them shown—and how do they show—their concern for the patient? We saw how ancillary workers almost brought the Health Service to a halt last winter when they went on strike. At that time management were afraid to be tough and afraid to let volunteers do the jobs. Patients had to be turned away. Even last month at Great Ormond Street Hospital a spreading, irresponsible strike of porters stopped admissions. The strike was caused by the suspension of a shop steward who became involved in a birthday party punch-up. I have in my possession the Press cuttings concerning that dispute. One employee at a hospital is reputed to have said:
"People die every day: what difference does it make if a few more die".
At another hospital a drunk porter on a ward was suspended on full pay pending inquiry and that caused an immediate strike by all the other ancillary staff at the hospital; cases of refusal to carry out their jobs; refusal to leave a canteen to help
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a 90-year-old woman from an X-ray table and repeated foul abuse to a hospital secretary. There were many examples, and these are just some examples of how some of them behaved. Yet management's hands were tied. Then came the strike. What did doctors find? I refer to a quotation from the Daily Telegraph. It says:
"There is a further lesson which the dispute has taught us, namely that the hospitals are quieter and function more efficiently when many of these workers are away. We have known for a long time that there are too many ancillary staff for the available work".
Hospitals varied and some suffered more than others; certainly not all had to put up with the monstrous behaviour that I have started to quote. No doubt there are many hospitals where relations with ancillary staff are excellent. But since the strike, in the bad hospitals, nothing has changed except some lessons have been learnt by management who have found themselves able to take a tougher line. Where four men have turned up to do two men's work, two men have been sent home, and where management has shown resolution the situation has improved.
But it is necessary that the Government should speedily amend existing legislation so that those comparatively few disruptive, destructive and non-working workers, who bring disrepute to their hardworking fellow workers, can be removed from the service. There are many economies that could be made—altering shifts and breaking some old traditions; but often the men will not even meet management to discuss the matter, in spite of the attempts by management to get them to talk.
It is traditional that the ancillary staff work a great deal of overtime—a relic of the days of low pay. Now it is difficult to reduce overtime, yet it is very expensive and should not be necessary and its reduction could result in a large economy. So progress to economies that would benefit patients, the economy and in the long run the staff, is often hard and the complicated complaints procedure to achieve dismissal is so heavily loaded in favour of the bad worker as to make discipline very hard to apply. Doctors still have to wheel patients into lifts because the porters are too long in coming. Of course, those conditions vary and there will be hospitals where ancillary staff are hugely co-operative. That does not alter

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the facts of the examples that I have quoted. Nurses still have to undertake menial tasks that should be carried out by ancillary workers employed for that purpose. They still have to re-do work badly done by ancillary workers. All the time spent by doctors and nurses sorting out these problems is time taken from looking after patients. All that behaviour saps the moral of the whole service.
In addition, the effects of the reorganisation have only added to the problems: dividing nursing from administration; removing the matron and substituting numbered heads; and removing authority—the authority where the buck stops. Nurses used to have time to talk to patients and used to control diet. Since reorganization that is often done by orderlies and often their attitude is impersonal and they have no concern for the patient's welfare. Nurses who have responsibilities to the patients see their pay rates vastly overshadowed by those of administrative staff who have regular hours. Little wonder that trained nurses move to administration and leave a shortage on the wards. Operating theatres close at five o'clock for lack of staff and trained nurses who have gone into administration. It is not surprising what there is a long waiting-list for operations. Yet, one writer states, when referring to administrators before and after the reorganisation:
"I worked in a hospital of 150 beds and the assistant matron ordered and distributed stores to kitchens and wards. When she was off-duty it was my job, and we were also doing nursing administrative work.
"Soon after stated take-over, a man was installed in the stores with a large new desk and large stock book. Soon after that he got a male assistant.
"In the local hospital in Huddersfield, the boardroom was taken over by office staff and soon after that a ward was closed to accommodate more office staff.
"One consultant may have a secretary of his own. Before takeover, one secretary worked for two or even three consultants".
I believe that there are now far too many over-protected administrative and ancillary staff. They could be drasticaly pruned without any damage to the patient and probably to the benefit of the morale and smooth running of the service.
Now NUPE challenges the present cuts as being detrimental to the patients and the service. Yet its notices in hospitals read, "Stop cuts and save jobs". It is
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hypocrisy for them to suggest that they are interested in patients—it is only their jobs that they want. Yet a hospital is not a factory or a job creation scheme: it is for sick people and they should be looked after by people who are dedicated. Yet many workers feel that they are in a factory and act with total unconcern for the patients. No one is forcing them to work in a hospital and they should leave and work with inanimate objects.
I believe that economies can and must be made by reducing administrative and ancillary staff. The Government must consider whether or not to return to pre-Salmon conditions; scrap the administrative build up; put back the matron with her supreme authority; increase the sphere of the nurses and pay them more for doing so.
For all its faults of overmanning, we have in this country exceptional talent in our doctors, we have dedicated nurses and a service sought by foreigners from all over the world and one that gives our own country great service. However, I hope and believe that the philosophy of this Government will succeed in making the most of that talent and dedication, in raising morale and in paring down that part of the service that is overmanned and constitutes a drain to those dedicated to providing a great service.
5.50 p.m.
Baroness MASHAM of ILTON: My Lords, I too should like to congratulate the noble Earl, Lord Erne, and the noble Baroness, Lady Ryder of Warsaw, on their sincere and admirable speeches. I have tremendous admiration for the work that the noble Baroness has done; on one occasion I visited one of her homes in Yorkshire and met a Polish girl who had been raped 28 times. I should like to thank the noble Lord, Lord Winstanley, for bringing this debate to your Lordships' House at this time.
Remembrance Sunday has just passed, when I am sure many of your Lordships remembered the souls of the Servicemen who died in the two world wars. My noble friend Lady Darcy de Knayth and the noble Earl, my husband, both lost their fathers serving for this country, as I am sure did many other sons of your Lordships' House. Many men lived,

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but remained paralysed from their wounds. It was because of those casualties that the Ministry of Pensions started the National Spinal Injuries Unit at Stoke Mandeville Hospital in 1944. It was under the medical direction of Dr. Ludwig Guttman, who revolutionised the treatment of paraplegics. Before that time paraplegics had been considered hopeless cases and generally died in the first few months from urinary tract infection or sepsis from infected pressure sores. The routine then became to turn patients every two or three hours night and day; the treatment of infections; and intensive physiotherapy and rehabilitation to teach the patients that they could again return to society and take up useful employment.
In 1952 that unit went into the National Health Service serving the whole of the South of England and, being the National Spinal Injuries Centre, taking patients from all parts of the country. Priority has always been given to Service personnel. The hospital was built by Canadians in 1939–40 as a temporary emergency hospital. It was meant to last about 10 years. The patching-up process stopped about eight years ago when a new hospital was to have been built. This has never materialised and the wards are still housed in flimsy old nissen huts.
The North of England, mainly because of the mining industry, established spinal units when the treatment at Stoke Mandeville had been proved to be effective. The sooner the spinal patient is got to a special unit, the sooner he is returned to the community. Apart from this being by far the best treatment for the patient, it is always the most cost-effective method to the National Health Service. It has been proved time and time again that the hospitals that hold on to their spinal patients and do not refer them to a special unit run into endless problems. Pressure sores develop due to the ward routine not being geared to the spinal patients; urinary and blood conditions arise as many doctors do not expect the complications; contractures of the limbs occur, as often in general hospitals there are not sufficient physiotherapists to treat patients of this sort; and depression of the patients, and their relatives, develops because they become specially difficult patients, as everything starts to go wrong.
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In a spinal unit there is always someone worse than oneself. I can assure noble Lords that a depressed patient with pressure sores is much more difficult to rehabilitate, and it takes months of unnecessary hospital time to heal the sores that should not develop. Over the years I have had desperate calls from paraplegic patients or their relatives, who have been landed in general hospitals. One was from a young man who had broken his neck while at borstal doing gymnastics. After treatment in a spinal unit he went home; some time after that he developed pneumonia. That was cured, but a massive pressure sore developed because he had not been turned, even though he had asked to be turned. A note written by a student nurse which came into my possession reads:
"Sue, if you don't get me out of here, I will die".
It was signed "John". Another example is of a man who had been in a general hospital for 18 months paralysed from the waist down. His mother called me in as her son had tried to commit suicide because of depression. He had terrible sores and contractures and rehabilitation had not started. Both these men needed a voice to speak for them. They went to spinal units and, after years of treatment for their desperate conditions, they are now married and living in the community.
In 1970 I tried to get the Government to make spinal injuries resulting in paralysis a notifiable condition. This would have helped the Government to carry out research into where and why such injuries occur. In the past few years it has been evident that the Spinal Injuries Centre at Stoke Mandeville Hospital has become overstressed and understaffed, and there has been an increasing inability by the National Health Service to meet the needs of patients belonging to that unit who needed check-ups and on-going care. The National Health Service was failing in its duty to patients.
At the spinal units in North of England I could see patients being called back for check-ups and IVP's on a routine basis every year for a review, and every two years for a thorough check. That is good preventative medicine and money well spent, as serious complications can take months in hospital to put right once a condition takes hold. That was unable to happen at Stoke Mandeville

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Hospital which has about 6,000 patients on its books.
Last year I visited the spinal unit with Patrick Jenkin, the then shadow spokesman for health. He saw the conditions for himself. With the snows of last winter several of the spinal wards' roofs fell in. I visited the unit again on 1st February, this time with Timothy Raison, the Member of Parliament for that constituency. Two of the wards were closed as the ceilings had fallen in on top of patients. Outside the operating theatre in the main corridor a large bulge in the ceiling had been incised by a surgeon so that the water dripped into a bucket, rather than the whole ceiling should fall down and cause a major disaster.
On 7th November a meeting was held by the area health authority to decide whether or not to cut a further ward from the Spinal Injuries Unit, when already the DHSS knows that there are 100 spinal beds short in the South of England and that two proposed much-needed units have not yet been built. The ex-patients could take no more. On 7th November they moved in and had a sit-in to show how strongly they felt. Their placards read such slogans as: "Enough is enough" and a paralysed soldier said "We fought for you. Now fight for us". The whole country knows about this: most newspapers reported it, and the television showed the nation just how serious the situation is.
At a conference on 19th September held by the National Association of Health Authorities in England and Wales the Secretary of State, Dr. Gerald Vaughan, said:
"We have taken on board the Royal Com- mission's point that people must not be left in an agony of indecision and uncertainty about their future"
Dr. Vaughan is to visit Stoke Mandeville Hospital on the 20th of this month. This is just what he will find. He will also find a spinal unit serving a vast part of England, funded by one area. This point has already been raised by the noble Lord, Lord Pitt of Hampstead, who has stressed, as I have, that funding of these special units should be done nationally. Without direct Government reorganisation there will be a disastrous effect on many patients in this part of Buckinghamshire. With a growth rate of 18,000 patients, and a lag of two years' allocation of resources for the current year, the fact
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that the Aylesbury and Milton Keynes health district has the most rapidly rising population in the country means that the problems are exacerbated. Already they have a waiting-list of almost 5,500 patients of various surgical conditions, and the Government have told this area to cut services to patients. This district by circumstance of fate, is supposed to run the National Spinal Injuries Unit.
The unit in theory is supposed to bring in extra resources for patients treated from outside the region, but in practice this has not happened. I should like to ask the Government what has happened to these extra resources. Would it not be wiser for the Government to treat the national unit as a national responsibility and collect the funds from the various regions and fund the district direct from the DHSS? These vital resources for the National Spinal Injuries Centre are being swallowed up by the Oxford Region, and are not going to where they belong.
The Spinal Injuries Association, of which I am chairman, does all it can to help and support the patients and their relatives with spinal injuries. We have written several books to help both sufferers and professionals. We are at present about to publish one on the first 48 hours of nursing care for spinal cord patients. We have three members of staff working flat out, and a voluntary management committee. As a voluntary organisation we shall do all we can to help the Government to keep up the standards of spinal care in this country. The need is urgent.
On the 29th March this year I put a Question to Her Majesty's Government asking:
whether they will ensure that in future volunteers will be able to help in hospitals during emergencies so that patients are protected "—[Official Report; col. 1652.]
Should it not be a human right of all patients who are under the care of Her Majesty's Government that they are well looked after? My Question of 29th March got support from all sides of the House. The noble Lord, Lord Sandys, said:
"where a robust attitude was taken locally, volunteers were warmly welcomed".—[col. 1654]
We all know that some local authorities are much stronger and better than others. The noble Lord, Lord Wells-Pestell, told

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the House that there were some volunteers who had not been able to get through picket lines. The noble Lord, Lord Carr of Hadley, asked:
"Should it not be possible for people to get through picket lines?"
He went on to say:
"People should always be allowed through picket lines. Picketing is the right peacefully to inform and persuade. If the present law is unenforceable, it should be changed".—[col. 1656]
The noble Lord, Lord Wells-Pestell, said:
"we have a number of plans which we propose to put into operation as soon as possible after 9th May".—[Col. 1655.]
His party did not get back into power. May I now ask this Government what they intend to do? Can they negotiate a clear policy so that guidelines are put out throughout the country? Negotiations should be, I feel, with Government, unions, and voluntary bodies dealing with volunteers. Surely it is in the Geneva Convention that patients should be protected.
Coming from the poorer North, as I do, I should like to bring to your Lordships' notice the concern from a few people that the proposed new contract for consultants will not benefit patients in the deprived areas. The new contract proposes to encourage private practice. I am all for free enterprise and incentives, but not at the expense of the poor areas where good health needs are so great. I should like to quote to your Lordships from a letter in the British Medical Journal:
"The Secretary of State should remember that one of his tasks is to safeguard the National Health Service. It is not his duty to subsidise private practice".
There are many full-time consultants in places or specialties which do not attract private patients, and these consultants are unfairly treated in the new contract. It looks as if the bright young consultants, with young families to educate and support, will be encouraged away from the poor northern areas to the places where there is scope for a thriving private practice. I hope that we do not get a two-tier system in the National Health Service: one for the rich and one for the poor.
I should like to end by congratulating the Spastics Society in this International Year
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of the Child for the excellent research they have done into ante-natal facilities in this country. It has been found that far more babies of Social Class V, in medical terms, die or are born handicapped. This is partly due to lack of attendance at ante-natal clinics. It has been found from research that pregnant women are not paid during the time they take off to go to ante-natal clinics from working in industry or large plants. Clerical staff would not lose their wages. It seems strange that single women, and those not having paid stamps, do not receive the maternity grant. These, most likely, are the girls and babies in greatest need. As there is a Bill coming into Parliament about this, I hope that the Government will look at this matter in depth. It seems an area that could be much improved.
It has also been found that if small babies weighing less than 1,500 grammes when born are transferred quickly to intensive care baby units, at such places as the University College Hospital in London and St. Mary's Hospital in Manchester, their mortality is reduced by 50 per cent. Understaffed baby care units with nurses who do not know how to use ventilators can become dangerous places, especially at weekends, and permanent handicap, which is a terrible cost to the nation, becomes a risk of such places. Regional referral units for intensive care with an expert staff will reduce calamities and be an effective use of existing resources in the long run.
6.8 p.m.
Baroness FISHER of REDNAL: My Lords, may I also join with other noble Members in congratulating the noble Earl, Lord Erne, on his maiden speech this afternoon. He outlined to us that the problems are not just of the capital city of England but are also of the rural areas, in what one would call the far flung parts of Britain. I want to pay special congratulations to the noble Baroness, Lady Ryder of Warsaw, to whom one listened with great interest, while admiring all the work that she has done for so many years for those less fortunate. The work that she enumerated this afternoon is particularly touching to me because it was this time last year that I lost my husband through that, perhaps one should say, dreadful disease. I hope we shall hear them both speak often in the future.

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This afternoon we have heard many speakers talking about the top-heavy administration. We have heard from the Government side that there are going to be fresh proposals brought at the end of the year. I hope that the fresh proposals are going to be much better than the Sir Keith Joseph proposals in 1974, when we became a top-heavy, administrative National Health Service. But I wonder. When one gets to administrative level in any organisation, they are the most difficult people to move. You can get rid of the cleaners of your corridors; you can get rid of the women who do the washing up; but the people who earn the money at the higher levels in administrative jobs are the most difficult to get at. I shall be listening with great interest and reading the Government proposals, but I repeat that 1974 was a black day for the National Health Service under the Conservatives and we hope for better at the end of this year.
This afternoon noble Lords have been talking about hospital closures. I do not have a great deal of knowledge about the situation of London hospitals and therefore will not speak about them, but I do know about those in another great city, Birmingham, and the feeling that the people of Birmingham have for their local hospitals is exactly the same as the feeling people have for their hospitals in Manchester, Liverpool, Sheffield and elsewhere. I cannot emphasise too much that people have strong feelings for their local hospitals as a result of trust and confidence having been built up in the services which are provided by those hospitals, service given by staff at all levels. These local feelings are of the greatest importance because they show consumer satisfaction, or dissatisfaction as the case may be, and are expressed clearly.
About 18 months ago the Birmingham Accident Hospital, which has a national reputation, particularly for its injury unit concerned especially with industrial injuries—and the West Midlands, being a great industrial area, has many industrial injuries—and an excellent burns unit and a special unit dealing with road traffic accidents was under threat. This hospital is in a very old building that was provided by the City Fathers of Birmingham many years ago. It is worth reminding our-
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selves when we talk about cuts in expenditure that, if our Victorian forefathers had talked about such cuts, we would not today have hospitals for use in our National Health Service because the majority of them are in such buildings, and the Birmingham Accident Hospital is no exception.
The powers-that-be decided that the building was not good enough because they could not purchase the equipment necessary to benefit the hospital and the patients. But there were strong feelings in the area over the issue and the Birmingham Evening Mail ran a campaign, as a result of which many thousands of pound were contributed to the hospital by trade union branches, women's organisations, Rotary, patients, patients' relatives and many others, the money supplying exactly the equipment that could not be provided from public funds. The result was that they got exactly the equipment the medical staff were asking for in that hospital. We are keeping our fingers crossed that the Birmingham Accident Hospital does not close.
How many people consider what happens when a local hospital closes? It is not like closing a local pub so that people cannot pick up their beer on the way home and drink it in the house. We are talking about hospital beds that normally contain patients; hospitals have casualty and out-patient departments. What happens to the people who attend those? They do not just disappear into thin air. Instead, they go further down the list and join the long queues already in existence at established hospitals. I sometimes feel that the people who decide on hospital closures imagine that once the doors are closed the patients just go away, like closing a cinema and the people saying, "We will not go to the pictures any more".
When the question of staff is discussed we should particularly bear in mind staff morale in the National Health Service. When morale is low industrial unrest can be caused. The point I wish to stress is that hospital closures are usually decisions arising from economic considerations; no medical considerations are taken into account. What is particularly worrying for those who work in the NHS, whether at the lower levels of the ancillary staff or whether at the higher levels of

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consultancy, is that those who are advising the Government on cuts in expenditure and economies are in the higher echelons of the Civil Service, and when they bring forward closure recommendations they are themselves completely shielded from the effects of their decision. They are the people who enjoy large pensions on retirement, inflation-proofed because of their own action, and they have the prospect of retiring five years earlier than the average manual worker, after complete job security.
Is it any wonder that the morale of those who work in our hospitals is undermined when the Government are assisted by such people who have no idea what their decisions and recommendations mean? As I have said, their decisions are economic ones. They look at graphs and statistics and make the figures do what they want. But the figures are people; they are the thousands of women who are waiting throughout the country for gynaecological and obstetric treatment. The figures and graphs must be interpreted into the children who are waiting for orthopaedic treatment. A Sheffield doctor, speaking out a few weeks ago, said that if treatment is not given early, children will be condemned for the rest of their lives. Those are the statistics which have to be related in human terms—men who are waiting for treatment, losing time off work and perhaps reducing production figures because of long queues for routine surgery. Certainly we must not waste money in the National Health Service and we must keep a watch on that, but when we are thinking of closing hospitals let us not get bogged down in economics. And before any local hospital is closed, the decision must be taken on a sound medical view of the situation and perhaps some of the economic arguments should be disregarded.
On the question of expenditure that is permitted, we see new hospital buildings and extended wards which cannot be used because we do not have enough money left in the kitty to man and run them. A man is now working for the Government and is going through all the Civil Service departments; I believe his name is Mr. Rayner who comes from a large firm called Marks and Spencer. I am not sure his organisation would not be building and opening
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shops in High Streets only to say, "They will not be open for 12 or 18 months because we do not have enough money for the tills and women to serve the customers" That is what it comes to. What the general public are saying is, "What a cockeyed way to run a hospital service!", when they see new buildings standing there but not enough money to pay the staff to run them and treat the patients.
I appreciate that the National Health Service will not suffer quite as severely as local authorities from the economy cuts. But it must be emphasised that the National Health Service is dependent upon the personal social services that a local authority provides, and so any serious cut-backs in home helps, night-watching services, or meals-on-wheels will automatically result in a greater pressure on geriatric provision in hospitals, because directors of social services will not carry the can for any difficulties that might arise among the elderly people they serve.
We have heard figures this afternoon about National Health Service expenditure. People obtain figures from all kinds of places, and perhaps mine have come from a different place than those already quoted. However. National Health Service expenditure as a proportion of overall Government spending has declined rapidly since 1964. In 1964 15·1 per cent. of overall Government spending was on the National Health Service. In 1973 the percentage fell to 13·75, and in 1974 it dropped to 11·58 per cent. Perhaps I may leave it to the Minister who is to reply to bring the House up-to-date on overall Government spending figures for 1975, 1976 and 1977.
I want to refer to a particular group of persons catered for in the National Health Service who cannot speak up for themselves; others have to speak for them. I speak on behalf of those thousands of people who are mentally handicapped. Time and time again not only this Government but the Government whom I supported have paid lip service to the needs of the mentally handicapped. I suppose that a reason for this is that these people cannot speak up for themselves. They cannot make their own protests, and very often their relatives do not want to make too much fuss because, unfortunately, they feel that there is a stigma attached to mental handicap. There is a propaganda

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campaign—and I say that it is a propaganda campaign—for community care for the mentally handicapped. I believe that it is a completely dishonest campaign, and it is a trick. It is aimed at getting the public, especially those engaged in the mental health field, to accept a running down of the National Health Service in the vague belief that other services exist for the mentally handicapped. Up and down the country, local authorities have not been able to provide after-care facilities or ongoing services for the mentally handicapped. I believe that the trick of community care that is being played on the mentally handicapped ought to be exposed.
I accept that under the National Health Service, there has been a marked improvement in the health care of thousands and thousands of people. Thousands and thousands of people have been very greatful for a return to good health. However, we must accept—and this point was touched upon by my noble friend Lord Pitt of Hampstead in relation to the London area—that those areas in the country with the most serious health problems have the poorest facilities and the fewest doctors; and in that way there are two divisions in the country. Many of the old industrial cities have very poor facilities. As my noble friend Lord Pitt said, they do not have the benefits of the large teaching hospitals which could help them out. They have old, Victorian buildings, converted from work-houses. Statistics show clearly that those areas represent the black spots on the map in our National Health Service. Is it merely wishful thinking to suggest that perhaps some of the eminent consultants who practice in the London teaching hospitals might give their services—I do not say voluntarily—to those regions of the country so starved of facilities, even if for only two days a month?
I do not want to delay the House too long, but I want to refer to fears that I believe are being expressed regarding the state of general practice in inner city areas. I speak as one from a large city that has its fair share of inner city problems. These fears are real. Doctors are no different than other people, in that if they can get an easier job in easier surroundings, they will go for that job. But it is important that the inner city areas are protected and that those doctors
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who are willing to work in such areas should be encouraged. Therefore I wish to ask the Government what future capital provision they are contemplating for these areas and for the GPs who are volunteering to work in them. I have in mind the kind of provision that is so necessary for health centres, so that there are available all the ancillary staff—the marriage guidance counsellors, the psychiatrists, the nurses and all the other people—who make up a complete team for the GP. If we are able to do this, there will be a considerable saving in drugs, through getting rid of stress. As the noble Lord, Lord Winstanley, said, it is easier to give pills than to give treatment.
My final words will be about children, a matter which has been touched upon by previous speakers. We must recognise that one of the best investments of a nation is to give its children a good start. As we heard this afternoon, Britain is not at the top of the league table in regard to infant mortality. Fifteen out of every thousand babies in this country die within a few days of birth. There are many babies with abnormalities and malformations, and one wonders why this should be. Will the Minister give an assurance to the House that he will undertake serious investigations and research regarding the infant mortality figures that were published last week. These figures cause great concern to those of us who live in the West Midlands—I am not saying in Birmingham—where there was quite a high incidence of infant mortality. There must be reasons for this. If one re-reads the court report one realises that today in this country children still die from 19th century causes.
I am not going to go into the question of increased prescription charges, which has already been discussed. However, I believe that while asking the patient to pay more for a prescription the Government should seriously consider asking the drug companies who have a complete monopoly in supplying the National Health Service whether they will take a cut and perhaps less profit.
I have been in active politics for a long time. I do not speak as an expert on medical matters, except to say that if one receives the services—and I have received them over the last 12 months on behalf of my husband—one sees that excellent

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service can be given, and one worries when one hears criticisms being levelled. I could have levelled many criticisms during my long time visiting hospitals, but it was said this afternoon, I think, that there are over 1 million people working in the National Health Service. There are also over 1 million people using the National Health Service every day, and their grumbles and their dissatisfaction permeates down to the people that work inside it. Here I would say that the morale of ambulancemen is lessened as people complain that they are having to wait two hours or three hours for an ambulance to return them home; and that the morale of the cook in the hospital declines as the catering officer says, "We have got to cut back; we have not got as much money to spend", so that he or she has to serve less appetising meals. And so their morale, already low, continues to sink.
I do not want to keep the House any longer because I know that there are many speakers who have interesting things to say. My final words would therefore be that I do not think the National Health Service has failed. What has happened is that it has lacked a real chance. I think that noble Lords sitting on this side of the House should perhaps accept some criticism, in that they looked upon the National Health Service too sympathetically and too paternalistically, instead of accepting that it was Nye Bevan who brought forward our National Health Service, and our memory to him should have been much more forceful in making it a better service than it is. When we established the National Health Service we had to accept that it was a compromise between the vested interests of the medical profession. I think that was recognised by this side of the House at that time; but what we have today—and this is recognised by many doctors who speak out against the inability of the National Health Service to provide all that their training qualifies them to do—is that interest being usurped by economists and balance sheet budgeteers.
I am sorry I have spoken so long, although I could perhaps have said a lot more. I do not speak very often in this House, but I have spoken this afternoon because I have been 16 years as a councillor in what might be called a down-town area
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in the City of Birmingham and the time I spent in the other House was again as a representative of a down-town constituency; so I know what poor housing and bad standards all round mean in health care. All I would say this afternoon is that I look forward to the Government bringing forward a much more imaginative proposal for the future of the National Health Service.
6.34 p.m.
Lord ROCHESTER: My Lords, from these Benches I should like to join in congratulating the noble Earl, Lord Erne, and the noble Baroness, Lady Ryder of Warsaw, on their maiden speeches. If I may say so, I particularly admired the evident compassion—I suppose it was predictable—with which the noble Baroness spoke. I want to speak on that part of the Motion which deals with the need to improve industrial relations in the Health Service, and I approach the subject with considerable diffidence because I have absolutely no experience of these matters in the service itself.
First, on the question of structure, I certainly subscribe to the objective of shortening the distance between senior management and staff as an aid to achieving a number of desirable ends—strengthening management in the front line; improving communications, both upwards and downwards; and helping to ensure that when disputes arise they are settled at the lowest possible level. As regards support for our front-line management, in my view specialising in the industrial relations field can nowadays lead to training on and off the job to develop considerable expertise in this field, and this is necessary if the management team of which they form a part is to have a chance to maintain sound industrial relations. I would add that from what I have read and heard it appears to me that the level at which the personnel function in the Health Service is most in need of strengthening is that of the district. But noble Lords who are closely involved in the service will of course be better judges than I am on that point.
In the matter of communications, it is essential, in my experience, not only that management at every level in an organisation should know from those above and below them what is going on, but more

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particularly that at the very lowest level there are meetings of staff which are held on a regular basis, so that there is a recognised forum for discussing matters of general concern before they develop into industrial disputes. When disputes do arise, it is essential, as I have said, that they should be settled at the lowest possible level, and this cannot be done without an adequate negotiating procedure for dealing with both individual and collective complaints. The Advisory, Conciliation and Arbitration Service had a good deal to say on this point in their evidence to the Royal Commission, and I noticed that in their own conclusions the Commission welcomed the proposals on the matter which had been put to the General Whitley Council, and hoped they would soon be introduced. In this, I would strongly support the Commission, but add that every bit as important as the establishment of such procedures is training aimed at ensuring that they are observed. I know something of this at first hand, and particularly of the difficulties which can sometimes arise in trying to arrange for the training of management, supervisors and shop stewards in a large organisation being done jointly; but from the same experience I also know that success in such training will be achieved only if there is a joint commitment to it by both management and trade unions.
I should like to turn now to this vexed question of how national disputes about pay in the Health Service are in future to be resolved. The Royal Commission understandably felt that it would take some time to devise a workable procedure; but I was frankly surprised to learn of their recommendation that the initiative in this matter should come from the TUC alone. It has long been my view that the pay of people employed in certain key occupations which are vital to the support of life should be determined by a single, independent body representing employers and employees, and comprising also an element independent of both employers and trade unions but acceptable to their representatives. I think, further, that the maintenance and independence of this body should be guaranteed by commitments entered into, not only by the Government of the day but also by the main Opposition parties, which commitments would include an undertaking that
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in all circumstances, and irrespective of incomes policies, the findings of the body would be implemented.
I do not think it is practicable that the people whose pay would thus be determined should be required to forego their ultimate right to strike in return for this special treatment, since in the case of the Armed Forces and the police they have no such right to forego and the representatives of others seem to me to be highly unlikely to surrender their pay negotiating rights. Indeed, it was partly for this reason that I could not see how the general body of Health Service employees could be included in any such arrangements at their inception. However, this whole process has been speeded up by the events of last winter and, as we all know, the pay of ambulancemen and of health staff ancillaries has now been adjudicated on by the Clegg Comparability Commission. That being so—and I was interested in what the noble Baroness, Lady Young, had to say on this this afternoon—it seems to me best that we should now try to build on the work that the Clegg Commission has begun, thus preserving that continuity of policy which with the rejection first of the Prices and Incomes Board and later of the Relativities Board has in recent years been so conspicuously lacking.
The Clegg Commission's terms of reference included responsibility to
"… assess the appropriate form of comparisons with terms and conditions in other sections of the economy and identify relevant comparitors".
A less well publicised aspect of the same terms of reference was in the particular service under review
"to report on the possibility of maintaining appropriate internal relativities".
It is perhaps understandable that in the time available the Clegg Commission seem to have paid more attention to external comparisons than to internal relativities. However, in my view this is a matter for regret, for it would no doubt be generally acknowledged that a certain instability has been caused in Health Service industrial relations by the inadequacy of current Whitley Council pay negotiating machinery and the discrepancies that this creates in terms of internal relativities. More particularly, reference to the Clegg Commission of the claim of

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Health Service ancillary staffs before that of nursing staffs seems to have led to an award for ancillary staffs based on external comparisons which carried with it the risk that the service could suffer all the consequences of an inflationary settlement without benefiting from the stability to be obtained from acceptable internal relativities.
However, better late than never. With some trepidation, I should now like to suggest that consideration should be given to establishing a job evaluation scheme having the widest possible application among Health Service employees and based on factor analysis of the same kind that was or has been used in the points scoring system for jobs at corporal level in the armed forces of which the Clegg Commission made some use in its first findings. In evaluating jobs, account could thus be taken of requirements such as previous training, experience, responsibility, physical or mental skill, the working environment and other factors which are relevant to the Health Service.
It is always risky to seek to transpose experience in one working environment to another, particularly when that experience is out of date. I well recall that when about 15 years ago we were seeking in the company for which I then worked to introduce, with the agreement of the unions concerned, what could be loosely called a productivity bargain, we could not have done this without an established job evaluation scheme which was applicable to all our general workers. We were endeavouring at the same time to bring the employment conditions of weekly wage earners more closely into line with those of monthly salaried staff, to inculcate the changes in attitude which those improved employment conditions necessitated, and to involve the employees concerned in deciding how productivity was to be improved. What happened very briefly was that those working in each plant were invited to determine, together with management, what work was to be done by whom, and then they were rewarded under the job evaluation scheme that we had on the basis of the degree of responsibility and other requirements for each reconstituted job in accordance with rates of pay for the various categories that had been agreed with the unions concerned.
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I can only say that it has always seemed to me that that was the best example of employee participation in real life that I have known. I recall moreover that senior line managers closely involved in the exercise at the time told me that it worked primarily because of the great efforts that were made to give management and supervisors generally training in what for want of a better word might be called leadership. That is another story, but it is relevant I suggest to this debate because in my experience it is the quality of leadership, management, getting things done through people, whatever you care to call it, which more than any other factor contributes to the success or the failure of an organisation.
I know that the situation in the public services today is very different from that in industry at the time of which I have been speaking, not least in relation to the reduced amount of money and the number of jobs that are now available. But I should like to ask the noble Lord who is to reply to the debate whether he thinks that there is any prospect of some such imaginative approach as I have sought to suggest being made to this problem of pay relativities within the Health Service, bringing in, as I have tried to indicate, even more desirable objectives into view including, as we are reminded by the Motion before us, the more efficient use of resources, particularly of people. It might be that those of your Lordships who have much closer knowledge than I possess of the operation of the Health Service will be able to think of all sorts of reasons why such a task cannot now be carried out: the size of the organisation, the possible cost of the exercise, and so on. Clearly it is for people other than me to determine how far the task is practicable and, to the extent that it is, the agencies that should be involved in undertaking it: the Clegg Commission, Whitley Councils, the General Whitley Council I suppose it would be, or some other body. I am consoled, however, by the reflection that, in my experience it has often been found useful for someone from outside to make a suggestion that is immediately seen by the insider to have obvious flaws in its first presentation but which nevertheless sparks off some variation of the same idea that eventually proves helpful. I hope it may prove to be so in this case.
6.39 p.m.
Lord RICHARDSON: My Lords, I should like to add my congratulations and pleasure at having heard the maiden speeches of the noble Earl, Lord Erne, and the noble Baroness, Lady Ryder of Warsaw. Both said things that must have had great interest to your Lordships and, in particular, to a doctor. Towards the end of his speech, the noble Lord, Lord Rochester, referred to what seems to me the very pertinent wording of Lord Winstanley's Motion:
"… the necessity for the more efficient use of existing resources".
The noble Lord, Lord Rochester, added to that: "This means, of people".
We have heard the word morale "frequently throughout the afternoon. Morale is very difficult to define but it was studied in depth by a professor of psychology at Cambridge Unversity as a result of his experience in the First World War. He incorporated it in a classical book called Psychology and the Soldier. His name was Sir Frederick Bartlett. He looked at morale on different levels. We use the word now so often in relation to the frustrations of our hopes—often unfortunately financial, and sometimes in terms of the resources that are available to us to do our jobs. That is one level.
Sir Frederick looked at it at the level of discipline and imposed morale. Discipline is not a feature of our national life at the present time; but he regarded true morale as something that is within the individual and that can withstand external forces which are inimical to him, and yet maintain a line of conduct that is directed to the service of those in a wide field and beyond his own interest. We are told—and I fear it is true—that morale is low in the Health Service, to which I am personally devoted. It is low at various levels, but if we are to make the most of our man and woman power—people—we have to try to do something to help the formation of a true morale coming from within.
In the war, service hospitals, when on active service in the field, had exactly the same quota of equipment and staff, one with another, the only difference being in actual size, and yet all those hospitals, were different. They all had their own particular sense of pride in their difference:
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they all wished to show their visitors the special things that they did particularly well, and their morale was extremely high. Of course, they had the great advantage that the war must be won and liberty must be established; but they had disadvantages in that they were mobile and constantly moving, roots could not be put down and there was no surrounding community to support them.
In our civilian life we have still the advantage of a common purpose, and that common purpose is not just the service of a patient or of the public in an abstract way: it is the service of ourselves and our own. We are the patients and we are the public. In civilian life we do not suffer from the disability of mobility. Our local area is our local area and we do not suffer from the unavailability of local support.
What I am coming to is this: that in any reorganisation and in any thinking, I do beg that the local interest is mobilised to the utmost. Other noble Lords have made this point this afternoon but I wish to make it most strongly, and I can claim to have worked in hospitals of various kinds ever since the inception of the National Health Service. Locally you can develop pride, locally you can develop service. People like working on medical matters. There is no difficulty in getting volunteers. Those in local service find it the mot interesting of all subjects, so they tell me. There is no trouble about getting people involved and interested if the opportunity is given to them and if they see that the fruits of their work are going into the areas of their interest, namely locally; and if financial saving is made it benefits the local situation.
The noble Baroness, Lady Young, referred to volunteers and to her enthusiasm for them. Indeed, I hope the point is really well taken by the Government. The noble Baroness, Lady Ryder, talked about voluntary organisations—yes, again, indeed. They must be encouraged and they must be made to work.
There is another thing that will promote a change in attitude, and that is of course very much the most important psychological aspect of the disturbances in the Health Service. It is the withdrawal of constant criticism. The noble Baroness, Lady Fisher, touched on this very clearly. She talked in relation to the cooks who are disappointed in that they cannot get the

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equipment they need. That applies at all levels, and there has been for years the insidious development of a feeling that it is a good thing to develop a demand for complaint instead of a demand for advice and help, instead of promoting some gratitude. Gratitude, of course, promotes effort and energy whereas carping criticism promotes anger and inertia. So I hope that the movement towards always trying to develop ever more complicated methods of complaint is looked at again so that the object of getting the very best for the patient can be seen not necessarily to be achieved by antagonising those who for the most part, at all levels of the hospital, are trying desperately hard to make the best of the resources that, we have heard over and over again this afternoon, are limited and are going to be limited.
When I was working at that great hospital across the water and I went to talk to a patient newly arrived and said, "How are you? How are you settling in?" over and over again I was told exactly the same thing. It was not just the welcome on the ward by the kind nurses and the gracious sister: it was the porters, my Lords—the porters in the porters' lodge who got the people out of the ambulances or the hospital cars and wheeled them or walked with them down the hospital corridors and carried their bags. It was they who made the patient welcome, and the result on the patient was quite dramatic: they were peaceful and prepared to face whatever had to be. That was only a minimum of time ago. There are many who will do exactly the same thing now. It has to be fostered and encouraged; the attitudes have to be changed.
7 p.m.
Lord AUCKLAND: My Lords, the two maiden speeches to which we have listened today have been of unique distinction. My noble friend, Lord Erne talked of hospitals and medical services in a very troubled part of the country, where nurses and doctors have to cope not only with what one might call conventional patients, but also with those who are victims of bombs and other very nasty and horrible forms of attack, and, alas! such incidents still take place in that part of the country. The noble Baroness, Lady Ryder, made what I thought was the
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most outstanding speech that I have heard in the 20 years or so in which I have been in this House. It was a speech of quite unique distinction, from somebody to whom many thousands of disabled and handicapped people owe so much, because, if it were not for the noble Baroness and her very worthy helpers, many who are already cruelly disabled would be very much more so today. The House will hope to hear from the noble Baroness very frequently in the future.
I shudder to think how many times I have spoken on the National Health Service in various guises, since I entered your Lordships' House. Indeed, the last time I spoke on it was in a debate which I myself initiated on 6th July, 1977, and I certainly do not propose to go over those points again. But the House is indebted to the noble Lord, Lord Winstanley, for enabling this very effectively worded Motion to be debated today and, as we might have expected, he presented his case clearly and very fairly and made a number of points which we all hope the Government will take on board.
In regard to what was said by the noble Lord, Lord Wells-Pestell, for whom I have had genuine respect and devotion over the years, because he himself has done so much for the National Health Service, I must say that I listened to the earlier part of his speech, at any rate, with a certain amount of depression. I say that because, in some ways, it was a re-run of his response to my own speech on 6th July, 1977, when the noble Lord was himself the holder of distinguished office in the then Government.
I just want to say this about private practice. I am one of those noble Lords in this House who do not use private practice. For financial and other reasons, my family and I use the National Health Service and, generally speaking, we have had excellent service from it. But if I may make very brief mention of the Wellington Hospital, I happened to visit that hospital fairly recently and talked to the medical superintendent, the hospital secretary and others. It is a fact that, in practice, the nurses there get rather less remuneration than nurses in the National Health Service, although it is perfectly true to say that the accommodation and possible other bonuses are more favourable.

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But I have never been very convinced by the argument that, because we have private practice in this country, it is siphoning off large numbers of nurses from the National Health Service. I served on the house committees of two hospitals, one a children's hospital and the other a mental hospital, before the reorganisation of the National Health Service, and I really wonder whether there is a single country in the world—and I include the Comecon countries, of which I have visited two—where there is not some form of private practice in operation.
Despite what the noble Lord, Lord Wells-Pestell, may say about my noble friends and myself, and about our attitudes to the National Health Service, I have always supported the concept of a National Health Service. I have read several times the reports of the debates in 1948, when the late Mr. Aneurin Bevan moved the Second Reading and other stages of the Bill, which followed very closely on the plans of the late Lord Beveridge. Even at that time—I have said this before in your Lordships' House—there was no open hostility in the Conservative Party to the Health Service as such, even though some of the proposals which were put forward at that time were regarded with a certain amount of scepticism, which has in some respects, at any rate, proved to be justified.
But the word which must really pervade any Health Service debate is "dedication", and I believe that nurses, doctors and others who work in the Health Service today are as dedicated as they have ever been, despite the fact that, as has been said, particularly by the noble Lord, Lord Richardson, in a very distinguished speech, morale is certainly not as high as it might be. The reasons for this are in some cases beyond the wit of any political party. Overall, the amount of money which is being spent on the Health Service today is higher than at any other time. Whether it is spent more or less wisely than at any other time is a matter for conjecture.
I speak with some feeling about the pay and conditions of nurses, because, like many noble Lords, I have a daughter who is a second-year student nurse at one of the big London teaching hospitals, where she generally enjoys her job and gets on well with her patients; and if she had
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not been dedicated to the nursing profession she would not have gone into that job. The rent which they have to pay for accommodation in nurses' homes, which are very often old, and undecorated, is, more often than not, the reason for morale not being as high as it might be.
We have to realise that, particularly in our teaching hospitals, we have nurses not only from Essex but also from Penzance and Wick—and similarly with doctors. Also, of course, we have nurses from many countries overseas—from both the old and the new Commonwealth and also from other parts of the world. To them, the nurses' home, for probably 50 weeks of the year, is their home. As I have said, some of the conditions in those homes are certainly not all that they might be.
I have given my noble friend notice of a number of other questions, but I should like to ask him whether, as soon as financial conditions allow, the Government will give priority to making sure that not only in the London teaching hospitals but also in the hospitals of big cities like Birmingham—a friend of ours is a doctor at the accident hospital there—there is a campaign to upgrade nurses' homes. I think that this would do a great deal to improve morale within the Health Service.
The other problem surrounding the Health Service is the plethora of blue papers, green papers and others that we have had upon the service. All of these committees have been headed by such distinguished people as the noble Lord, Lord Porritt, the late Lord Platt and the noble Lord, Lord Briggs, a copy of whose report, which dates back to 1972, I happen to have here.
I should also like to ask my noble friend when the Government intend to act on some of the more important proposals which Briggs put forward regarding the committee on nursing services. Successive Governments seem to have fought shy of this. May I draw your Lordships' attention to paragraph 1 of Chapter 1 which deals with the background to the work of the committee. I quote its purpose:
"To review the role of the nurse and the midwife in the hospital and the community and the education and training required for that role so that the best use is made of available manpower to meet present needs and the needs of an integrated health service".

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Much has happened in the Health Service since then, but the same urgent problems remain to be solved.
There has been, alas! the reorganisation of the Health Service under the party which I support. I make no apologies for having opposed that particular scheme root and branch ever since I spoke on the Second Reading of the Bill. I hope, with others who have spoken, that any reorganisation, any removal of a tier, ensures some local representation. I am thinking in particular of the local hospital management and house committees. Although I am no expert on the question of industrial unrest, I venture to suggest that at least some of the industrial unrest which we have had in our hospitals is due to the lack of communication in a very large organisation. When there were hospital management committees, a relatively small complaint could often be looked at very quickly, even if not rectified. I know from the experience of one of our local mental hospitals that very often one now has to wait some time before the local area health authority or community health council visits that particular hospital.
These are the kind of matters which I think the noble Lord has put at the forefront of the debate. As a result of it, I hope that we shall get at least reassurance from the Government on two matters: first, that when the new reorganisation—if that is the right word—takes place, communication will be the foremost point to be looked at ; secondly, that the nurses' pay review will be looked at as quickly as possible. At the moment, not only in this country but in others, nurses are having to do all kinds of jobs. In casualty departments, very often they have to cope with drunken and violent patients. For this kind of work they get no extra pay. It is a miracle how many survive the course.
I have said this before in your Lordships' House but I conclude with these words: the National Health Service of this country is an example to the rest of the world of how medical treatment is given, devotedly and conscientiously. It is unfortunate, when there is industrial unrest from time to time and when a patient dies on the operating table, that the communication media publicise it to the hilt. It is right that these things should be publicised.
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Equally, it is essential, when this country is going through a difficult period and will do so for some time to come, that our National Health Service's creditable points should be revealed—because they far outweigh the others—so that those who use the Health Service, and above all those who work in it, are assured of at least the goodwill of Parliament for their welfare.
7.18 p.m.
Baroness DARCY DE KNAYTH: My Lords, I am most grateful to the noble Lord, Lord Winstanley, for initiating this debate and for giving us the opportunity to hear two maiden speakers, whom I should like to congratulate most warmly on extremely interesting speeches. I should also like to express my admiration for the work done by the noble Baroness, Lady Ryder of Warsaw. I have no intention of likening the noble Lord, Lord Winstanley, to the Mafia, but having been involved in the sit-in last week at Stoke Mandeville when ex-patients occupied two wards at that hospital, I really did feel that in presenting us this week with an opportunity to take part in this debate he was making an offer that I could not refuse.
My noble friend beside me on the "mobile bench" has already spoken of the problems of the National Spinal Injuries Centre at Stoke Mandeville. She spoke of their serious consequences in the debate on the family last month, so I shall try not to bore your Lordships by going over ground which has already been covered. However, the present problems of the NSIC are so important and so urgent that I really do feel that they bear underlining.
First let me tell your Lordships very briefly about the sit-in, because perhaps not many of your Lordships have ever been involved in a demonstration of this sort. The sit-in started on 7th November, the day that the Bucks Area Health Authority were to meet to decide upon the proposed closure of one whole female ward—what was the only other female ward is now a mixed ward—and also on the closure of the children's annexe which has recently been renovated by voluntary contribution. Unlike most demonstrations, this had no political or union undertones whatsoever. It was organised entirely by paraplegics, among

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them ex-servicemen, retired civil servants, a solicitor, an ex-jockey, housewives. They were all ex-patients who were so worried by the proposed cutbacks that they felt some action was necessary. I think it would be true to say that none of these people had ever been involved in a demonstration of any kind before.
The sit-in was well organised, well behaved and caused no serious disruption to the running of the hospital, only minor inconveniences—and it had its effect. The area health authority deferred its decision until after the Minister of State for Health visits the NSIC on the 20th November. The Member of Parliament for the area came down to discuss the problems and the Minister himself had a friendly, and I hope constructive, consultation with a small deputation of us, and agreed to meet the ex-patients again when he visits the unit and talks with the consultants there on 20th November.
When I spoke of ex-patients, I should really say "old patients" or "on-going patients" because in the case of spinal cord injury there is no such thing as an ex-patient, unless he be a dead one. There is a need for continual regular checkups and in all probability the need for readmission at some stage to treat, for example, a pressure sore or urinary or kidney problems. The national spinal injuries centre, being the only spinal unit for the whole of the South of England, has to care for somewhere in the region of between 4,000 and 6,000 such old patients. The pressure is so great that the patients are not called in for check-ups; they have to ask for one. If there are no known problems check-ups are done only every two years instead of annually.
My noble friend has already told your Lordships of the much more satisfactory situation in the northern units. I know of patients who have had to go to their local hospitals for check-ups which consequently were incomplete because the waiting-list at the unit is so long. Those with pressure sores may have to wait vital weeks before being admitted and the needs of these patients are very clearly not being met.
For the newly injured spinal patient the situation is even more grave, and I cannot stress too often how essential it is to get
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the correct treatment and nursing from the very start to prevent complications—as my noble friend also has said—such as pressure sores or contractures. A pressure sore may seriously retard a patient's rehabilitation and continue to be a problem throughout his life. If contractures of the limbs are allowed to develop through insufficient physiotherapy a patient may never become as agile and fully rehabilitated as he might have been. Therefore, it is essential to be in a spinal unit from the earliest possible moment. Some consultants in general hospitals at present do not even bother to contact the NSIC to find out whether spinal patients may be admitted because they have heard of the problems of the unit and think that the waiting-list may be too great.
But, my Lords, general hospitals simply do not have the specialist knowledge required, apart from the fact that it is psychologically important for a spinally injured patient to be with other paraplegics from whom he can gain knowledge and support and hope for the future. My noble friend has already cited several cases of patients who have been in dire plight in general hospitals, and the same is still true today. A friend of my daughter recently broke her neck in a car crash and, after a few weeks in one of the best orthopaedic hospitals in this country, arrived at Stoke Mandeville with a pressure sore on—of all places—her head. Some of your Lordships may have seen the horrific sores on the patient featured in "Nationwide" last week. I can assure your Lordships that when that patient arrived in the unit they were far worse; they were large enough to get one's fist into them.
This is waste, not only in human terms but in financial terms. My noble friend has already mentioned cost-effectiveness. A patient can spend six months in a spinal unit, repairing such damage—an expensive exercise, as your Lordships will be aware. It is reckoned that a paraplegic, correctly treated, can be rehabilitated and discharged within four to five months. A tetraplegic—that is someone who has broken his neck and consequently has not got movement in his hands and possibly not in his arms, either—within seven months. Why double the cost by incorrect treatment at the start? This cannot be the most effective use of resources.

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When the National Spinal Injuries Centre was transferred from the Ministry of Pensions in the early 1950s it had a two-year special allocation and then came under the Oxford Regional Health Authority; and as your Lordships have already heard from my noble friend this region has severe problems of its own because it is so rapidly expanding in population. The present system of funding simply has not worked as money allocated to the NSIC is not easily identifiable. I will give your Lordships an example of this. In another place, in his adjournment debate on Stoke Mandeville Hospital, on 2nd February 1979, the honourable Member for Aylesbury spoke of the special spinal weighting factor that was going to be introduced to provide more money for Stoke Mandeville Hospital. This was following the visit the previous year of the then Minister of State for Health, Roland Moyle, to Stoke Mandeville Hospital. This special weighting was expected to produce an additional £400,000.
In February, in an adjournment debate, the honourable Member spoke of the anxiety of the Stoke Mandeville Hospital staff to know what had happened to that sum. Although the national allowance had been made the Oxford region was spending up to its so-called RAWP level—the resources allocation mentioned by the noble Lord, Lord Pitt of Hampstead—and the £400,000 appeared to be a mythical bookkeeping transaction. In his reply the Minister said that the special weighting would come into effect for the financial year 1979–80. We are now well into that financial year and the unit has still not seen a penny of that sum. Perhaps the noble Lord who is to reply for the Government can discover what has happened to this before the Minister of Health visits Stoke Mandeville on 20th November.
The unit has been starved of money over the past 10 years and is already seriously below par so that the cuts are really not comparable with other similar cutbacks. At present it is the only spinal unit in the South of England from the Severn to the Wash, covering a population of 23½ million people. Patients also come from outside this area and from overseas, and the Department of Health has recognised that over 100 spinal beds are needed now in the South of England. The
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proposed unit at Odstock, which will be 50 to 60 beds, will not be operational until mid-1983 at least, and the unit at Stanmore, which is a small one of 20 beds, somewhat earlier. I submit that we cannot therefore allow the NSIC to be further reduced at this moment. I very much hope that after the Minister's visit on 20th November he will produce some practical and workable solution and some way of ensuring that money allocated to the NSIC actually gets there.
We are talking about one of the foremost hospitals in the world for the treatment of spinal injuries. Can we afford to let its reputation die as its Nissen huts crumble and patients have to be refused admission? International prestige and human lives and suffering apart, can we, in purely financial terms, afford the cost of repairing damage to spinally injured patients—damage that need never have occurred had they been correctly treated in the first place and in the right place?
7.29 p.m.
Lord MURRAY of GRAVESEND: My Lords, I should like, first, to thank the noble Lord, Lord Winstanley, for having initiated the debate, but, having said that, I always feel that there is an air of sadness about these debates. One air of sadness is to hear the noble Baroness who has just spoken of the individual problems that spending cuts raise and the fact that I genuinely feel sure that nothing is going to be done as a result of this debate. I think that the Conservative Government are on a course of spending cuts, and whatever we say here, or whatever they say in that House across the way, nothing will be changed. We have to start and have a look at some of the things which my noble friend Lord Wells-Pestell said about their election Manifesto. In the election campaign the Labour Party said that there would be cuts in the spending on health and the Tories denied this, but in fact we have been proved right.
In any other field the Tories would have been prosecuted under the Trade Descriptions Act, because over a whole range of areas, whether educational or health, we are now going to see a series of cuts that will, in my view, take generations to remedy. They have got

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this thing about public spending, which is partly a myth, because the amount we spend, the Government expenditure of the gross domestic product, is lower in this country as a percentage than in any other country in the European Community.
One of the priorities that the Government ought to have been looking at when they came into office is at least maintaining the Health Service as it has been maintained over the last 30 years, because it is a fact that in many years there is more time lost through ill health and sickness and accidents in our places of work than through bad industrial relations, which again is an area which the Government seem hell-bent to do something about. I believe that this Government are moving us towards a mean-minded and hard-hearted society. We are moving into that area of Proposition 13 in California where we are witnessing what Galbraith said:
"private affluence and public squalor".
I think that all of us ought to be very concerned about what they are doing to the Health Service.
Baroness YOUNG: My Lords, if the noble Lord will give way for one moment, I think if he looks at the Official Report tomorrow he will see that I said that the volume of Government spending on the Health Service will increase by 3 per cent. over next year; this will more than make up for the slight cutback there has been this year, and in fact will mean a one half per cent. improvement. So that statement is not true and what we said at the election is true.
Lord MURRAY of GRAVESEND: My Lords, I am afraid the noble Baroness is wrong, because at least 1 per cent. is needed to take up the demographic question of people living longer. That has immediately overtaken your half per cent. growth. We ought to be looking to maintaining and improving the service. The cuts also do not take into account the question of wage increases. They do not take into consideration that the Health Service will be paying £40 million a year in increased VAT. So I think that myth has to be dealt with. Again the cuts always affect the least well-off in our society, whether they are the people receiving treatment or needing treatment or whether they are the people working in
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the hospitals, and we know that they are mostly the people in this society on lower incomes.
Mr. Jenkin in the other place said that administration will be the target and not patients. I think that is another bogeyman. If that is the case, Sir Keith Joseph ought to be making a public apology to the country for the reorganisation of the Health Service, when we are now told that we can save £30 million a year by cutting out one of the tiers which was created by the last Conservative Government. But if we look at the question of non-hospital administration costs in this country, again that is lower than most of our partners in the European Community. It is certainly lower than France, which runs at 10·8 per cent.; it is certainly lower than Germany, which runs at 5 per cent. Our non-hospital administration costs in this country run at something like 2·6 per cent. Again I think it is a matter of setting up a bogeyman and saying it is bureaucracy causing all our problems in the Health Service.
What this Government ought to be concentrating on is the fact that we have on our waiting lists in this country at the present time something like 620,000 people. We have a situation where wards are being closed all over the country and we have at the moment 8,000 nurses who are unemployed. It would be interesting to see the equation of what we may be paying those in unemployment benefits as against what they would be paid if they were able to do the job for which they were trained. It is a service that is already under pressure in this country. Half of our hospitals were built in the 19th century. If the Minister wants to say—and I dispute her figures—that they are running at just above the previous level, we ought to be injecting more money and making sure that the people who work in the hospitals and the people who have to use the hospitals as patients get the best possible hospitals.
We can only admire those people who work in the hospitals. As the noble Baroness has said there are over 1 million working in the National Health Service, and nobody can doubt the record they have in terms of industrial relations over the past 30 years since the inception of the National Health Service, and that is at all levels. They are obviously not con-

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cerned only with the wage levels but with the problems and the need to serve the community in this country.
Occasionally we have industrial disputes. We had in the last week or so the question of Charing Cross Hospital; that situation was highlighted and people were being harassed and pressed by the media to see how they were cutting off supplies to the hospital. But we must recognise, and the Government ought to recognise, that it is only a tiny minority of people who cause these sort of difficulties. Indeed, if we look at the record of last winter, when there were disputes in the National Health Service, I would have thought what the Clegg Commission did, as a result of those disputes, was to say that the workers in the National Health Service certainly had a case. The previous Government were trying to fix a ceiling of 5 per cent. and indeed Clegg gave them increases varying between 15 and 27 per cent.
In my own area in Kent we have the problem of cuts in the Gravesham and Dartford area of something like £500,000. We are facing the problem in Kent of something like £100,000 having to be saved on the ambulance service which does such fine work in our county. We are having ward closures and unit closures in the Medway towns. This is the area of Dickens and certainly the hospitals there were built when Dickens was living and working in the Medway towns. We have the problem of the closure of the orthopaedic ward at the Medway Hospital and psychiatric unit.
People are trying to have to raise money to keep two units open in Kent. In my view this begging-bowl mentality for maintaining the Health Service is the wrong way to go about it. I should say that in that area the Evening Post, the local Medway paper, has been running a campaign to raise money, and they have done remarkably well in raising money. But in my view that is not the way to run our Health Service and people should not have to be raising money once again after having paid their taxes and their health insurance stamps to maintain hospitals which should be their right. We are moving back into the area of Poor Law Guardians. The Government ought to to be looking at
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what we can do to improve the Health Service rather than saying we should be cutting services and having ward closures, not only in Kent but all over the country.
I think we ought to get some answers from the Government, and if we do not get them tonight I hope we are going to get them in the document they are producing later. There are the problems of teaching hospitals and their position within regional health authorities; whether the burden of that should be placed on regional health authorities, having to disburse those funds. There is the question of whether we should, as the Royal Commission suggested, abolish prescription charges. After all, they only contribute something like 1£6 per cent. of the funding of the National Health Service. I wonder whether, with the administration involved, it is worth while having prescription charges purely on economic grounds, apart from my political feeling about them.
Then there is the question—again a question raised by the Royal Commission—of pay beds. There is also the question of trade unions and industrial relations within the National Health Service. The noble Baroness spoke about volunteers in hospitals. I am not so certain about that aspect. I am not certain that, at a time when we want to go into the possibilities of achieving a better trade union relationship and industrial relations with the trade unions in the National Health Service, we should be talking about having volunteers in the National Health Service if there is a further breakdown in negotiations. I do not think that that is the way we should be embarking on the negotiations. There are—this is one of the problems of the National Health Service—something like 44 different bodies with negotiating rights at national and local level. I think that the TUC accepts that something needs to be done about that. The TUC has set up its own training courses to give instruction, help and advice to those people who are shop stewards in the National Health Service. There is the question of whether we ought not to abolish VAT for the National Health Service in the same way as we do for local authorities. It is paying a great deal of money and, as the Minister said in another place, there will be an increase of £40 million over and above what it already pays in VAT.

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There is also the question of whether we should be looking at cutting down drug costs. About 60 per cent. of the drugs used in this country are imported. We should be looking at whether there is a better way of dealing with this matter and whether more drugs could be manufactured at cheaper cost in this country. There is the question of the promotion of drugs in this country. Every doctor to whom one talks mentions yards and yards of paper. We talk about Government paper work, but let us consider the paper work that comes from drugs companies and others interested in selling commodities to doctors. I am thinking of the reams of paper that come through their letter boxes and the samples. Perhaps we should look at whether there is over-promotion of drugs. I hope that the Government—and I say similar words at the end of most of my speeches—will re-examine whether they should be moving along the path of cutting down the National Health Service. I hope that they will not go much further down that path. If they will not stop, then certainly when we return to power we shall do something about it.
7.43 p.m.
Lord SMITH: My Lords, I too believe that this House owes a great debt of gratitude to the noble Lord, Lord Winstanley, not only for the opportunity of this debate, but for the terms in which the Motion was moved at the beginning of the debate. He placed the emphasis where it should be and that is on the needs of patients. Before I leave that point I should like to say how much I enjoyed both of the maiden speeches. However, I was particularly moved by the splendid speech of the noble Baroness, Lady Ryder of Warsaw.
Emphasis should be placed on the needs of patients, but I think that right at the beginning we should take a good look at those needs and, before we accept unreservedly what might be an implied criticism of the National Health Service for not meeting those needs, we should be quite sure that they are needs which a National Health Service can in fact meet. Before trying to answer what is obviously a fundamental question, I ask your Lordships briefly to look at what has happened to medicine in the last few decades and in particular the last 10 to 15 years. Changes have occurred which
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would, in any case, have presented us with huge new problems—problems just as pressing in countries that have not made the attempt to bring into being a national health service.
To begin with, there has been, and still is, a huge and rapidly growing expansion in the demand for medical services of all kinds. Your Lordships will, of course, know that, but I hope that noble Lords will bear with me while I mention briefly some of the causes of this expansion as seen by those who provide the services. There have been totally unprecedented scientific and technological advances. One could mention a couple of dozen advances without having to stop to think. However, from the surgeon's point of view let me give as examples the whole new area of coronary artery surgery and the whole new area of replacing joints, of which new hip joints for old is just one example. They have all provided new hope for patients. However, as they do so they have provided new headaches for those who have to pay for those services.
The expansion is also due to the survival into old age of a much higher percentage of the population. It is also due to large increases in the screening and immunising programmes. It is due to a great demand at the small hospitals and at small community level for services previously confined to the large hospitals, universities, or specialised hospitals. I am thinking of services such as kidney machines, intensive care units, coronary care units, sophisticated new diagnostic machinery and highly sophisticated new modern surgery.
The expansion is due to a much broadened view of what is, in fact, a need. For the unjustified demand yesterday becomes a need today and will become a right tomorrow. Moreover, there is the "We have paid for it" syndrome—that is, the belief in the minds of many that National Health Service contributions carry an entitlement to everything which medical science has discovered, however exotic and however costly. The latter presents growing problems, because, human nature being what it is, any service that appears to be free at the moment of delivery will generate its own unreasonable demand. Moreover, as the public becomes better educated in health matters—there is a good side

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and there is also a bad side—the demand becomes not only quantitative but qualitative. The increased demand is not just for more services, but for services of a higher and therefore a most costly standard.
I believe that that last factor is largely uncontrollable if every element of personal responsibility in regard to the provision of health care is removed from potential patients and vested solely in the State. Doctors who are anxious to see the Health Service succeed—and that is most of them, certainly, I would say so—have from the start seen this as a danger point. For centuries our hospitals and individual doctors, too, have been actuated by the belief that, "Yes, I am my brother's keeper, provided he needs to be kept". It is a considerable step to add, "Whether he needs to be kept or not"; and not only that, but ,"Whether he wants to be kept or not".
Together with the huge expansion in demand there has been an equally huge and accelerating increase in the cost itself. That is so, not only in countries where there is a national health service—it is worldwide. In the United States of America the published costs of health care in 1950 amounted to 12 billion dollars. Twenty-five years later that 12 billion dollars had become 118 billion dollars. In the four years since then the figure has risen, and it appears that by the end of 1979 it will top the 200 billion dollar mark. Both as regards technology and management, the costs are increasing and they are increasing at an accelerating rate. Here, the cost of the National Health Service—which before the Health Service first started was put as low as £40 million a year—has crept up beyond the £9,000 million mark.
This produces terrifying problems for patients, doctors and for any Government. From the patients' point of view there is a constricting combination of heightened expectation, lack of availability and lack of the means to pay for what is available. As for doctors, their professional pride in advancing the frontiers of medical knowledge is accompanied by a disillusionment in the lack of means to apply his knowledge. From the point of view of any Government, with medical costs out of control there is a need to look at three linked questions.
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The first is: can any State afford the highest standards of medical care for everybody? If the answer to that is "No", what standards can be provided, and how can we set this standard? Thirdly, once we have set that standard, will it inevitably decline with time? I do not mean decline in absolute terms, but certainly decline in relative terms, as the gap widens between what medical science tells us can be done and what we know can be afforded.
One of the major difficulties, of course, in maintaining standards goes right back to the definition of the purpose of our own National Health Service contained in the White Paper of 1944. It says:
"The proposed service must be ' comprehensive ' in two senses—first, that it is available to all people and second, that it covers all necessary forms of health care".
That was in 1944. In 1966, in Canada, almost the same words were used. In introducing the Bill containing plans for a national health insurance programme, the Prime Minister listed certain basic requirements. The first two were that it must be universal—available to all; and that it must be comprehensive and cover all needs. That is history repeating itself, but alas! one of the unpalatable facts of life today is that every time history repeats itself the price goes up.
In 1974—a mere five years ago—I was President of the Royal College of Surgeons and I asked the Prime Minister of the day—because it was obviously useful for doctors to know this—whether the policy of his Government was still that the Health Service must be comprehensive in these terms: providing everything for all people. He answered: Yes, it was. It was shortly afterwards that I became less than popular with the then Secretary of State for Health and Social Security, with whom I had many interesting conversations at that time, for expressing the view that medical science was advancing at such a rate that already the expense of providing, through taxation, everything for all people was beyond the means of any Government and that we had entered an era of health care rationing.
Today to say such a thing raises not a ripple. We know that there is this gap and it is painfully obvious to us all that the rationing of health care in this country is a fact. Moreover—and this is not an

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illogical parallel—if a Government, through the worthiest of motives, said: "Let us feed the hungry", and then decided that it would be a better idea to feed everybody, in times of shortage the thinly spread subsistence might prove inadequate for any; and then not only might the original intent of feeding the hungry be lost, but deficiency diseases would be apparent everywhere. That is what is happening today to our National Health Service. To provide everything for all may have sounded right in 1944; it may have been right in 1948; but it is creating near-insuperable problems as we approach the 1980s.
What can be done? I believe that it is not a problem that can possibly be solved merely by increasing the percentage of the GNP which is applied to health care, though in some countries, as we know, this percentage is higher. But this would be a short-term expedient and I believe would make no attempt to identify and tackle basic problems. The report of the Royal Commission says:
"The impossibility of meeting all demands for health services was not anticipated. Medical, nursing and therapeutic techniques have been developed to levels of sophistication and expense which were not foreseen when the NHS was introduced".
In a different place in the same report it says:
"It is important to remember the almost unlimited capacity of health services to absorb resources".
That is right. The expanding field of modern medicine has a voracious appetite, and would swallow up any additional allocation and simply ask for more.
On the other hand, are we doing enough, or is the situation totally out of control? I am sure that there are things that can be done and many that certainly should be done. In the short-term we must, of course, use resources to their best effect and eliminate waste, including the waste of over-complicated and over-proliferated administration. I believe that no one should or would blame the ills of the National Health Service on our administrators who, in the main, are highly skilled and highly motivated professionals who serve our Health Service well.
But there is a difference between good administration and an obstructing bureaucracy. We must find some way of keeping
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the former and getting rid of the latter. I do not believe that it is enough to delete a redundant tier, which perhaps we never ought to have had in the first place. We must go back much further than that. I was greatly affected by what the noble Lord, Lord Richardson, said. We must try to simplify more than that. I should like to see us re-animate our hospital management committees. I should like to see given back to the profession the boards of governors of the university hospitals that served us so well. I should like these to work directly with regional hospital boards. Then we would have got back to the local control of affairs, to which reference has already been made this evening.
Also in the short and the long term, clearly, we should hope that we may improve industrial relations in our hospitals. This is not a matter which I shall talk about in detail, but in this context perhaps I might remind the Government that in this House on 25th January (at column 1582) I asked a question about the situation in our hospitals while a solution is being sought to a major problem. The question was:
"Is it really a task beyond the intelligence and ingenuity of our society to devise some way in which at least the safety of patients in hospital, incapacitated by illness or by injury, might be guaranteed?"
In asking that question, I received some considerable support from various noble Lords, but since then I do not think I can recall any question that seems to have stirred up so much apathy. I hope that my question has not been forgotten or that it is now considered to be of no importance. I do not think that patients who were in hospital last winter have so easily forgotten.
I turn now to the long term. It is not enough to identify this gap and merely to watch it widen. Surely the State and the health care professions in partnership can do better than that. I believe that one mistake that is in some danger of being perpetuated is in assuming that independent medical practice is inimical to the Health Service, a danger to it and must necessarily develop in isolation. If we continue along that road, all too easily we can arrive at a situation which is ethically disturbing to doctors and perhaps also politically precarious for any

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Government in power. For if those in relatively low income brackets perforce accept treatment in a contracting National Health Service and those in higher income brackets have access to an expanding independent medical sector, this tacitly accepts two standards in medicine, which must diverge as increasingly the State is compelled to provide not the best Health Service it can design but the best Health Service it can afford.
I believe the philosophy of isolating independent medical practice from the National Health Service might thus irreparably damage the Health Service itself, and also reintroduce class differences that at the present time are fast disappearing in relation to health care in Britain. The reverse of course would be to accept that there is a limit to what the State can do, that there is a gap, and that one might hope the closer links between State medicine and independent medicine might fill some part of that gap, or at lease mitigate its effects.
That is an overlong and perhaps grammatically clumsy sentence, so let us go the whole hog and end it with a "proposition": supposing there were already in being a small group whose sole concern was the liaison between State medicine and independent medicine, and that whenever a hospital, a department, a ward were in danger of being closed for lack of resources this group were merely asked, "What could you suggest, working together, might be done to keep this open?" Might this not help patients? Might it not maintain employment? Might not private hospitals, some of them of high standard, train nurses? Might not private hospitals on occasion provide registrar posts for those aiming at a specialist career? Is not the concept at least worthy of some detailed examination?
The concept of the National Health Service is a great one of which I think all in this country ought to be proud, and still, despite its many detractors, it could be the envy of the world, though many countries looking in on us from outside do so with anxieties and wonder whether it could become a casualty of our economic difficulties. We simply must not let that happen. Can it not be accepted that "the needs of patients", the entirely appropriate words used in
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the Motion, would best be served by a partnership between the State on the one hand and the whole of medicine, including the independent sector, on the other? What is needed is merely, I believe, for the Government to say, "Let us examine this proposition together". If such an approach were made—I speak today as a doctor and for many doctors who feel alike as I do—I know the answer would be that we believe this to be right, and would support it. If you would test our sincerity in this matter, just try us and see.
8.3 p.m.
Lord COLWYN: My Lords, while wishing to thank the noble Lord, Lord Winstanley, for initiating this interesting and wide-ranging debate this evening, I must apologise to him and indeed to the speakers from both Front Benches, and to the maiden speakers, for not being in my seat during their speeches. I should like to be able to say that I was unavoidably detained in my National Health Service practice seeing my National Health Service patients, but regrettably I am now getting far too old to deal with the vast numbers of patients many of my colleagues have to see under the National Health Service. However, I hope perhaps to say a few words about that tomorrow night in our debate on flouridation.
Clearly there is a limit to the funds which we can put into our public services; even the most worthy ones such as the National Health Service. The current financial constraints can be seen constructively as providing an incentive to the Health Service's managers to look for improvements in efficiency. I have no doubt that there is scope for this in many parts of the service, including services in my own dental field. But keeping to the general for the moment, one of the areas which is widely seen as in need of pruning is administration, and again I have to agree.
The 1974 reorganisation has proved cumbersome and unwieldy. Too many people spend too much time sitting on committees and taking part in other administrative rituals rather than getting on with their real work. I think it is common ground between us that the Health Service would do well to simplify its administrative structure. But how this simplification should be carried out is

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not an easy question. The structure which is appropriate would depend on the geography of the area being served, and it would depend on the nature of the service being managed.
The Royal Commission on the NHS emphasised the need for flexibility. In the Commission's words:
"The needs of Wester Ross and Tower Hamlets are obviously entirely different".
Equally, a structure which is appropriate for managing 200,000 ancillary staff, or 400,000 nurses and midwives, is unlikely to be ideal for organising the community dental services, which number only 2,000 dentists over the whole country.
In fact, and in spite of its other faults, the 1974 reorganisation recognised this. So far as dental services are concerned the organisational focus has been at area level. Districts have had little significance for dentistry, and neither in practice have regions. Effectively our structure is already simple: it is already single-tiered. It is therefore with some concern that my colleagues have heard the Health Minister, Dr. Gerard Vaughan, suggest recently without qualification that it is almost certainly area health authorities which will go in the forthcoming restructuring.
Now I am not suggesting that this may not broadly be the right thing to do, but I am suggesting that it is not the whole answer. If areas go, then in some parts of the country and for some services efficient management will require something else very like them. What I also suggest is that it is not good industrial relations for the Minister to give an incomplete statement of his intentions to a party conference in advance of publication of an important White Paper. The fact is that the Minister's statement has given rise to considerable anxiety, certainly in the community dental service, and probably in other services too. Careers face disruption again only a few years after the last reorganisation, and as yet no protection arrangements have been agreed.
This is not the way to persuade people to work more efficiently. Good industrial relations need openness, clear intentions, consultation, and in the present situation when we are about to change the Health Service's administrative structure an
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important need is to minimise career uncertainties for people working in the service, otherwise declining morale could undermine the whole running of the service. I am sure that we all wish the Minister success in his efforts to improve the Health Service's use of its resources in this difficult time. I hope he will bear in mind that better industrial relations are essential to more efficient management.
8.9 p.m.
Lord BROCK: My Lords, first of all I note that Lord Winstanley's Motion is very carefully worded, in that the first impression on reading it is that it directly accuses the National Health Service as such as going wrong, but more careful study reveals that it does not specify who is responsible. The general impression easily accepted is that the NHS itself is at fault, and with this I wish to protest strongly. There is little doubt that there is much wrong with the service that it provides; but is this the sole fault of the service or something else? It is not so long ago that we were being told that the NHS was the best in the world and that we could be proud of it. How does it come about that now it is said to be running to seed?
I have been associated with the hospital service since 1924, and with the National Health Service itself from its commencement in 1948 until 1968, when I retired. Since then I have observed a steady deterioration in what is being provided, but not in the service itself which is still splendid; the work of the doctors at all levels from consultants downwards, is as good as ever. The nurses also do just as good work. I have a daughter who is ill in hospital and she becomes lyrical about what the nurses do so magnificently; often dirty, unpleasant and hard things, without protest.
It is in certain of the ancillary services that I see a falling off as a positive hindrance to good work. Their antics, actions and intentions have even begun to affect the speech and thoughts of the doctors, nurses and other workers who have at times even mentioned such shabby, unprofessional and unacceptable things as threats of industrial action. Many of the ancillary staff, no doubt influenced by union action, have already descended to this. It is clear that if you touch pitch

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you may be defiled. A year or two ago the country was electrified by the statement of some foolish woman that food should no longer be served to private patients in hospital. A big London teaching hospital which cost many millions of pounds is now threatened with closure because a group of hooligans are stopping its oil deliveries. Since then we have had the sad tale of similar disruption and threats.
When I look back on my long years of service with the hopsitals and with the NHS, I retain a very different impression of doctors and nurses, who in general are eager and dedicated people, falling over themselves to do a good job. This same spirit of service and of devotion was still to be seen in the NHS that I knew from 1948. I continued to be fully impressed with what was being done. After 1968, when I retired, I began to notice disturbing elements. Things were just not so good and one heard many sour comments and criticisms. Things altered so much that one even accepted the statement that it was just as well not to be in the NHS.
But despite these misgivings and criticisms, I was still very impressed with the high standard of excellent work being done. It is true that adverse comments were continually heard about certain levels of ancillary staff whose behaviour was, frankly, disgraceful, but the real high standard of good work went on. Take, for instance, the conduct of obstetrics, a common and much-needed discipline. I was recently talking to an obstetrician friend who would enthuse over what it now has to offer, especially, for instance, in the way of monitoring the health and performance of newly-born babies. Then one thinks of advances in hip joint replacement and many joints in surgery pioneered by Sir John Charnley and followed by many surgeons. Many thousands of patients have been, and are being, benefited by this, including, I imagine, not a few in your Lordships' House. This is a field where previously there was almost nothing, and it now offers complete relief from a severe crippling complaint.
There is then the whole field of cardiac surgery, a virtually completely new industry which brings so much to so many where before there was no hope of relief. Only recently we had the news of
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a politician in prison for his criminal activities but let out temporarily so that he could benefit from the operation now available. We also had news of a distinguished and popular entertainer who was able to have the same operation as a life-saving procedure.
Rather more esoteric, but none the less very important and supplying a much needed advance, is the replacement of diseased organs, especially kidneys and liver, and now even the heart with which success is being achieved. Although less spectacular, but still a very successful form of tissue transplantation, is the whole saga of blood transfusion for which service the NHS has much to be proud. When I reflect on all these things and the many others we owe to the NHS I continue to marvel at the success and progress of this much criticised and maligned service.
The defects lie scarcely at all with the professional element, the doctors and nurses, but the disturbances lie with many of the non-professional or ancillary element; by no means with all of them, many of whom maintain the high and praiseworthy standards that pertain to the doctors and nurses, but it is not possible to ignore the harm done by a certain element. While these continue to be disruptive, there is going to be discord in the service. But I must point out that they form a group new to and inflicted on the original NHS, and it is they who are responsible for the disharmony that exists. But they are not intrinsically part of the NHS as I and many others used to know it. They are a new element. Their control is not the prime concern of the NHS. It is a Government function and Government should rid us of these disturbing elements.
Some of this has arisen from the enabling legislation of 1972 or 1974 directed at the reorganisation of the service. I well remember the long hours of debate that we got involved in. Much of it seemed complex and unconvincing to me, and doubtless to many others; we were just presented with a vast bureaucratic upheaval or earthquake, much of which was wished on us and was just too complicated. So it has turned out to be, and now we are finding that the control is too complex and far too expensive, and it is

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proposed that it be simplified. With this we must agree. There is at least one too many among the tiers of control, expensive in itself.
All this reorganisation requires thinking out again and modifying. Whether improvement will result it is difficult to say, but something must be done, and again it is the Government's task to do so. It is not the responsibility of the NHS, which seems to share the blame, but is a function of the Government and it falls to them to correct it; to try among other things to control the disturbing elements that are doing so much harm and are chiefly responsible for the disturbing things the Motion speaks of. Let us get the affairs of our NHS in order and make it again something of which we can all he proud.
8.18 p.m.
Lord HENLEY: My Lords, I am grateful to the noble Lord, Lord Winstanley, for giving us the opportunity to discuss the various problems which beset the National Health Service. Many of those who have spoken can justly claim to be experts on the subject of the Health Service, and I especially wish to include the two maiden speakers whom I join other speakers in congratulating. I am afraid I have no expertise at all and I can only speak from my own recent personal experiences as a patient under the National Health Service.
The noble Lord, Lord Wells-Pestell, does not seem to think that many on these Benches use the NHS. Like my noble kinsman Lord Auckland, I have made full use of it. I spent the whole of last week and the week before in the Middlesex Hospital; I was there under the auspices of the NHS and not privately. I was taken in rather suddenly and so there was no question of any delay, and I can therefore say nothing about the problems of long waiting lists for less pressing treatment. Others, notably Lord Winstanley and my noble friend Lord Gisborough, have mentioned this problem this afternoon. I am sure it exists but I am not qualified to speak on it. All I can do is give my impressions of the NHS as I saw it from my bed in the Middlesex Hospital. It might be that my views are of very little relevance. The Middlesex Hospital is one of the large London
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teaching hospitals and for all I know it is not typical in any way of NHS hospitals; I have never been to any NHS hospitals, or to any hospitals for that matter, in all my life since I was born and therefore do not know much about them. I suppose that one of the great teaching hospitals has much greater resources to command than do many of the regional hospitals. At the same time, I imagine that it has many disadvantages in being in Central London, with relatively old buildings, rather crowded. I must add that while I was there I was completely unaffected by any industrial action, or any other disaster, and so my experience is probably totally untypical of what other people have had to undergo. Nevertheless, I hope that what I have to say will not be entirely irrelevant to the debate.
I will not keep your Lordships very long because I want to say only one thing; namely, how very impressed I was with the whole set-up. The picture of the Health Service painted in the Press has very little in common with what I saw. Some newspapers would have us believe that the whole system is falling apart at the seams, that it totally fails to meet the needs of the patients. In fact, from reading the Press it is very easy to be rather frightened of going into hospital at all; I certainly was. There are fears that strikes will prevent any oil getting in or food being cooked, and one reads reports of the wrong foot being cut off or of some other ghastly amputation. I suppose that all these things can in fact happen, but again I hope that they are not necessarily typical.
I have absolutely no complaints about the manner in which I was treated by all the staff at the Middlesex, whether the doctors themselves, the nurses, or even the dreaded ancillary workers, who many have criticised this afternoon. They seem to be rather partial to various industrial disturbances of one kind or another, and as a result they are very much a bête noire in the eyes of the Press. But they caused me no problems while I was there, so I am not going to criticise them. If I might, I should particularly like to thank the nursing staff with whom obviously I came into most contact. Despite the long hours they work, despite very difficult patients—and I expect I was probably one of those difficult patients—and despite their relatively low pay, I do not think I saw

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any ever lose their temper or behave in anything but an exemplary manner. They deserve all the praise they receive.
I have already said that I do not know whether what I saw in the Middlesex was in any way typical of the National Health Service, and I am prepared to concede that it probably might not be in that it is a large hospital with large resources. I think that it has about 750 beds and a staff of over 3,000. I have not checked those figures; I do not know whether they are correct. But my experience does at least show that parts of the Health Service are working well and efficiently and are meeting the needs of the patients, which after all is what the debate is supposed to be about. I do not want to sound complacent, but things do not really seem to be as bad as some people would have one believe. The Health Service might not be perfect, it might have a great many failings, but what I saw from my bed appeared to be a highly efficient hospital. It would be a credit to any health service.
8.24 p.m.
The Countess of LOUDOUN: My Lords, services for the elderly are one of the current National Health Service priorities, along with those for the mentally ill, the mentally handicapped, and children; and it is about this first group, the elderly, that I should like to say a few words. The major problem of mental illness is now the dementias of old people, and it is therefore impossible to plan services for the old and the mentally ill separately. As people grow older certain organs, in particular the brain, tend to lose a number of cells. In most people this gradual loss has no effect at all, but dementia occurs in elderly people whose brain cell loss is abnormally heavy. This may take the form of depression, which is a psychotic disorder, where the sufferer's mood sinks to a level not experienced by someone who is mentally healthy, and can lead to suicide; or paraphrenia, a form of schizophrenia in elderly people, which is likely to affect those suffering from loneliness, poor vision, or deafness. This is a feeling of not being wanted, a type of persecution mania.
In the less acute stages of brain cell loss stress on an elderly person can cause the mental state diagnosed as confusion,
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where a person can be alert and articulate one minute and drowsy and incoherent the next. But where the cell loss is abnormally heavy the resulting dementia is permanent, irreversible, and tends to get worse. Although nothing will change a person with dementia back into someone who is mentally normal, it is possible to slow down the process of deterioration. There is an urgent need for more counselling services for the elderly, particularly in times of crisis such as those caused by bereavement, retirement, loneliness, or ill-heath, which can be major upheavals to those concerned.
Then there are the dangers of overmedication and mal-medication, all of which can be potential causes of mental ill health; yet little gets done about them. Though most GPs are conscientious and utterly trustworthy, there are some who automatically dish out tranquillisers rather than try to find the cause of the problem. There are those doctors who issue repeat prescriptions without even seeing the patient.
I think that one must recognise that some forms of mental disorder are avoidable altogether, and that others can be handled successfully if proper care and attention are available at an early stage. Assessment of the elderly patient by both health and social services staff, preferably at home where the patient feels most at ease, is vital. And what then? Owing to the piecemeal development of residential services by both the National Health Service and local authorities these services for elderly, mentally infirm people are at best inadequate and at worst untenable. The only answer, surely, is joint planning between local authorities, the Health Service, and voluntary organisations, to develop a range of residential services which complement each other and offer a choice to meet the needs of individuals.
The Health Advisory Service has for years expressed concern about the quality of life in geriatric and psychiatric hospitals, many of which fall short of acceptable standards. Can the Government tell us when the report of the working party on management of hospitals is likely to be published? Can the Government see any virtue in giving psychiatric hospitals more control over their own hospitals, so that those responsible can plan their own

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budgets? There is a shortage of staff, both trained and untrained, in these hospitals. Many nurses prefer not to look after mentally disturbed old people, though this, one of the most demanding branches of nursing, is also one of the most rewarding, calling for personal qualities and skills of a high order. A high proportion of the staff are men and women from overseas who have given invaluable service in psychiatric and geriatric hospitals, but problems sometimes arise due to an imperfect command of English and the fact that they come from cultures with different assumptions and conventions.
But apart from the elderly, mentally infirm person living in some kind of residential provision, there are many more living in the community, mostly with their families. Surely one of our priorities must be to maintain these elderly people in the community for as long as possible, thus easing the strain on hospital and local authority provision. But to achieve this we must aim at complete co-operation between health and social services staff, including social workers and community psychiatric nurses. This would cut out some of the waste now prevalent due to overlap and ensure that the best possible use is made of resources already available to the patient, without necessarily spending more money. Cooperation and co-ordination between all the statutory and voluntary services involved in the care of elderly, mentally ill and infirm people is essential if we are to allow them the quality of life to which they are entitled and allow them to be treated with the humanity and respect to which they have a right.
8.30 p.m.
Lord WALLACE of COSLANY: My Lords, we are now approaching the end of a somewhat long but extremely useful debate, and I should like to congratulate and thank the noble Lord, Lord Winstanley, and his party for initiating it. The noble Lord may recall that some years ago he had the responsibility of whipping me off, in an emergency, to Westminster Hospital. I have now fully recovered, although they never in fact discovered what was wrong with me. I should also like to congratulate the two maiden speakers, the noble Earl, Lord Erne, and the noble Baroness, Lady Ryder of
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Warsaw. We look forward very much indeed to their participation in the future. There are two other speakers that I should like to thank and congratulate. 1 have called them "the dynamic pair". They are the noble Baroness, Lady Masham of Ilton, and the noble Baroness, Lady Darcy de Knayth. I hope that the message that those two energetic Members of this House put forward will be accepted and dealt with, as indeed they have the greatest possible public sympathy.
While I agree that severe problems exist in the National Health Service, nevertheless the service compares favourably with conditions in many other countries. Those of us who have been faced with a sudden disaster overseas realise the sense of relief when a member of the family is eventually returned to National Health Service care in Britain, and receives that high standard of medical and, particularly, nursing care which still exists at home. In passing, I should like to pay a personal tribute to one aspect of health care and service that is hardly ever mentioned. I should like to pay a personal tribute to the fine standard of service at Heathrow Airport Medical Centre, so often the point of transhipment for those stricken with sudden illness or accident overseas. The service is admirable, compassionate and efficient.
I deplore attempts to "knock" the National Health Service in order to advance private schemes. Harsh words indeed have been used earlier in this debate. Medical need should not be subject to financial considerations. I believe strongly that the best possible treatment should be available to the sick in body or mind, irrespective of class, colour or creed. Freedom of choice most certainly, Yes, but no question of first- or second-class citizens. It is true that today the National Health Service faces severe problems, not all of them financial. At all levels of staff there is evidence of low morale. What has gone wrong? There is not the slightest doubt in my mind that the primary cause is the disastrous reorganisation carried out by a Conservative Government and engineered by Sir Keith Joseph. On the Third Reading of the Bill in another place I warned him of the chaos that would arise, and my worst fears have indeed been confirmed. The result has been a bureaucratic monster smothering patient care with mountains of paper work,

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and faceless individuals with electronic calculators producing incomprehensible statistics on bed norms. I always thought a bed norm was a parasite: on second thoughts, perhaps I was right.
I do not want, in any case, to show too much political bias in this debate. I am now going to support my arguments with a quotation from a very useful document which the noble Baroness herself has no doubt read. This is from a working party on "the Cinderella service". It says:
"The Working Party found widespread criticism of the reorganisation of the National Health Service, which had resulted in low nursing morale. There was a feeling that the service had been depersonalised because the level of effective management was now so far from the level of clinical practice. The administrative structure was top-heavy, with one tier of authority too many. Lines of communication were over extended and considerable overlap of responsibility had almost submerged nurses in paperwork, and had added to postage and telephone costs. All the respondents stated that this was one of their principal frustrations".
I could go on, because this is an excellent report; and, for the record, it is a "Report on the Nursing Profession presented by a working party of the Women's National Advisory Committee of the National Union of Conservative and Unionist Associations". I commend the reading of this document, but it shows the criticism that I have already made in my speech.
There is no doubt whatever that reorganisation was a disaster, but the comment made in this report on the nursing profession applies to all levels of staff. I agree with the report entirely that there is one tier too many. We are now told that area authorities are to be phased out and replaced by some 200 district authorities. Great care will have to be taken to avoid another upheaval, leading to a further lowering of morale. There will be staff redundancies, and careers will be blighted. Those responsible for sorting it all out will have an agonising job. I know only too well, because I had to take part in those agonising procedures, when we had a short list of officers, for all of whom we had the highest respect and all of whom had excellent records, and we had to choose one for a post, the others having to go searching elsewhere. Some of them, excellent people, had to leave the service. In fact, one of my officers emigrated to New Zealand to get out of the country;
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he was fed up to the teeth with the situation.
Every effort must indeed be made to return to more localised control, creating a more corporate entity, staff loyalty and sense of unity. Newly appointed district authority committees must go out of their way to be known by staffs, collectively and individually. That was the strength of the management committees before reorganisation—trust and confidence on both sides. It is also essential that members appointed have local knowledge and experience.
Now I come to industrial relations, and may I say that I agree almost entirely with the speech on this subject made by the noble Lord, Lord Rochester, who has a great experience in this field, as we all know. From the old atmosphere of loyalty and dedication, we now have the problem of industrial relations, which became severe last winter and continues today in incidents which can bring comfort to no one. Faults exist on both sides. No-strike contracts are not the answer. They may possibly be negotiated, but reality must be faced. Dispute situations will still arise unless a better atmosphere is created. I am well aware of the disputes procedures put into operation by my honourable friend David Ennals when he was Secretary of State. Admirable as they are if fully carried out in good spirit, they do not go deep enough to the source. Something additional is needed; and what I say about those procedures is also what is in the mind of the noble Baroness, Lady Young, in the proposals that are coming, to which we are all looking forward. Something more is needed.
What is the answer? May I submit it, with all humility, in three words: communication, consultation and cooperation. Hospitals are communities in themselves, but abound in rumours—small, perhaps, but if not dealt with they snowball into disputes; and those of us who have connections with hospitals in any way know how quickly rumours can spread. Area health authorities have joint consultative committees with union representation, but their field is limited. Hospital JCCs rarely exist, and in fact are frowned upon by some chairmen and administrators in case secret decisions and discussions are leaked. I, after some

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difficulty with my area health authority, did get one set up in a certain local hospital. It was set up with elected staff and I can say with definite assurance that it worked well and re-created trust and confidence. Some of the old goodwill and good spirit has returned. Although I had to resign when I became a Lord-in-Waiting, I understand that the committee is still continuing with some good effect.
Nothing is lost and much is gained by taking hospital staffs into full consultation and providing information. Patient care means dependence on all levels of staff working together: doctors, nurses, technicians, catering staff, porters, domestics and many others are all primary units in a team. There is no comparable industrial set-up elsewhere to compare with it. The tendency since reorganisation has been to regard administration as the primary factor. The service, in my view—and I have some experience in this field—is over administered. There has to be a new concentration on communication to all levels. There must be a joint consultative system at hospital level comprising elected representatives of all levels of staff together with management: lay and professional. There must be a full and free discussion and maximum information.
Trust in staff will in turn create greater trust and confidence in management. Reduction of the present bureaucratic mess and creation of a system of consultation and co-operation will not only improve morale and patient care, but could lead to better financial control. In my little JCC we had suggestions how money could be saved. I am sure that the staff could make intelligent and constructive solutions and suggestions if only they were given the opportunity to do so. The suggested change of abandoning AHAs gives a great opportunity to create a far better atmosphere which in turn would eradicate much of the dispute situation which exists today, which I am sure we all deplore.
In conclusion, may I say this. No one in his right mind wants the National Health Service to become a political battleground. We are all in it together; we can all make our constructive contributions. Our aim is, and must be, to reconstruct a service which has been, and can still be, the finest in the world.
8.43 p.m.
Lord CULLEN of ASHBOURNE: My Lords, at this time of night I feel that I should be as short as I can, but I should like to start by saying how gratified I was that so many things that the noble Lord, Lord Wallace of Coslany, has said are exactly how we see things ourselves. My right honourable friend the Secretary of State has frequently admitted that the reorganisation in 1974–1975 was a mistake, and that is something to which he is turning his attention now and the consultation document will be out by the end of this year. It is expected that that consultation will take six months or so and thereafter matters can be gradually dealt with and not rushed.
We should be more than grateful to the noble Lord, Lord Winstanley, for initiating this debate. It has been to me extremely interesting and I have learned a lot this evening. We have had very distinguished speakers and again I feel many of those speakers will be rather pleased when they see the consultation document before the end of this year. There is much agreement between Government thinking and many of the speeches that I have heard this evening.
The noble Lord, Lord Winstanley, spoke of the workload which will be increasing. There is no question that that is so with the prospect over the next decade of an ageing population. The noble Lord made a balanced and very fair speech. He did not attack either noble Lords opposite or ourselves for the cuts or things that have gone wrong; he made constructive suggestions as to what could be done in the future to make improvements. I thought that he made a lot of extremely useful points, and I have no doubt that they will be much appreciated by my right honourable friend. I thought the noble Lord, Lord Wells-Pestell, made a rather sharp attack. I cannot help asking him why, as the Party opposite was in power for five years, if they really thought that the reorganisation was so erroneous, they did not take any part in altering it.
Lord WALLACE of COSLANY: My Lords, may I briefly say that I was going to mention that in my speech. I was furious one day in this House. I was having tea and I met Mrs. Barbara Castle. I said, "For God's sake reorganise the Health Service" She said:

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"George, it has been mucked up enough already, we cannot give alarm and despondency to the staff. You will have to wait."
Lord CULLEN of ASHBOURNE: My Lords, perhaps it is more suitable that we should reorganise the Service again, having reorganised it wrongly in the first place. I may take rather a long time in reply because I have an enormous number of notes, there have been rather a lot of speakers and a great many points raised. I will answer some questions now and write to a number of speakers whom I cannot answer.
The noble Lord referred to community health councils and asked me a particular question. One community health council was prevented from taking action. We know which one and I will write to the noble Lord setting out the situation as we sec it. My honourable friend the Minister of State is meeting the Association of CHCSs tomorrow and I would rather deal with the matter in the light of that meeting. My noble friend Lord Erne made an excellent speech. I should like to congratulate him on it. It was short, to the point, and non-controversial. I hope that we shall hear from him many times in the future.
He asked me two questions: one was about infant mortality. An advisory committee on infant mortality and handicap was appointed in November 1978 by the former Minister of State for Northern Ireland with responsibility for health and social services, the noble Lord, Lord Melchett, to advise on the whole range of preventive and caring measures in the field of infant death and handicap, and to make recommendations for action. In addition to a medical chairman, there are 12 members on the committee, two community physicians, one university; two obstetricians, one university; two paediatricians; two general medical practitioners; a midwife; a social worker; a health visitor and a layman having a particular interest in socio-economic an d environmental factors. The work of eight sub-groups set up by the committee is now almost completed, and their reports are to be considered during the next few months. The advisory committee hopes to complete its work before next summer, when it is likely that its report will be published.
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The second question the noble Earl asked me concerned continuing problems in maintaining acute hospital services in the Western area to which he referred. A joint working party comprising representatives of the Department of Health and Social Services for Northern Ireland and the Western Health and Social Services Board was set up in 1976 to study the existing provision of hospital care and to make recommendations on the pattern of service which would best ensure stability for the future.
The working party's report recommended that acute services should be based at two centres only, namely, Londonderry and Enniskillen, and that a number of existing hospitals should become community hospitals, including Tyrone and County Armagh which at present provide acute services. No final decisions have yet been taken, however. The Western board, which is at present consulting a wide variety of interests, is to submit its conclusions to the Minister of State charged with responsibility for health and social services in Northern Ireland. The Minister then intends to consult interested parties further before taking a final decision.
We then had a most fascinating speech from the noble Baroness, Lady Ryder. It was a joy to listen to and I hope we hear from her often again. We are, of course, aware of and deeply grateful for the work of the Ryder Foundation and other voluntary organisations. We intend to encourage voluntary effort. There are obvious limits to what can be done in the present circumstances, but we shall do what we can to support voluntary effort.
My noble friend Lord Gisborough then spoke. He referred to making better use of ancillary staff and to seeing that overmanning is cut out wherever possible. However, I think my noble friend was painting a slightly unfair picture. The overwhelming majority of ancillary staff do sometimes very important work effectively and have the best interests of the service firmly in view. We had very sad occasions last winter which I hope we shall never see again; but I think we must remember the good rather than the militant minority. My noble friend also mentioned administration, and again I think he will appreciate our consultative paper when it comes out later this year.

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The noble Lord, Lord Pitt, referred to some of the deprived areas of London and to the Resource Allocation Working Party. He queried whether or not London was properly looked after in this respect. I think this is rather a big question to go into tonight, and I will write to the noble Lord on that score. He also referred to the Elizabeth Garrett Anderson Hospital which, as noble Lords know, is being kept open but not with all the services that it previously had.
The noble Baroness, Lady Masham, spoke on the subject of Stoke Mandeville Hospital, of which she has spoken several times before. I do not think I can say much to her this evening because, as she told the House, my honourable friend the Minister of State, Dr. Vaughan, is visiting the hospital on 20th November and I think that if I said anything about that in the meantime it would be inappropriate. The noble Baroness also spoke about the importance of volunteers, as have many other speakers; and we are entirely in favour of making the maximum use of volunteers both in good times and in bad, and also of supporting and encouraging voluntary organisations wherever we can.
The noble Baroness, Lady Fisher, spoke about hospital closures. I think I must say that no Government of whatever colour likes closing hospitals. The policy of Her Majesty's Government is to keep open all the hospitals they possibly can, and particularly small hospitals. I know people get very fond of their local hospitals and even though the facilities may be greater in a larger hospital some way away, they would rather go to the hospital which they know.
The noble Baroness mentioned waiting lists and, of course, we share her concern, but getting waiting lists down is not going to be easy. They have risen by 50 per cent. in the last five years—from 500,000 to 750,000 or so—and it would certainly be our greatest wish to reduce those waiting lists as quickly as we possibly can. We hope that the restructuring of the National Health Service will help towards that end.
The noble Baroness also mentioned the cut-back in personal social services: again, most regrettable. But social ser-
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vices cannot be isolated from other forms of public expenditure. Unhappily, the public expenditure plans of the previous Administration were based on an expectation of growth of, I believe, 2 to 3 per cent. which, as we all know very well, did not occur. Without making any particular aggressive party point, it is rather a mystery to me why they actually expected such a growth rate, because during the period of their time in Office I do not think they ever got anywhere near that. However, the cut-back in the social services is certainly regretted and my noble friend has made it very clear that he hopes the elderly, the sick and the deprived people will suffer to the least possible extent, and that will be for local people to look after.
I was asked for the level of expenditure on health as a proportion of total public expenditure programmes, and the noble Baroness gave earlier figures. The figures for which she asked are for 1974–75, 11·8 per cent.; 1975–76, 12·2 per cent.; 1976–77, 12·7 per cent.; 1977–78, 13·4 per cent.; 1978–79, 13·1 per cent. and we anticipate 12·6 per cent. for 1979–80.
Like the noble Lord, Lord Wallace, I entirely agree with so much of what was said by the noble Lord, Lord Rochester. He has very great experience in this field and his words will be read with great interest by my right honourable friend. I thought that we had an immensely impressive speech by the noble Lord, Lord Richardson, the chairman of the General Medical Council. It seemed to me that both his speech and the speech of the noble Lord, Lord Smith, covered so many of the things that we feel. His concern over the morale and discipline of the service, the wish to look beyond self-interest and to encourage local pride in the work, is exactly the kind of thing that we ourselves are after. I am sorry to be taking rather a long time over this, but there were a lot of speeches.
My noble friend Lord Auckland asked me several questions. He spoke about the need for better nurses' accommodation. I am sure that this is an important matter, but, though we sympathise with what he said, our philosophy is to leave it to local people to determine local arrangements and priorities. I do not think it would be right for central Government to determine local priorities, in the way that my noble friend suggested. He also asked

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me when we were going to go further with the recommendations of the Briggs Committee. I am afraid I cannot answer that, but I will write to my noble friend on that point. My noble friend inquired what was happening about nurses' pay. Of course, the Clegg Commission is looking at this and will be reporting early in the New Year. The Clegg award will be implemented in two equal stages, with effect from August, 1979, and April, 1980, and we shall be honouring the commitment made by our predecessors.
The noble Baroness, Lady Darcy de Knayth, also spoke about Stoke Mandeville, so I must give her the same answer that I gave to her noble friend Lady Masham. She asked too about the missing £400,000. I will ensure that my right honourable friend the Minister of State looks into this matter, and will write to the noble Baroness as soon as possible.
The noble Lord, Lord Murray of Gravesend, spoke about the cuts. I think that my noble friend Lady Young put the position very clearly as to what actual cuts are being made, and what is the position over the two-year period. He definitely had a point about the I per cent. increase which is necessary to maintain services at the same standards. But without talking party politics, we inherited a rather difficult situation. As I said, there was an expectation of growth of 2 to 3 per cent. by the Labour Party. I do not blame them for that. It must be extremely difficult to work out these things. Anyway, the final effect is that there is not as much money in the kitty as we should like to have.
Also, I am sure it is true to say that had the Labour Government been re-elected they would have had to cut back on public expenditure. The money was not there. They would have had the alternatives of very high increases in taxation or of borrowing money from abroad, and I doubt whether they would have wanted to do that again. I do not think I shall go any further into that point.
The noble Lord, Lord Murray, also suggested that the NHS might be exempted from the payment of VAT. I am sure that a lot of people would like to be exempted from the payment of VAT.
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When VAT was first introduced, it was decided that health authorities and most other public bodies should pay VAT. Extra resources were given to health authorities to enable them to meet the extra cost, and it is intended that cash limits for 1980–81 will include provision for the full year effect of the June, 1979, increase in VAT.
I think that the noble Lord, Lord Smith, answered many of the points which have been made today and said many of the things that I know my right honourable friends at the Department of Health and Social Security themselves feel. We agree with the noble Lord's observations in so many ways—in particular, about not knocking the National Health Service without appreciating its achievements over the years. We were extremely lucky to have so many distinguished speakers, and I immensely enjoyed the noble Lord's speech.
My noble friend Lord Colwyn, who is also to speak tomorrow evening on the subject of fluoride, talked of the need for flexibility and setting new structures. I think he will find that our proposals will provide for flexibility. He talked of uncertainty. Uncertainty is never good for morale. I think he should wait until the consultative document comes out, with which I believe he will be pleased.
The noble Lord, Lord Brock, spoke about ancillary workers and also about structure. I have covered both of those points in dealing with other speeches. The noble Lord, Lord Henley, spoke of his spell in the Middlesex Hospital. It was very encouraging to hear my noble friend's account of his stay there. I am sure that his experience is typical. Indeed, consumer surveys of the service show high levels of satisfaction with the quality of care which is given.
The noble Countess, Lady Loudoun, spoke of services for the elderly mentally disturbed. She has drawn attention to a very real problem—one which has not, perhaps, been given the attention that it deserves. We are anxious to see improvements in services for this group of patients. In general, I agree with the noble Countess's remarks and will write to her shortly setting out how we see policies developing over the next few years. The

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report of the working group on the management of mental illness hospitals will be published soon, hopefully by Christmas or early in the New Year.
I have done my best to deal with the points which have been raised by noble Lords. I shall, as I promised, write to noble Lords on any questions to which I have not replied.
9.12 p.m.
Lord WINSTANLEY: My Lords, as the mover of this Motion it would normally be appropriate for me merely to say a few quick words of thanks to all those who have spoken, congratulate the maiden speakers—which I shall do with all possible warmth in a moment—and then beg leave to withdraw the Motion and sit down. However, may I crave the indulgence of the House and say that these are not entirely normal circumstances for me, in that this is one of the two debates in this House for which my noble friends on this Bench are allowed to choose the subject. Normally it would be the practice of the House for one of my noble friends to say a few words so as to tie up the ends above the line, as it were. However, as I informed the House, my noble friend Lady Robson of Kiddington was suddenly snatched to the grass roots of the Health Service to deal with a very urgent hospital crisis and was unable, therefore, to perform this function. Then my noble friend Lady Seear, who was to take her place, was suddenly taken ill and had to go home. Therefore we had nobody in that particular position.
I shall be very brief. This creates no precedent, but I hope that I am not abusing the courtesy of the House if I say a few words more. Of course, I have not been entirely alone. I had excellent support from my noble friend Lord Rochester who, I thought, made a most balanced and thoughtful speech. I was deeply grateful to both the noble Lord, Lord Wallace of Coslany, and the noble Lord, Lord Cullen of Ashbourne, for the way in which they so readily embraced his words, took them on board and promised to think further about them. This was particularly gratifying to me because I was most impressed by what was said by my noble friend. As has been said, he has great experience and I
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am delighted to know that his wisdom is not to be totally disregarded.
I also had eloquent support from the noble Lord, Lord Auckland, who made a most balanced and interesting speech, for which I was most grateful. If he did nothing else, surely he will have convinced even the noble Lord, Lord Wells-Pestell, that the Benches opposite are not entirely occupied by the serried ranks of BUPA.
Perhaps I should also say that I had the most sterling support from what was so eloquently described by the noble Baroness, Lady D'Arcy de Knayth, as the "mobile bench". Perhaps noble Lords will think it not inappropriate that a noble Lord on the Liberal Bench should have some affinity with those on the mobile bench, but I was delighted to know that our views are clearly reciprocated on that mobile bench. The noble Baroness and also the noble Baroness, Lady Masham of Ilton, stressed the importance of specialised units and the great importance of nationalised funding of those units. That is something which I would certainly like to underline. I believe also underlying their words was the point that it is really a waste of resources for everybody to be trying to do everthing on a small scale when some things can be done so very much better in specialised units such as that particular one which I know so well and for which they were speaking so eloquently.
I must now come rapidly to two very distinguished and impressive maiden speeches. The noble Earl, Lord Erne, warned us of the danger of being too preoccupied with what happens in London and other major conurbations. How right he is! And how better to remind us of that than to hear a voice that comes from a rural area just about as far from London as one could possibly get? It was really a great pleasure to hear him and I hope we shall hear him on many more occasions.
He reminded us, too, of the existence of what I had begun to think was an endangered species—the single-handed GP, were it not that the noble Lord, Lord Pitt of Hampstead, actually claimed to be one. But when the noble Lord, Lord Pitt, said, "I am a single-handed GP" I seemed to detect that somehow quietly under his breath he said, "and God bless the emergency call service"! I mention

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that merely to stress that we do have new developments in medicine. We have group practice, but with group practice I think there is a feeling that somehow the old close personal relationship that used to exist with the single-handed GP is disappearing. It is a fact that it really is rather difficult to establish a very close personal relationship with an emergency call service. So it was delightful to hear that there still are single-handed GPs.
Lord PITT of HAMPSTEAD: My Lords, will the noble Lord allow me to intervene? When I started my practice, for the first five years I did night service for a doctor who lived down the road, so having a deputising service is not as new as all that.
Lord WINSTANLEY: My Lords, I am grateful to the noble Lord. With regard to the brief quarrel (if I may so describe it) between the two Front Benches, naturally I took no part in it because it happened after I had spoken. I will only say this: the subject of private practice cropped up. I have no brief for private practice, but I would say both to the noble Baroness, Lady Young, and to the noble Lord, Lord Wells-Pestell, that the one thing that private practice does is to act—or it can act—as a very sensitive barometer of what is happening in the public sector. That is true not only of health but also of education. When one suddenly sees a growth in the private sector, and a growth in the demand for private practice, then one should start to look immediately and carefully at what has happened to the public sector. It is my honest view that for those who wish to get rid of private practice there is no better way than to improve the Health Service. Where hospitals are new, where waiting-lists are short, where doctors' lists are manageable, one looks in vain for private practice.
So far as finance is concerned, that, too, was interesting in so far as there was a dispute between the two Front Benches. I am sure the noble Lord, Lord Wells-Pestell, will forgive me if I say that there were a great many things which his Government—if I may so call it—would have liked to do and believed they ought to have done, had the money to do those things been available. But the money was
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not available at that time, and therefore I do not criticise the late Government for not doing some of those things. But the money is still not available. I am by no means convinced that the new Government are necessarily on the right course in order to get that money and to make it available. It may be they are and it may be they are not; time will show, but at least I am personally very grateful indeed for what the noble Baroness, Lady Young, said. She said, clearly and unmistakably, that she personally and her colleagues would like to spend more on the National Health Service, and when we had more money they would spend more on the National Health Service. I hope that, if and when that time comes and if and when her Government are in power, she will have great influence to make absolutely sure that that undertaking is fully and effectively carried out.
We heard two excellent speeches from two most distinguished doctors, Lord Richardson and Lord Smith—if the noble Lord, Lord Smith, a surgeon, is prepared to accept the term "doctor" in its broadest sense. I think they made most interesting contributions. Lord Richardson stressed the need for a new mood, or perhaps, more appropriately, a return go an old mood, which was well recollected by the noble Lord, Lord Brock. The noble Lord, Lord Smith, used the words "rationing of health care is a fact". I accept that. I would merely say to him and others who heard those words that I think he would agree with me that people practising medicine today and in recent years, in whatever capacity, even as the president of the Royal College of Surgeons of England, have been forced to cut corners in order to get work done at all, but they have cut corners on a random basis. When I talk about the need for some cost-effective studies about some of our routine procedures what I am in reality saying is that it is high time we learned not how to cut corners on a random basis merely because we have to, but how to cut corners on a planned and calculated basis so as to minimise risk and maximise use of resources which are in desperately short supply.
I could go on and on. I really am so grateful to so many noble Lords for taking part in this debate on a very important subject. I think noble Lords have had

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very important contributions to make. I could have gone on and on referring to their speeches, but I am sure your Lordships would not wish me to. I should merely like to thank each and every noble Lord who has taken part, and those who have come and listened to noble Lords who have taken part.
Once again I congratulate the two maiden speakers on remarkable speeches. I do not think I finished on the speech of the noble Baroness, Lady Ryder of Warsaw. I know that I speak for every Member of this House when I say that we are very proud to have her in our House and we hope she will speak to us very often about her wonderful work. How right she was to remind us of the benefits of priming the pumps of the voluntary sector and to remind us that if the Government try to save money by ceasing to prime those pumps they will pay very dearly for that so-called economy! My Lords, I am most grateful to all who have taken part, and with those words I beg leave to withdraw the Motion.
Lord WELLS-PESTELL: My Lords, before the noble Lord sits down, may I say this: The fact that I remained silent when he referred to what I had said with regard to the private sector must not be understood by him that I am in complete agreement. It is merely that because of the hour I am exercising very great control.
Motion for Papers, by leave, withdrawn.

FELIXSTOWE DOCK AND RAILWAY BILL
Queen's Consent signified: reported from the Unopposed Bill Committee with amendments.
RESIDENTIAL HOMES BILL [H.L.]
Reported from the Joint Committee with an amendment, and recommitted to a Committee of the Whole House; Bill to be printed as amended.