§ 3.27 p.m.
§ The MINISTER of STATE, DEPARTMENT of EDUCATION and SCIENCE (Baroness Young)
My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.
Moved, that the House do now resolve itself into Committee.—(Baroness Young.)
§ On Question, Motion agreed to.
§ House in Committee accordingly.
§ [The LORD ABERDARE in the Chair.]1308
§ Clause 1 [Power to make changes in the local administration of the health service in England and Wales]:
§ On Question, Whether Clause 1 shall stand part of the Bill?
§ Lord WELLS-PESTELL
Clause 1 is designed to undertake a fundamental reorganisation of the National Health Service, and we on this side of your Lordships' Committee have not put down any amendments because we are broadly in agreement with what is set out in that clause. Clause 1 gives the Secretary of State powers to make changes in the local administration of the Health Service. As we understand it, district health authorities are to be set up in place of area authorities, and I should like to ask the noble Baroness the Minister whether she is in a position to say how many district health authorities there will be. As I understand the situation at present, there are 90 area health committees and something like 209 district authorities. Is the noble Baroness in a position to say what the organisation will be, because in my submission, clearly there are unlikely to be 209 district health authorities and, obviously, because of the size of the area health authorities, there must be more than 90?
I am wondering whether the noble Baroness the Minister is in a position to give the Committee some indication of what the pattern is likely to be. At present, the boundaries of the area health authorities fit in very nicely with some, if not all, of the local authority boundaries and it makes administration of medical services and co-operation with the local authorities very much easier. I wonder whether the setting up of the district health authorities will take into account the areas of the local authorities. Although I recognise that it will not be possible to fit them in completely, will they ensure that if a district health authority has to cover more than one local authority, as far as possible it takes in one division or two divisions of another local authority so as to keep the administration as simple as possible? Can the noble Baroness the Minister say how many hospitals are likely to be closed under this new arrangement when it comes into being?
1309 Bearing in mind that the changeover will take some considerable time—I have heard it said that it will take one year, two years, and even four years; I am quite certain that a reorganisation of this magnitude could not possibly take place in one year—is the noble Baroness in a position to say how long it will take, and is it the Government's intention that all area health authorities will be designated district health authorities? The Bill does not seem to me to be as clear on this as I had hoped. I should like to refer to the Notes on Clauses, at the top of page 6, where it is said:Subsection (1) enables the Secretary of State by order to establish health authorities for districts as well as or in substitution for the existing AHAs".Therefore, it rather suggests that some area health authorities may remain, and I thought that that was contrary to the idea of the reorganisation.
I should also like to ask the Minister whether there is any implication of all this on the regional health authority. In what way will the regional health authorities in the country be affected, and will there be any change in their responsibilities? Further, I should like to ask the noble Baroness what sort of saving will be achieved. I understand it has been said that something like 10 per cent. will be saved, but I am not clear—perhaps I ought to be—of what it is 10 per cent. of. I notice that in another place it was mentioned that there would be a saving of about £30 million, or perhaps even more. I should like to know on what basis this 10 per cent. figure is given.
Furthermore, is it right to assume that the £30 million saved will result from the loss of jobs on the part of a good many at present working in the area health authority, or will it result from some other cause? So far as I can work out, having regard to the number of people employed, if the saving of £30 million is to be made as a result of a reduction in staff, it will mean that the jobs of about 3,000 employees will be terminated. If the figure is more than £30 million, presumably the number of people who will lose their jobs will be greater.
There is only one other matter which I should like to raise, and I hope that on this the noble Baroness the Minister can 1310 give some sort of comforting reply. We, on this side, have a strong feeling that the Government wish to bring to an end the community health councils. I cannot imagine that anybody who is familiar with the work done by community health councils could possibly come to the conclusion that their usefulness had come to an end. Notwithstanding that our hospitals deal with millions of people every year as out-patients and an enormous number as in-patients, and millions of people see their doctors and so on, the only watchdog that the consumer has—and in this particular instance the consumer is the patient—is the community health council. I should like to take this opportunity—in case I do not get one later on during the Committee stage of this Bill—of paying tribute to the work of the community health councils. I know that some area authorities, some regional hospital authorities, have found them to be a nuisance. But it is part of their rúle to be a nuisance in the sense that it is part of their responsibility to draw to the attention of the various medical committees, the area health authorities and the regional health authorities matters that are happening that ought not to be happening. We really ought not to be afraid of it. We ought to be glad that there is such a body of people, because the National Health Service is, as I said, an enormous concern dealing with tens of millions of people every year. It cannot always hope to do the right thing; it cannot always expect to do it. There are bound to be difficulties.
I believe that the community health councils have rendered the community —particularly those who are in contact with doctors and hospitals—a very valuable service. I hope that the noble Baroness the Minister will be able to say that it is not the intention of the Government to seek to do away with the community health councils. I apologise for putting so many questions to the noble Baroness, but I thought it was better done under Clause 1 than to try to bring them in elsewhere.
§ 3.38 p.m.
§ Baroness YOUNG
I think that the whole Committee will be grateful to the noble Lord, Lord Wells-Pestell, for giving us an opportunity to look in some detail at Clause 1 and for the way in which he 1311 has introduced his remarks. It gives us a chance to look at the very many matters which come under this very important Part of the Bill. I am also grateful to him for giving me notice of a number of the points that he wished to raise. It is important for the Committee to recognise that Clause 1 is purely a permissive clause. It enables the Government to carry out the changes proposed in our consultative document, Patients First, if, in the light of the responses to the document, it seems right to do so. Therefore, it may help the Committee if I give some indication of the tenor of the responses that we have already received to this document.
There has been, particularly from within the National Health Service itself, a widespread welcome for the Government's broad objectives; these objectives are to simplify the structure of the NHS and to strengthen management at hospitals and community services level. Equally encouraging, there has been a welcome for the Government's specific proposals to achieve these objectives. In the context of this clause, that means the possible abolition of the area tier of health authorities.
There is a fair measure of agreement within the service that the major structural weakness of the 1974 reorganisation was the establishment of the multi-district area. The concept of the statutory authority at area level with its own team of officers administering an area divided into two or more non-statutory health districts, each with its own team of officers, has not worked as well as had been hoped. Lines of accountability have become blurred; there has developed an over-complex bureacracy; staff and patients have seen the authority as remote and impersonal.
If your Lordships approve this clause it will be possible to establish a general pattern of smaller unitary authorities based broadly on existing health districts, each with its own clearly accountable and simplified management structure. Your Lordships will note that the clause is so drafted as to permit a gradual change. This is an important point. There will be no one appointed day when the entire service undergoes an upheaval. We envisage that that change, if change there is to be, should be within an overall time 1312 scale and should come at an evolutionary pace to minimise any disruption as far as possible.
I should say right away that the Bill does not compel change at the level of the regional health authorities—this is one of the points that the noble Lord asked—nor indeed at departmental level. This does not imply that we regard the scope for change as existing only at the local level, but we propose no immediate change in the size, membership and functions of regional health authorities. I think it would be helpful to clear that point.
May I now turn to the detailed points that the noble Lord asked. He asked how many district health authorities there might be, and whether there would be the same number as area health authorities at present. The answer is that it is not possible to say precisely how many district area health authorities may be established if our proposals are implemented. We estimate that there might be between 150 and 180 such authorities, some 70 to 90 more than the existing 90 area health authorities. But decisions about this have not yet been taken, and I would draw the noble Lord's attention, on the point about links with local government and as to whether or not the district health authorities are coterminous with local government boundaries, to page 6, paragraph 5, of the Notes on Clauses in which he will see:Subsection (2) enables the Secretary of State to determine that a district may correspond with an existing area. In these cases the existing area health authority may simply be reconstituted as a district authority and renamed accordingly.Decisions on these points have not yet been taken, and therefore there is considerable flexibility about it at this stage".The noble Lord then went on to ask about the time-scale. I hope I have said enough for him to recognise that we are not going to have one day on which this will happen. It will be a gradual process, which I think everybody will come to believe is a much wiser and more sensible way of going about this. If the proposals in Patients First are confirmed we shall be asking regional health authorities to conduct reviews of structure at area and district level and to make recommendations to the Secretary of State.
We envisage that many changes could be effected by mid-1982, but that might 1313 not be possible for all. Our present aim, as set out in Patients First, is that all structural changes should have taken effect by the end of 1983. The timing of changes to management arrangement will depend first on the date of establishment of new authorities who it is proposed will carry responsibility for these reviews, secondly on the availability of suitable officers, and third, on the possible need to negotiate changes to Whitley agreements.
The noble Lord asked me about the savings that we anticipated. Our judgment on this matter is that after the initial years when transitional costs will have to be met, the implementation of our proposals would result in a reduction in management costs of up to 10 per cent. I think that is where he has the figure of 10 per cent. At current prices we should expect this saving to be of the order of £30 million.
On the question of the numbers of jobs that might be lost, it is difficult to estimate a figure until the reviews, both of the structure and the management arrangements, have taken place. But we can say that there are at present 251 separate area and district headquarters organisations, and if our estimates of between 150 and 180 district health authorities prove to be accurate there would be a reduction of between 70 and 90 of these headquarters organisations with some consequent loss of posts. I see from the further amendment that the noble Lord has down that we shall be looking at this whole area of questions about redeployment, and so on, and I think it would be helpful if I left the rest of my remarks on that subject until we come to debate that particular amendment.
Finally, the noble Lord asked me about the future of community health councils. I recognise the force of what he has said, and I am sure that there are many people who recognise the valuable work that community health councils have done. I should like to confirm that my right honourable friend the Secretary of State for Social Services will announce his decision on this matter when he makes his general policy statement on the structure and management of the service later this month. I hope, having answered these specific points and given our background to the thinking on this clause, that the Committee will feel that it is an 1314 essential part of the Bill and that we have taken account of the views that have been expressed to us on a very wide scale. We are, of course, still receiving information on the consultative document and we shall be proceeding gradually over the implementation of these proposals.
§ 3.46 p.m.
§ Baroness PHILLIPS
I hope that the Minister will heed the plea that where possible the area health authorties will be coterminous with existing authorities. One of the things that people suffer nowadays is that they have hardly got used to the name of the authority before it is changed. Certainly it is possible to be in one area for health, another area for education, another area to pay your electricity bill, another one for the Post Office, and so on. We add all the time to the complication of life to a number of very simple people who, in the end, really do not know where they go for the particular services they demand. This has never been more noticeable than in the health services.
If this change can be effected with as little complication as possible, I am sure that the Minister will see that this happens, even if we have to have a change of name yet again. That is in itself a confusion. But if the area could at least run counter to some of the areas that people already know, this would make life a little easier for the people who have to use the services.
Lord WALLACE of COSLANY
Following on Lady Phillips's remarks about areas and having a name to cover a whole series of services, I would put a point to the noble Baroness for the Government to consider. I am not here to put forward any political criticism at all. I think that the noble Baroness and the Committee will agree that some reorganisation of areas covered by regional health authorities is in fact necessary. The most outstanding example is London and Greater London—the GLC area.
The present situation is chaotic in London with its divisions into sections controlled by a number of RHAs covering not only parts of the GLC area but large areas of rural and semi-rural districts with interests and problems completely different from the metropolitan area. In fact, the diversion of funds to outer areas by RHAs 1315 has enforced debateable economies in the GLC area, and led to hospital closures and other cuts against the needs of Greater London residents and also the needs of commuters travelling from the favoured outer areas who need and get treatment in London hospitals.
St. George's Hospital, as we know, has been closed, and Westminster is under threat because the proposed closure of the medical school will mean a drastic reduction in beds and reduction of service, albeit with a financial saving which seems to me the basic reason behind it. Apart from this, many thousands of medical cases are sent to London hospitals from all over Britain for investigation and very often treatment. I think it is an accepted fact that London has become a very important centre of medicine with a world-wide reputation.
The case for a regional health authority for London covering the GLC area is overwhelming, not only because of its density of population but also because of its unique position as a centre for famous teaching hospitals, and also taking into account the tremendous daytime increase in population through workers employed in offices, shops, factories, markets, et cetera, together with visitors for business and pleasure, and travellers in transit by air, rail, and road, all of whom present demands on the metropolitan health services, and hospitals which are not fully met or covered by the present piecemeal set-up of the regional health authorities.
One regional health authority for London would provide better liaison with the GLC and its associated London boroughs, providing, as they do, social services closely allied to the health service. It seems to me to be unthinkable that the country's capital, with its special needs, has been divided up so far in such a fashion, which has seriously eroded its medical needs. Here I attach blame to all the Governments who have handled the health service since its inception. In conclusion, may I say this: The Government must think seriously about this situation, which must surely be remedied, and in this I feel sure they would have the support of the Greater London Council and the people the council strives to serve.
§ Baroness MASHAM of ILTON
I should like to support what the noble Baroness, Lady Phillips, has said. Corning from a rural area, I should like to tell the Government that their health district is served from Northallerton and the social services from Harrogate, which is in a totally different health district. It would be very much easier for health and social services to co-operate if they came from the same district and people knew each other. The poor old patient just does not know where to go or who to contact.
§ Baroness ROBSON of KIDDINGTON
Obviously, I was very interested, because of my interest in a regional health authority, to hear the noble Baroness express a desire that the change that is coming should be as evolutionary as possible. I believe in that myself, but only to a certain extent, because I think we have got to balance very carefully the feeling of uncertainty that will hang over a large number of National Health Service staff if the change is too evolutionary. I think it is essential that we set a deadline, for instance, for the appointment of chief officers to the new districts and that we should try in all regions to stick to that deadline as far as humanly possible.
I would hope that the noble Baroness the Minister implied in her reply that the reorganisation and the appointed day within a region would still remain the responsibility of the regional health authorities. But there is one thing that worries me enormously about the whole of this change. That is the responsibility left on regional health authorities to keep financial control during the period of change. That is another reason why I do not want the evolutionary change to be too elongated, because it is going to be very difficult to keep financial control during this period. There are many areas in this country which have created centralised finance offices for more than one district. It does not take a great amount of imagination to see what will happen when the chief officers of that area authority apply for the district finance officer's post. They have to safeguard their future; they are looking to where they are going in the future. The problem of dividing that finance office into three different finance offices, while at the same time keeping financial control, is not going 1317 to be an easy task, and the longer that period is the more difficult it is going to be.
§ Baroness YOUNG
I and my colleagues are grateful for the general welcome that has been given to this clause and the very helpful and constructive suggestions that have been made by all those who have spoken. The noble Baroness, Lady Robson, raised a very important point about not allowing the reorganisation to go on too long. Can I reiterate what I said at the beginning in answering the noble Lord, Lord Wells-Pestell, about the time-scale of this? We hope that all the structural changes will have taken place by the end of 1983. This should give time for some evolution, but clearly not an indefinite length of time, for precisely the kind of reasons the noble Baroness herself has made clear, particularly about staff appointments.
The noble Baroness, Lady Phillips, and the noble Baroness, Lady Masham, both raised important points about coterminosity of local authority areas and possible district health authority areas. We recognise that coterminosity is important, but it is not necessarily the overriding factor in the structure of the NHS. We very much take the point about the value of coterminosity and will certainly emphasise its importance in any guidelines that we issue, taking account of the very practical point that the noble Baroness, Lady Masham, has made on this matter. But it may well be that health service considerations such as the numbers of patients in one particular place or the siting of major hospitals might argue against coterminosity in some places. Practical effects as to where one actually has a hospital and whether it can, in fact, fit in with the local authority must also be considered. However, we take this point very much and I am quite sure that my right honourable friend the Secretary of State will take note of the points that have been raised, because they are ones with which we are broadly in sympathy.
The noble Lord, Lord Wallace, raised a point about reorganisation in London. As he probably will know from a number of Questions asked in your Lordships' House on this very point, quite recently we have been considering once again many of the problems of London. What is needed now is not really a further inquiry 1318 but some action, and my right honourable friend the Secretary of State has established a London advisory group to help him reach decisions on London. It will be advising on major health service issues in London and it has been asked to give priority to considerations of the pattern of acute hospital services in London and to the new structuring of the health authorities. We did in fact have some discussion on this very point in a parliamentary Question not so long ago, and I am quite certain that the right way of proceeding is to wait until this committee has given its advice on this matter. But, again, this is a matter on which no decisions have yet been taken because we are waiting for the result of this particular report.
I should say in conclusion that I realise I did not answer the question asked by the noble Lord, Lord Wells-Pestell, about hospital closures, but at the start of our deliberations I should like to confirm that we are not talking about hospital closures at all in this Bill. The reorganisation of itself will not lead to any hospital closures; that is an entirely different issue.
§ Clause 1 agreed to.
§ 3.58 p.m.
§ Lord WELLS-PESTELL moved Amendment No. 1:
§ After Clause 1, insert the following new clause:
§ Health Service Staff Commission
§ (".—(1) It shall be the duty of the Secretary of State to appoint, within one month beginning with the date of the passing of this Act, two Commissions to be called the National Health Service Staff Commission and the Welsh National Health Service Staff Commission; and the Commissions—
- (a) shall consist respectively of such persons as the Secretary of State may from time to time appoint as members of the Commission after consulting the bodies appearing to him to represent persons employed in England, or, as the case may be, employed in Wales who are liable to transfer in pursuance of section 1 of this Act and any other bodies appearing to him to be concerned with transfers of such persons in pursuance of that section; and
- (b) shall in the case of the National Health Service Staff Commission exercise its functions in relation to England and in the case of the other Commission exercise its functions in relation to Wales.
§ (2) It shall be the duty of each Commission—
- (a) to keep under review the arrangements made by relevant bodies in recruiting and
1319 engaging employees and the arrangements made in transfers in pursuance of section 1 of this Act and to give advice to the Secretary of State and the relevant bodies with respect to the arrangements;
- (b) to consider and advise the Secretary of State on any matter which he refers to the Commission as being a matter which in his opinion arises in connection with persons liable to transfer in pursuance of section 1 of this Act;
- (c) to consider and advise the Secretary of State on the steps required to safeguard the interests of persons liable as aforesaid; and
- (d) to arrange for the consideration of representations made to the Commission by an employee transferred from the employment of one health authority to that of another objecting to such a transfer and for the giving of advice to such employees by the appropriate Commission;
- (e) shall so advise health authorities that no officer employed by a health authority at the date when the Commissions are appointed shall be deprived of employment within the National Health Service in consequence of this Act save with his express consent freely given to his employing health authority and the appropriate Commission in writing;
§ (3) The Secretary of State may—
- (a) give directions to each Commission with respect to its procedure;
- (b) give directions to relevant bodies with respect to the furnishing by them of information requested by the appropriate Commission and with respect to the action to be taken by them in consequence of advice given by that Commission;
- (c) pay to any member of either Commission such remuneration as the Secretary of State may determine with the approval of the Minister for the Civil Service;
- (d) defray any expenses incurred with his approval by either Commission in the performance of its functions; and
- (e) wind up either Commission in such manner and at such time as he thinks fit;
§ (4) In this section "relevant bodies" means bodies from and to whose employment persons are liable to be transferred by virtue of section I of this Act.").
§ The noble Lord said: I beg to move the amendment standing in the names of myself and my noble friend Lord Wallace of Coslany. The purpose of this amendment 1320 is to establish a health service staff commission, and the amendment sets out clearly the scope and function of the health service staff commission which we on this side of your Lordships' Committee recommend and hope to see. I am going to assume that all noble Lords have studied the amendment very carefully, and therefore I do not propose to deal with it line by line, but just to speak to it in a general way. In the last analysis—and I think this is confirmed by what we have heard from the noble Baroness the Minister and others who took part in the discussion on Clause 1 standing part—the reorganisation of the National Health Service as envisaged in the Bill will be a tremendous undertaking and we must not close our eyes to that fact.
§ Not only will it be a tremendous undertaking, it will affect a large number of individuals, and in many cases—and we must not run away from this—it will affect a large number of jobs. The best estimate—if "best" is the right word to use—is that it may result in the loss of 3,000, or possibly more, jobs. The Minister was right not to attempt to give a figure because it is extremely difficult until the thing gets rolling to know what will be the outcome. Thus, a large number of people will be threatened with dismissal, and it is therefore important to keep the human factor in the forefront of our minds.
§ I do not want to repeat what I have said on other occasions, but we are in danger of thinking of unemployment as a statistic. It is not a statistic to the individual who finds himself or herself without a job. It can be the most traumatic experience of any experience, and in moving the amendment I am not unmindful of the duties and responsibilities of the Whitley Council. The nature and size of the reorganisation is such that my noble friends and I are strongly of the opinion that there must be a health service staff commission. I hope the amendment will commend itself to the Government, and as a similar clause was embodied in the National Health Service (Reorganisation) Act 1973, there is nothing new in this; it has been done before, seven years ago, when the health service, which we are discussing today, was reorganised. In the circumstances, I hope the Government will 1321 not be opposed to the idea in principle, even though they may say there were difficulties on the last occasion.
§ Any major reorganisation—and, as I have said, this is one—is bound to affect a large number of people, and those who are likely to lose their jobs must have every protection and consideration. Noble Lords who remember the reorganisation of the health service in 1973 will know something of the morale of the employees and the shattering effect it had on them. I believe that to some extent—I cannot say to what extent—it had a lasting effect. From 1973 to 1980 there have been many difficult periods in the history of the health service and a number of unfortunate incidents, and there has been a great deal of turmoil in the NHS in the last seven years. That turmoil undoubtedly affected the service which the hospitals were able to give, and it undoubtedly affected many thousands of patients. We cannot allow that kind of thing to recur and we must do everything we can to prevent it. It is not unfair to say that this Government—and I am not out to make political points—are not very good at industrial relations. We are much better at it, so they should take our advice.
§ We have before us a Bill which will soon become an Act, yet no word from the Government as to what is involved or how the problems arising will be tackled. If I had not been raising the matter this afternoon, I do not suppose for one moment that anybody on the Benches opposite would have raised the question as to what will happen to so many people at present in the NHS. If the Government are aware of the magnitude of the undertaking and problems involved, now is the time to tell your Lordships what they propose to do. I hope they will say that they will deal with it by adopting the amendment. In the other place, the Secretary of State was not forthcoming on this subject in Committee. If, therefore, the Government will not accept the amendment, then I must ask for a clear and reasonable explanation as to how they propose to deal with the chaos which is bound to arise.
§ We are glad to see the reorganisation, but let us face the fact that it will throw 1322 up many problems affecting individuals, and they must have somebody to look after and watch their interests. I can say that a NHS staff commission is wanted by the staff side and by the unions—I think the noble Baroness, Lady Young, will take my word for that—and that is a desire coming not just from these Benches or from certain people who are sometimes awkward; it is the desire of the staff and unions. The unions connected with the Whitley system have been involved in reorganisation, not only in the NHS but in other public services—I have in mind local government reorganisation, new towns and a number of other bodies—and in all those instances staff commissions were established and greatly assisted in the smooth transition of the reorganised services.
§ I have referred to the size of the task facing the Secretary of State and his department, a task which, it is thought, could take up to the end of 1983, three and a half years from now, to achieve. But whatever the time taken, it will cover a very wide field of interests taking in a large number of people, and to embark on such a reorganisation without a staff commission will militate against a trouble-free reorganisation. It is not only that we want the reorganisation to go smoothly—nobody would gain anything from it being otherwise—but we must speak of this as employers, for I suppose that every one of us in your Lordships' House, as Members of Parliament, stands in that kind of relationship with everybody employed in the NHS, if not legally then certainly morally. The Secretary of State must carry the staff with him, and acceptance of the amendment would assure that, because, as I have said, it is what they want.
§ I ask the Committee to bear in mind that several groups of different disciplines will be seriously affected by the reorganisation. I understand that they include—and the Minister was perfectly frank about this—the managerial side, but we are thinking of nurse managers, works officers, senior catering staff and several other groups, managerial people who will not find a job very easily in the present or future circumstances at the age they will be if they are deprived of their employment. We must bear in mind that they have given excellent service and have made improvements arising from their own skills. Let 1323 us pay tribute to the people in our employ. By their skill and competence they add to the general efficiency and smooth working of institutions and organisations, and now many of them will lose their jobs. I am sure that the Government are aware of that.
§ We on this side of the Committee hope that the reorganisation will be achieved in the shortest possible time. My noble friends and I share the view of the noble Baroness, Lady Robson of Kiddington, in this matter. We hope that those who will be displaced will be considered in such a way as to be able to seek employment perhaps elsewhere in the National Health Service, should an opportunity present itself. Those who do not succeed in retaining their jobs should be able to obtain all the advice and help they need. Redundancy and similar matters have to be considered, and in my view and that of my noble friends a staff commission is essential. The staff must know that there is an independent body looking after their interests.
§ I hope that on this occasion the noble Baroness will show some understanding—I do not mean that unkindly, though I realise that it may sound unkind—because I believe this matter to be of supreme importance. Bearing in mind that we are dealing with flesh and blood, with human beings, I hope that the rest of your Lordships will feel that there must be set up the kind of organisation that we propose which would be in evidence and would give help to those who need it. I beg to move.
§ 4.12 p.m.
§ Baroness YOUNG
My Lords, may I say at the outset that this is a very important issue that the noble Lord, Lord Wells-Pestell, has raised. It is most useful that at the start of the Committee proceedings we should be debating the whole question of a staff commission and the arrangements that we are proposing for the staff. We accept just as much as does the noble Lord the importance of maintaining the confidence of the staff during this period of reorganisation. The noble Lord asked for a clear and reasonable explanation of what is to happen to the staff, and I very much hope that I shall be able to answer the questions that he has raised and to reassure the Committee on these particular points.
1324 My right honourable friend the Secretary of State for Social Services has made it clear on several previous occasions that the Government's view is that national staff commissions for the purpose of any National Health Service reorganisation which follows decisions taken on the document Patients First are unnecessary. However, I wish to emphasise that that in no way implies that we are unsympathetic to the understandable anxieties of health service staff, simply because we do not believe that staff commissions will necessarily smooth the path of reorganisation, from the point of view of either management or staff. In fact, the proposed new clause does more than seek the establishment a national staff commission or commissioners; in one particular respect it seeks to determine what advice they shall give to authorities. I shall return to that point.
I recognise that the proposed new clause reflects the wish of NHS staff side representatives that staff commissions should be established, and I take the word of the noble Lord, Lord Wells-Pestell, that that is the wish of the trade unions as well. However there remains the question: are the commissions necessary? No one has argued convincingly that a staff commission should, as the 1974 English commission was, be involved in the actual appointment of individual officers—that is, by shortlisting. Indeed, I have heard criticisms of the 1974 commission's role in this respect and fears lest complex arrangements of that kind should apply again.
So we come to the procedures for appointing staff. For the 1974 reorganisation, the staff side were consulted by the staff commission, following which the procedures were laid down. On this occasion, the staff side have told us that they wish procedures to be agreed between management and staff sides; and we have accepted this. The staff side have argued that discussions and negotiations over the whole range of staffing issues should take place within the ambit of the General Whitley Council. Again, we have accepted this, and taken action accordingly. This leaves only the question of appeals, and all along we have said that we accept the need for an appeals mechanism, if necessary with an independent component.
1325 In short, I do not think that a convincing case has been made for the need for staff commissions of the kind that have been described. However, I think that the respective positions of those who do and those who do not want staff commissions are not necessarily irreconcilable. There is some middle ground, and we must find it, perhaps by building on the recognition —shared, I believe, by both management and staff interests—that an effective appeals mechanism will be needed to ensure that everyone is treated fairly. Perhaps agreement can be reached in this direction. If members of your Lordships' Committee, and in particular the noble Lord, Lord Wells-Pestell, or the noble Baroness, Lady Robson of Kiddington, wish to give advice on the form that that mechanism might take, I should be very happy to convey it to my right honourable friend as a matter of urgency. The advice could be given in the course of the Committee proceedings, or noble Lords may care to write to me, or perhaps discuss the matter between now and the next stage of the Bill.
now wish to turn to that part of the amendment that would require a commission to advise that there should be no compulsory redundancies, and to confirm straight away that we are anxious that these should be avoided if at all possible. Indeed, there are a number of proposals which are either specifically, or at least in part, designed to see that compulsory redundancies are reduced to an absolute minimum; and if that minimum proves to be nil, then it will be all to the good. First, we think that any reorganisation should be spread over a period of time—and I have already indicated the timescale: this is in part to help with the problems of the staff. That, with sensible recruitment policies in the meantime, will mean that we can count on natural wastage to take care of much of the expected reduction in posts.
Secondly, there are proposals for a premature retirement scheme. Again, I believe that this will have a very significant effect on the picture and, as with natural wastage, will take care of a significant number of posts. Of course, natural wastage and premature retirement are, in a sense, negative ways of avoiding redundancy, and we believe that we must 1326 be positive, as well. There may be people who, because of the changing needs of the service, have certain skills which are no longer needed, but they may have a depth of background knowledge of the service which we would do ill to ignore. In such cases we should use to the maximum any opportunities that there may be for redeployment, and, if this can be helped by retraining, we should see that this possibility is fully explored. I believe that if these measures do not entirely rule out the need for compulsory redundancies they will very much reduce them. But at this stage I cannot give a guarantee that there will be no compulsory redundancy. What I shall say is that terms that we shall offer to anyone who is made compulsorily redundant will be fair, and we are quite ready to discuss them with the staff side.
What is now important is that we should quickly get down to joint management/staff side discussion of these important issues: how posts are to be filled; protection of pay; the terms for premature retirement; and, in the last resort, redundancy. A joint mechanism for these discussions has now been agreed with the staff side—a committee of the General Whitley Council. Offers have been made to the staff side and the first joint meeting of the committee has been held. We have a duty to allay the natural anxieties of those staff whose posts could be affected by reorganisation, by reaching and publicising firm agreements on all these matters.
The Committee may wish to know that, with the exception of pay, which will remain a matter for the functional Whitley Councils, negotiation of the whole range of staffing issues will take place in a special committee of the General Whitley Council. This committee has held its first joint meeting, and is to meet again later this month.
I hope that by setting this out very fully I have said enough to assure the Committee that we do understand the points put so well and so clearly by the noble Lord, Lord Wells-Pestell, and the anxieties of the staff; that we have got agreement about these procedures with the staff side; and that the committees are meeting. I hope he will feel that we have met what I think are the quite natural anxieties as to the proposals that we are making.
§ Lord WELLS-PESTELL
It is always difficult to take in what people say, and I should like to look at Hansard tomorrow and read carefully what the noble Baroness the Minister has said. But may I ask her whether I am right in thinking that when she says, "We will see" and "We will offer", she means that the Secretary of State, through his representatives, will consult with the staff side of the Whitley Council on all matters relating to staff—the transfer of jobs, the loss of jobs, redundancy or whatever may result from the reorganisation?
§ Lord SHINWELL
Before the noble Baroness replies in detail, may I say that one listens to a debate such as this without having much knowledge of the subject; but I am bound to say that although the noble Baroness expressed sympathy and understanding and replied to almost every one of the points raised by my noble friend, the one point to which she did not reply, and which concerns me as a listener, is whether my noble friend was justified in asserting that as a result of this reorganisation probably 3,000 people associated with the National Health Service will be made redundant. The noble Baroness said that it was not the intention to institute compulsory redundancy. That is all very well, and she did refer to the possibility of wastage. But the question which really concerns one in a matter of this sort is whether, as a result of reorganisation —and reorganisation, no doubt, is essential —3,000 people are going to have their services dispensed with. I think that question ought to be answered, because I am bound to say that if it is not answered satisfactorily, although it is not my business (I am not on the Front Bench and do not decide matters of this sort) I should like to vote against the noble Baroness.
§ Baroness YOUNG
I hope that I shall be able to reassure the noble Lord, Lord Shinwell, on the point that he raises. In answering the first debate that we had, on Whether Clause 1 shall stand part of the Bill?, I tried to answer the very question that his noble friend Lord Wells-Pestell put about the numbers of people who might be affected by the reorganisation. The figure which has been quoted is 10 per cent. of management costs; that 1328 is the amount of savings. But the fact is that we cannot give an estimate of the number of jobs which might be lost until we have the reviews of both the structure and the management arrangements, and these have not yet taken place. What I have said is that we do not intend that there should be one appointed day when the new arrangements will come into force, and one of the reasons for this, of course, is to allow time for consultation and for redeployment, and to meet the obvious staff problems that will arise and which, quite rightly, cannot be settled very quickly.
We have therefore, with the agreement of the staff side, set up the joint management-staff side discussions; and I should like to confirm to the noble Lord, Lord Wells-Pestell, that the kind of issues they will discuss are how posts are to be filled, the protection of pay and the terms of premature retirement and, in the last resort, redundancy. I should like to confirm that should there be compulsory redundancies we shall be looking at the compensation arrangements, and in the case of anybody who might be made compulsorily redundant the matter will be discussed with the staff side; and the staff side has agreed to these arrangements. What we want to do is to try to avoid any redundancies, but there will be all sorts of other matters that I think can be discussed, negotiated and agreed. We believe that the time lag between now and the end of 1983 should make a lot of these difficulties somewhat easier, because it gives us time to consult concerning staffing arrangements and to redeploy, and, of course, for there to be some natural wastage, which will also make the situation much easier.
§ Lord HOWIE of TROON
I am particularly interested in the turn which this short debate has now taken. In answer to my noble friend Lord Shinwell, when he asked how many jobs would be lost and if it were right that perhaps 3,000 would go, the Minister made a reply which related not to the precise question but to the savings in management costs; and I think I am right in saying that she thought there would be a 10 per cent. saving in these. I may be wrong, but it strikes me that part of the saving in management costs presumably relates to the reduction in manpower and 1329 relates to such items as wages, compensation, redundancies and all that kind of thing.
I am really now wondering what thought we can believe has been given to this estimate of 10 per cent. if we cannot be told how many jobs are to be lost. If the number is 3,000, the saving from wages and so on will be £x; if the number is less than 3,000, it will be less than £x, and if it is more than 3,000 it will be more than £x. At any rate, there must be some relation-ship—it may not be precise, but there must be a relationship of some kind—between the savings in management costs, said to be 10 per cent., and the number of jobs lost. I know that the number of jobs lost is only one part of the total savings, but I think the noble Baroness the Minister should go a little further in replying to my noble friend Lord Shinwell.
§ Baroness YOUNG
I am not sure whether the noble Lord, Lord Howie, was in his place when I was answering the first debate, but at the risk of repeating myself let me say that I do not know where this figure of 3,000 has come from. I have not given it, and so far as I know it is not based on any estimate at all. I am not trying to conceal anything from the Committee; I am giving the Committee all the information at my disposal, and should I find that I have any more information that I can give I will of course come back at a later stage. When I was asked by the noble Lord, Lord Wells-Pestell, how many jobs I thought might be lost, I said that we cannot give an exact figure, but what we can say is that at present there are 251 separate area and district headquarters organisations, and, as we believe that after our proposals there will be between 150 and 180 district health authorities, this means that there will be a reduction of between 70 and 90 headquarters organisations; and it is on that estimate that the figure of 10 per cent. is based.
How many redundancies there might be is quite a different matter, and really would be impossible to calculate for the reasons I have given, because a number of things will inevitably take place in the intervening time while all this is worked out. The assurance I want to give is that we are doing everything we can to 1330 minimise individual hardship and difficulty: we are giving the extra time in order to help these procedures along; and we have got agreement over this joint cornmittee, which I hope will prove to be successful.
§ Baroness ROBSON of KIDDINGTON
May I come in at the end of this debate? I probably should have spoken a little earlier. May I say that, personally, I have great reservatons about a national staff commission. I have reservations because I lived through the last re-organisation of this service, when the national staff commission, the shortlisting and the national advertising of the jobs of all the top officers created really enormous problems and, I believe, great hardships for the staff involved in the National Health Service. So I would hope that we would not have a staff commission which undertook duties of that kind. I should have thought that it might be necessary for each regional health authority to have an appropriate organisation within each region to look after the interests of staff and to deal with appeals machinery within the region.
If we are to avoid an enormous up-heaval, we must keep these changes on a regional basis. What worries me is what the noble Baroness said in reply to the question of redundancies; that there would be a 10 per cent. saving, a saving of roughly £30 million. I agree that the figure of 3,000 is a figure that cannot be justified. Until we have carried out the reorganisation of the management structure within each district, we do not know what it will be; but my understanding of the reason for the reorganisation is that it is not to save 10 per cent. on administration, but to create a better-managed health service. I believe sincerely that there will be hardly any redundancies, because we need to strengthen the management at unit level—which is going to take care of the people who in the past re-organisation were pulled up to the top and were not close enough to the decision-making process. Taking account of natural wastage, if we are to reorganise the service so that it is managerially more efficient I do not believe that we are going to have a great many redundancies. We might have a few. Each region should set up its machinery to deal with the problems thrown up in that way.
§ 4.32 p.m.
§ Lord GIBSON-WATT
Following what the noble Baroness has rightly referred to as her view of the future of the reorganisation—and I speak as one who was closely embroiled in the last reorganisation in the 1970s—I agree with what she says of the unforeseeable difficulties in this particular line that we ran up against after that reorganisation. I do not think that figures mean a great deal, when we are talking about 10 per cent. or 30,000. I would agree with her that that is not the core of the argument. I listened carefully to the excellent speech of the noble Lord, Lord Wells-Pestell, voicing, rightly, the deeply-felt understanding of those who work in the health service. I myself believe that what my noble friend has said about the appeals mechanism is really the core of the matter. I look forward to hearing more from the Government on how this will work out. I would hope very much, so far as Wales is concerned—for that is my particular interest—that there will be a separate appeals mechanism operating in Wales for the seven areas health authorities that exist there. But I believe—and I stress the point made by my noble friend—that when talking about a period of three and a half years, we will have automatic wastage whether or not we like it; we all grow older. The important thing in this, as she has said, is that every single case which is a problem and which could lead to any redundancy should have very special consideration by the special committee of the Whitley Council and by the appeals mechanism to which she referred. I repeat that I look forward to hearing more about that in the future.
§ Lord AUCKLAND
I rise to support what the noble Baroness, Lady Robson, has just said. I well remember speaking on the 1973 reorganisation Bill in this House—and speaking on it in a highly critical manner. Having served until then on the house committee of a large mental hospital, I have some experience of the problems up to that time and of the problems that have ensued since. This particular clause, as my noble friend has said, is the core of the Bill. The amendment which we are discussing, although it has some shortcomings, is one which I hope the Government will consider further; because the disruptions and the disputes within the health service over both 1332 Bills have arisen very largely as a result of reorganisation. The hospital management committees were wound up; we had the very large authorities, which undoubtedly served as best they could, but communications within the authorities and within the hospital staff (were they nurses or administrative staff) were not of the best.
I think the main problem of the noble Lord's amendment is this. This commission will presumably cost a fair amount of money to set up. We do not know how many people will serve on it; we do not know how much they will be paid for, presumably, they will have to be paid. Such savings as one hopes there will be as a result of the Bill may be eaten up in the setting up of a staff commission. One wonders how one is going to get over the problem of looking after the industrial relations side during this period of reorganisation. Although I agree that there should be no flexible appointed day, nevertheless I hope, for the sake of the staff and for the sake of the National Health Service as a whole, bearing in mind how much reorganisation there has been, that the period is not over long.
Lord WALLACE of COSLANY
1 should like to intervene, first, to say that there will be some very agonising decisions to be taken by those responsible for deciding between one officer and another. It is not a pleasant task and I am thankful that I am not involved this time as I was last time. I do not agree with the noble Baroness, Lady Robson, when she says that there will be practically no redundancy. I do not speak from the regional health authority angle, but from the area health authority angle in as much as I was a member of an area health authority for some time. In the present set-up (and some noble Lords will appreciate this point) there is almost a complete duplication, from top to bottom, of the area health authority staff and the district authority staff. That is one of my objections to it. If one takes that into account, even allowing for wastage, there is bound to be considerable redundancy. I am not prepared to put a figure on it. Nobody can. But I would forecast a far higher figure than any of those already given. This is inevitable, due to the structure of the service at the present time.
§ 4.40 p.m.
§ Lord WELLS-PESTELL
I think the Government must know more than the noble Baroness the Minister is telling us. I have a shrewd suspicion that she is drawing a veil over this. The noble Baroness referred to 251 management teams. I do not know the exact number of staff in a management team, but it is very substantial. She says that at the very most there will be 180 district health authorities, and perhaps as few as 150; but that around 70 to 90 management teams will go. I do not know the size of a management team. It would require only 30 people from each of those management teams to be discharged, and there would be the 3,000 I have been talking about.
I know that there is no point in arguing this matter any further because I am sure that we shall get no more information out of the noble Baroness the Minister. But I do not think that we ought to allow ourselves to be lulled into a sense of false security, supported, if I may say so, by the noble Baroness, Lady Robson, who says that the figure cannot be justified. I am sure that she is not in a position to say it cannot be justified; she can only say that she would be very surprised if the number was as large. I am relying upon the figures that the Government have given: the 251 management teams will be reduced to between 150 and 190. I say that that will mean a very substantial number of people losing their jobs.
§ 4.41 p.m.
§ Baroness YOUNG
I should like to confirm again that the object of this Bill —certainly this clause—is not to save money. I was grateful that the noble Baroness, Lady Robson, made this point quite clear, because our whole objective in this connection is to get a simplified management structure with better accountability. We believe this is something which will be welcomed by the public and it comes about as a result of our consultative document Patients First.
We have become drawn into the question of costs and savings, quite rightly, because the noble Lord, Lord Wells-Pestell, raised it. Having said we think there will be some savings, that suggests that is the purpose of the Bill. I assure the Committee that is not the case. I should like 1334 to reassure the noble Lord, Lord Wells-Pestell, that I am not hiding something from the Committee. I wish that I could give the information that he would like. Perhaps I can try another explanation and say that there is no direct relationship between the 10 per cent. figure that I gave of reduction in management costs and reductions in manpower, which is a very important point to make.
The reason why I say this is that the 10 per cent. reduction in costs is in fact our judgment of what we think can be saved as a result of the reorganisation. The fact is that the precise amount will depend on a whole host of local decisions taken within overall national parameters, but on local decisions about the grading of staff and the like. We cannot possibly judge now at this stage what reductions in manpower there might be. For the reasons that I have given, I do not believe that it is a very profitable exercise to go round saying that thousands of people will be made redundant. The noble Baroness, Lady Robson, quite rightly made the point from her great experience in hospitals that there will be a lot of redeployment into more effective organisations. I was glad to have her support that we could well manage our affairs within the structure that has been agreed rather than by having a staff commission.
My noble friend Lord Gibson-Watt made the important point about the appeals machinery. This is a matter on which I have asked the Committee for their views because we have no determined policy on this matter. This is something on which I hope very much noble Lords opposite, the noble Baroness, Lady Robson, or my noble friends Lord Auckland and Lord Gibson-Watt, with their experience, may have something to say. That would be helpful.
Regarding regional mechanism, which was referred to by the noble Baroness, Lady Robson, I agree that there should be regional appeals mechanisms. Indeed, we want as much as possible to be handled at regional level. As I said earlier, we should be grateful for advice on the precise form that this might take. Only when regional mechanisms cannot resolve disputes would we see matters needing to come to some form of national appeal. This is very much in line with what the noble Baroness hoped. Perhaps I might 1335 confirm that we propose that there should be a minimum of national rules, and that flexibility should be given to regions to apply those rules by local agreement in the way which best meets the needs and circumstances which apply locally. We accept entirely that any variation from the national rules or guidelines should be the subject of agreement of the staff side interests; and, furthermore, that an effective appeals mechanism should be available for anyone who felt that he had been unfairly treated.
I think that I have given to the Committee all the information I have. I should like to give the assurance that if there are other matters they want to raise between now and the next stage, I shall be happy to write to them or meet them and discuss these issues. I should like to get as much agreement as I can over this important matter of staff. We believe that our approach is one that has been accepted by the staff side and therefore
§ will work helpfully. I should like to reiterate that on this one area of the appeals mechanism on which we have not reached any decisions we would be very glad to hear from noble Lords any ideas they may have. I hope that with those assurances the noble Lord will feel able to withdraw his amendment.
§ Lord WELLS-PESTELL
I am grateful to the noble Baroness. It is comforting to hear her words. This must be the first Bill that has been introduced into the House of Lords in the past 12 months where somebody on the Government side has said: "The object of saving money is not the purpose of this Bill". I cannot accept what has been said, and I must test the Committee on this particular amendment.
§ 4.47 p.m.
§ On Question, Whether the said amendment (No. 1) shall be agreed to?
§ Their Lordships divided: Contents, 57; Not-Contents, 105.1337
|Aylestone, L.||Hatch of Lusby, L.||Ross of Marnock, L.|
|Balogh, L.||Henderson, L.||Sainsbury, L.|
|Beswick, L.||Houghton of Sowerby, L.||Sefton of Garston, L.|
|Blease, L.||Howie of Troon, L.||Shinwell, L.|
|Blyton, L.||Hughes, L.||Stedman, B.|
|Boston of Faversham, L.||Irving of Dartford, L.||Stewart of Alvechurch, B.|
|Bowden, L.||Jacobson, L.||Stewart of Fulham, L.|
|Brockway, L.||Jacques, L.||Stone, L.|
|Brooks of Tremorfa, L.||Kaldor, L,||Strabolgi, L.[Teller.]|
|Bruce of Donington, L.||Leatherland, L.||Strauss, L.|
|Collison, L.||Leonard, L.||Taylor of Mansfield, L.|
|Cudlipp, L.||Listowel, E.||Underhill, L.|
|Davies of Leek, L.||Llewelyn-Davies of Hastoe, B.||Wallace of Coslany, L. [Teller.]|
|Elwyn-Jones, L.||Lloyd of Hampstead, L.|
|Gaitskell, B.||Lovell-Davis, L.||Wells-Pestell, L.|
|Galpern, L.||Oram, L.||Whaddon, L.|
|Gordon-Walker, L.||Pargiter, L.||Wigg, L.|
|Goronwy-Roberts, L.||Parry, L.||Wootton of Abinger, B.|
|Greenwood of Rossendale, L.||Peart, L.|
|Hale, L.||Ritchie-Calder, L.|
|Ailesbury, M.||Brock, L.||Ellenborough, L.|
|Airey of Abingdon, B.||Caithness, E.||Elliot of Harwood, B.|
|Alport, L.||Chelwood, L.||Elton, L.|
|Amherst of Hackney, L.||Clitheroe, L.||Faithfull, B.|
|Ampthill, L.||Clwyd, L.||Falkland, V.|
|Auckland, L.||Colyton, L.||Ferrers, E.|
|Avon, E.||Cork and Orrery, E.||Ferrier, L.|
|Balfour of Inchrye, L.||Cottesloe, L.||Fortescue, E.|
|Banks, L.||Craigavon, V.||Fraser of Kilmorack, L.|
|Barnby, L.||de Clifford, L.||Gainford, L.|
|Barrington, V.||De La Warr, E.||Garner, L.|
|Beaumont of Whitley, L.||Denham, L.[Teller.]||Gibson-Watt, L.|
|Bellwin, L.||Derwent, L.||Gisborough, L.|
|Belstead, L.||Dormer, L.||Glenkinglas, L.|
|Berkeley, B.||Drumalbyn, L.||Godber of Willington, L.|
|Bessborough, E.||Dundee, E.||Gore-Booth, L.|
|Gridley, L.||Marley, L.||Selkirk, E.|
|Hailsham of Saint Marylebone, L. (L. Chancellor.)||Masham of Ilton, B.||Sempill, Ly.|
|Merrivale, L.||Skelmersdale, L.|
|Hampton, L.||Montgomery of Alamein, V.||Soames, L. (L. President.)|
|Hanworth, V.||Morris, L.||Spens, L.|
|Henley, L.||Mowbray and Stourton, L.||Stamp, L.|
|Holderness, L.||Murton of Lindisfarne, L.||Stanley of Alderley, L.|
|Hunt, L.||Norfolk, D.||Strathcarron, L.|
|Hylton-Foster, B.||Northchurch, B.||Strathclyde, L.|
|Kilmarnock, L.||Nugent of Guildford, L.||Swinton, E.|
|Kimberley, E.||Orkney, E.||Trenchard, V.|
|Kinnoull, E.||Orr-Ewing, L.||Ullswater, V.|
|Lauderdale, E.||Porritt, L.||Vaux of Harrowden, L.|
|Lloyd of Kilgerran, L.||Redmayne, L.||Vickers, B.|
|London, Bp.||Renton, L.||Vivian, L.|
|Long, V.||Robson of Kiddington, B.||Waverley, V.|
|Lyell, L.||Rochester, L.||Winstanley, L.|
|Mackay of Clashfern, L.||Rugby, L.||Young, B.|
|Macleod of Borve, B.||Sandys, L.[Teller.]|
|Mancroft, L.||Savile, L.|
Resolved in the negative, and amendment disagreed to accordingly.
§ Clause 2 agreed to.
§ Schedule 1 agreed to.
§ Clause 3 agreed to.
§ Clause 4 [Power to make grants towards expenditure on services of common concern to health authorities etc. and local authorities]:
§ Baroness ROBSON of KIDDINGTON moved Amendment No. 2:
§ Page 5, line 22, leave out from ("which") to end of line 26 and insert ("in the view of the Area Health or District Authority in consultation with the local authority will benefit or assist the public health, health education and welfare of the population within the local authority concerned;").
§ The noble Baroness said: I rise to move Amendment No. 2 and at the same time I should like to speak to Amendments Nos. 3, 4, 5, 6 and 7 because they are really consequential. I will address my words to Amendment No. 2 but, subject to what happens to that, the rest follows, I believe.
§ I welcome very much the fact that Clause 4 of the Bill makes joint financing statutory and that it extends its provisions to Scotland. I also welcome paragraph (b), which extends the use to which joint financing can be put to district councils in relation to their responsibilities under the Residential Homes Act 1980. All those things I agree with and, as has been said before, we are here discussing an enabling Bill, which, in the light of the outcome of the consultations on Patients First, will become the basis of reorganisation of the health service. 1338 To me, the whole ethos of that document, Patients First, is about a return of he maximum of power of decision-making to the local community. This is something with which, as has already been said, all noble Lords in this Chamber agree.
§ What I am attempting to do in substituting the words in 28A(1) under Clause 4 is to proceed along exactly those lines, to give greater power to the local people and to the communities to decide how they spend their joint financing. I am perfectly aware that a large number of different uses can be made of joint financing under the present legislation, but I am concerned that there seem to be what I think are unnecessary restrictions on its use in relation to local social service authorities. One of these, for instance, is in the field of health education. Health education is perhaps one of the most important things that we should undertake, because it is only by first-class health education that we will prevent unnecessary illnesses and perhaps be able to make sure that the NHS can meet all the demands of the community. Human beings themselves have got to do something to keep fit, and health education is one way in which we can help people to lead more healthy lives.
§ At present—this happened as a result of the last reorganisation—health education is the responsibility of three separate authorities; the education authority, the environmental health department and the NHS; and probably the largest chunk of it is carried on by the NHS. I believe it is essential that we should bring together in some form these three different authorities. We can do that by using joint 1339 finance to create something similar to a health education team, and thereby help to pool the resources of the three bodies and achieve a more effective result. If one thinks back to the medical officer of health's department in local authorities, that was more or less what happened.
§ It would also help to overcome the very fine line between the responsibilities of those various three authorities. This is something on which we cannot use joint finance at the moment. I should, therefore, like greater freedom for local authorities to take decisions themselves on how to use the limited funds that are at their disposal for joint financing.
§ In my view, joint financing will become increasingly important, because almost everyone now admits that with our desire to try to keep people out of hospitals, to keep them out of long-stay institutions and to keep them out of geriatric homes, we are moving more and more towards community care, and it is in community care where the interaction between local authority social services and the health services is very great.
§ Our aim should be to keep people in the community. For instance, there are schemes afoot so that attached to a Part III accommodation we might build a small nursing wing, which would enable social services personnel, community nurses, district nurses and health visitors to have a bed to which people, who normally lived in their homes, but who, for some reason or other, needed pure nursing care for a period of time, could be taken.
§ Under present legislation for joint financing, we can use joint financing money for putting that kind of wing on to a Part III accommodation. But, amazingly enough, under the legislation we cannot add it to a health centre; we can do it only if it is called a hospital. There are a great number of these small, niggling restrictions on how joint financing can be used, which is quite wrong. But they will always exist as long as the rules and regulations on how to use joint financing are laid down from upon high.
§ The Government are committed to returning power to the community. Here is a perfect example of where, if the joint consultative committees, on which 1340 both local authorities and health services are represented, feel that a scheme is justified, and they consider that they should use joint financing, that should be enough. Therefore, I sincerely hope that the noble Baroness the Minister will be able to accept my amendment. I beg to move.
§ 5.4 p.m.
§ Baroness YOUNG
I am sure that the whole Committee has listened with great care to what the noble Baroness, Lady Robson, has said, in speaking to Amendment No. 2 and to the series of amendments. I am glad of the general welcome that she has given to Clause 4 on the joint financing arrangments. The amendment that she has proposed would have the effect of extending the scope of joint finance beyond the personal social services to a broad range of functions, some aspects of which lie outside the responsibilities of local government. Indeed, she herself argued her case on extending the area for joint financing schemes. However, the intention behind Clause 4 is to give legislative expression to the present well-established arrangements known as joint financing.
The purpose of joint financing is to enable health authorities to grant-aid personal social services projects that are likely to be of value in the overall provision of care in the area; thus, incidentally, benefiting also the health services. The words that the amendment seeks to remove contain the statutory definition of the personal social services.
The funds for joint finance are part of those voted for health and personal social services, and the Secretary of State for Social Services is responsible for both. That is one reason why the Government believe it is appropriate for the National Health Service to help fund joint schemes in the social services field, but consider it would not be appropriate to extend the use of NHS resources in the way that has been suggested.
Perhaps I might take the example to which the noble Baroness referred of health education, which, indeed, is singled out in this amendment. In addition to the activities of the Health Education Council and those of the health authorities themselves, both of which are funded by the Department of Health, aspects 1341 of health education are carried out by local education authorities, the Department of Education and Science, the Department of Transport on such matters as road accidents, the Department of Employment regarding safety at work, the Ministry of Agriculture, Fisheries and Food on various nutritional matters, the Department of the Environment on health education with regard to sport and so on. It would be difficult to accept that National Health Service funds should be used for all of these matters.
The position in the public health field is that collaboration between local authorities and health authorities is already very close. The functions previously exercised on behalf of local authorities by the medical officer of health are now, following the reorganisation of local government in 1974, generally undertaken by an officer of the health authority appointed for this purpose by the local authority—usually a community physician.
Legislation specifically requires the Secretary of State for Social Services to make available the services of staff and facilities to enable local authorities to discharge their functions relating to public health. In these circumstances, it seems unnecessary to have to consider depriving the social services of any of the limited joint finance available to them.
The trouble with the term "welfare", which is included in the amendment, is that it does not have a generally agreed definition and could embrace a variety of matters, including social security. It is, however, often used to mean the personal social services and in so far as it does the clause, as it presently stands, enables joint finance to be applied to those services.
Even restricting consideration to matters which are specifically the responsibility of local government, there are clearly many fields with a health dimension where the health services can benefit from joint planning and collaborative effort. Such collaboration has increasingly been a feature of the work of the joint consultative committees, and we very much hope that this will continue and expand.
However, acknowledgement of such interdependence is not a convincing reason for using National Health Service and 1342 social services resources to fund the responsibilities of others. I think that the Government's position on this amendment is aptly summarised in paragraph 2.7 of the Report of the Royal Commission, which saidThe National Health Service cannot cover the whole field".It may be helpful to the Committee, if I add that we recognise that joint finance, provided with a statutory basis as it is by this clause, has a very useful part to play in assisting the continued development of the personal social services and in enhancing collaboration at local level. In recognition of this, my right honourable friend has said that the amount allocated to joint finance will be gradually increased over the next few years.
§ 5.10 p.m.
§ Baroness ROBSON of KIDDINGTON
I am very grateful to the noble Baroness for her reply. When I suggested that the use of joint financing should be extended, I apologise if I gave the impression that I thought it should be extended to all the fields which the noble Baroness mentioned. I thought that freedom to use joint financing should be extended, so long as there was agreement by the JCC. The JCC consists of representatives, members and officers of the health authorities and representatives, members and officers of the local authority. I should have thought that the knowledge that members of a health authority have of the limited funds available would mean that the way in which they would agree to money being used for the improvement of health education and welfare—I agree that "welfare" is a difficult word to define—within their local community was in safe hands.
I was hoping that, somehow, in the introduction to this Bill we could remove many of the restrictions that hamper people when they are trying to perform services to the community. I am sorry that the noble Baroness cannot accept the amendment. I shall read with interest exactly where I went wrong and perhaps will move a similar amendment on another occasion. In the meantime, I withdraw it.
§ Amendment, by leave, withdrawn.1343
§ The DEPUTY CHAIRMAN of COMMITTEES (Lord Derwent)
I take it that the noble Baroness is not moving Amendments Nos. 3 to 7?
§ [Amendments Nos. 3 to 7 not moved.]
§ Clause 4 agreed to.
§ Clause 5 [Power of health authorities, etc. to raise money etc. by appeals, collections, etc.]:
§ On Question, Whether Clause 5 shall stand part of the Bill?
Lord WALLACE of COSLANY
We oppose Clause 5 as we feel that it is completely and absolutely unnecessary. Considerable fund raising activities are being carried out all over the country by voluntary bodies such as leagues of friends and other organisations. There is evidence that such efforts are extending into the field of providing not only comforts at Christmas and so on but also—and this is very important—urgently needed equipment. Because of the financial limits imposed upon health authorities, they are not permitted to spend money on such equipment at this time. Why encourage health authorities to engage in efforts to raise additional finance when, let us face it, their major duty is to ensure the efficient administration of the health service? This work is being carried on by voluntary effort, at no cost to the health service. Therefore I repeat: why engage officers, and it may be quite a number, in fund-raising efforts when their primary duty and obligation to the health service is to see that it is managed efficiently?
Furthermore, and this needs extremely careful consideration, the effect of fund raising efforts organised by officials of a health authority could be to dampen down voluntary effort. The great value of leagues of friends, apart from their fundraising value, is the involvement of many people in the community and the creation of a relationship not only with the hospital but also with the staff and patients.
I mentioned this point during my Second Reading speech, and I invited noble Lords to come along to a fête in 1344 which I had a certain interest. I can say that the result of that fête, on a rotten, wet Saturday afternoon, was a net profit of over £4,200. My experience at that fête was remarkable, considering the weather. There were happy crowds of people at the fête. When I say "happy", I mean that I did not meet a miserable person. What is more important, the staff—the nurses and others—were running stalls and taking part in the effort, bringing some of the elderly patients around in wheelchairs. Most sensational of all, I found a chamber orchestra performing most beautiful pieces of music. When I inquired of the senior nursing officer where they came from she said, "They are our medical staff". This was a completely happy relationship.
May I put it this way: I doubt whether rank-and-file hospital staff would cooperate if it were a fund-raising function organised by officials of the health service and the hospital. Nor do I think that we should get the same community commitment and the involvement of so many people.
I appreciate that the Government intend the provisions of the clause to be permissive, but it is, in a sense, an encouragement direction. We are given a very vague indication of the sort of money raising activities that are envisaged. I think it was the noble Lord, Lord Cullen of Ashbourne, who gave us a list which was reminiscent of a little function run by the Mothers' Union—the sort of stuff that is part and parcel of friends' activities. And they do much more than was mentioned.
This is a very important point. What are the officials going to be involved in? We have to be very careful, and there has been a request for guidance. All the guidance that we have had so far has consisted of extremely vague assurances from Ministers, both here and in another place. We have had a vague assurance that there will be no striptease dancing—and that, I am pretty sure, will disappoint some noble Lords. There will also be no topless go-go dancing. I have no idea what go-go dancing is, but I have a vague idea of what "topless" means. There are many other things like that. Apparently, there will be no pop music; we do not know for sure, but this is what we are vaguely told.
1345 There are other important things which should be included in the guidelines. Let us suppose that the district health officials decide that there should be a fête. That is all right, but there is nothing here to indicate that the Government must insure the fête, otherwise public money may be wasted in organising it. But when fêtes are organised by volunteers, they take that in their stride. It is beyond my capacity, with so many lawyers in this noble House, to explain in detail the legal complexities, but what about all the legal complexities of running fund-raising schemes? We do not want a district health official to be pinched and brought before the courts for having contravened a certain regulation, simply because the Government want him to indulge in fund raising.
I am not joking about this. These questions have to be thought about, and quite clearly the Government have not given thought to this. It is a great idea to start fund-raising to help the health service but it is already being done in a better spirit than it will be done by officials. I am serious about these guidelines. If the clause is passed, then these guidelines must not only be published and made available but they must also be approved by both Houses. They must be made available to every authority before they start so that they know where they stand. If not, there will be plenty of dangerous pitfalls ahead.
The clause refers to encouraging the gift of money or property in trust. How will this be done? Again I am not joking, because this is quite a possibility. One can foresee some enthusiastic official getting posters done and put up in hospitals on these lines:"Have you made a will? Don't forget your hospital". A nice sort of greeting for someone coming in for a major operation! The noble Baroness laughs, but some enthusiastic official might do just that, or something very similar. So that is the sort of thing that we must be careful about.
How will these gifts of money and other property be encouraged? What is in the Government's mind (if anything) and is it really necessary, when already considerable numbers of people and families are doing this by means of their wills and gratitude gifts are not unknown. In fact 1346 they are common, for the saving of a life or the birth of a child. At a maternity unit with which I have had very close connections (my grandson was born there) and which is a very important place to me because I have fought for it over many years the staff are suggesting to people who wish to make a present—always when a baby is born everyone seems to be happy and there are usually boxes of chocolates and so on for the nurses—"If you want to say 'thank you' give us a donation for the new foetal units which we are trying to purchase". These are units which can preserve a baby's life and ensure that it lives a healthy life, even before it is born. A number of people in my area have already donated considerable sums of money towards this end, although I do not know whether it is approved by the department, we are encouraging parents and grandparents of new born babies to give something towards these units.
I really cannot understand this proposal. The point is that this is already going on. Is it not beneath the dignity of the National Health Service for this system of special pleading, officially directed, to be included in Government legislation? I really do not like it. People are willingly responding to voluntary effort, and I am pleased to see it because whatever official direction there is of any Government service, be it the health service, education or anything else, voluntary effort is a very good ally to have, and the health service already has it, as the noble Baroness Lady Macleod of Borve said, in Bethnal Green and in a wealthy area that she knows. The enthusiasm is there: do not negative it by bringing in official schemes when the officials should be otherwise engaged.
Let us face it, official money-raising does not get the same result as voluntary effort. I quote the example of local government lotteries, which are not included in this clause; at least we have had some vague indication although nothing official. But they have been an absolute flop. The clause has many subsections which are not necessary in any case. The use of the health authority land, for instance, for fund raising; that already happens. We had our fete on hospital land last Saturday week. It goes on everywhere—why put it in the Bill? It is absolutely useless. Then there is 1347 property and money held in trust. Good Heavens! That has been going on for years. One of the problems of re-organisation is the passing over of trust funds. Why burden legislation with the useless and the unnecessary?
This clause is wrong in principle; it would be wrong and divisive in practice. It is vague and indefinite; it is completely unnecessary, it is completely useless and should be withdrawn from the Bill.
It may be helpful if, before the noble Baroness the Minister replies, I make it clear that we on these Benches have no very special fears about Clause 5, although I take the point made very clearly by the noble Lord, Lord Wallace of Coslany, with regard to the possible effects of official action on voluntary activities by friends of hospitals and people of that kind. I share that possible anxiety although I cannot go with him in his fears that the area health authorities might dream up highly imaginative schemes and launch into extreme eccentricities with regard to strip shows, and so on. Indeed, if I had any fears it would be that they would be perhaps too little imaginative rather than too much!
Lord WALLACE of COSLANY
I did not say that. What I said was that vague assurances had been given in another place that there would be no topless go-go dancing and no striptease shows. I am sorry; the noble Lord might be interested, I am not.
Let me move on. I have risen before the noble Baroness replies merely because there is one point on which I should welcome a reassurance. This is a matter which was raised at Second Reading and it is one on which I think fairly positive reassurances were given. Nevertheless, I believe it would be helpful to your Lordships' Committee if we could be reassured again on one particular point. I should not like to think that there was any possibility whatsoever of a health authority that was particularly successful in raising money by these means later being penalised because consideration of its finances was taken into account by Government in allocating resources of another kind.
1348 It would be helpful if we could have reassurances on that specific point before we dispose of this clause.
§ Baroness MACLEOD of BORVE
I must apologise to the Committee for not being in my place when the noble Lord, Lord Wallace of Coslany, started to speak. I must tell him that the annunciators in the dining-room were not working and as I was having my first meal of the day I had no means of knowing that he was speaking.
In 1948 when the appointed day came and the Minister brought into being the National Health Service he said quite categorically that no officials of any sort were to help in any way with fund raising. Over the years that prohibition has been relaxed more and more until now the Leagues of Friends—as the noble Lord has said, I have the honour to be national chairman of the 1,080 leagues of friends—nearly all have an official of the hospital on the board. They have a matron, if there is a matron, or otherwise perhaps a No. 10, or they have the Administrator. They have somebody from the official side of the hospital, so inevitably when the subject of fund-raising comes up those people help. From those people down to the nursing staff, they now all help to raise money, as the noble Lord has said.
However, when it comes to the vast sums of money which this Part of the Bill will enable the authorities to ask for, in my view that is a very different thing altogether. For instance, it is within my knowledge that two of my friends happen to be chairmen of very large hospitals which need a great deal of money; so much so that each one of them is attempting to raise £5 million. There is no way in which an ordinary small league of friends, however hard it worked, could possibly provide that shortfall. Therefore I certainly support Clause 5, because it will enable people, whatever size of hospital they support, to be backed up by the authorities in the hospital.
One thing I should like to stress is that, with the network we have built up throughout the country of very good voluntary work, such as has been spoken about by the noble Lord, Lord Wallace, it would be a thousand pities if the authorities did not consult with, take 1349 notice of and act in co-operation with, the voluntary bodies in their neighbourhood. Of course, I speak primarily for the League of Hospital Friends, because they are specifically for hospitals, but there are many other voluntary organisations within the ambit of the local hospital who would like to come in if the authorities asked them to do so. As we all know, money is not easy to get, but I think that if they work together and never oppose each other then the health service can be enhanced by this clause. I am quite certain that the Minister is right and I would go so far as to say is very imaginative, in my view, in putting this clause in. I think it will be welcomed by everybody, certainly, as I said, on my side, so long as the good will of voluntary people—who work so hard to provide amenities of all sorts, from bedsocks to chapels, from lifts to golf courses, for psychiatric hospitals; everything for their hospitals—is not in any way dampened. I am quite certain it will not be dampened by this clause, and I certainly support it.
§ Lord PARRY
Before the noble Baroness replies, could she assure us that there will not be competition with existing large charity organisations which fund such activities as those of the Spastics Society and other bodies, and that we shall not see competition on a fairly grand scale for such funds as might be available?
§ Lord AUCKLAND
I approach this clause with some misgivings, although I think, broadly speaking, bearing in mind that we are living in an inflationary era, nationally and internationally, that the clause is necessary. But in the last analysis it is the voluntary effort, the voluntary contribution, which not only raises the funds but raises the morale. My noble friend, Lady Macleod, mentioned the leagues of hospital friends, of which she is the very distinguished national chairman, and I know from experience what excellent work the leagues of friends do, particularly in the long-stay mental hospitals. They provide teas for long-stay patients and parents and other relatives on Sunday afternoons. In fact my wife and I have in the past helped out in these various functions. So I think it would be a great pity if the voluntary spirit of raising funds was lost. At the same time, as my noble friend Lady Macleod said, very often the matron or 1350 the chief nursing officer is on the committee of the league of friends. This is certainly true of the hospital with which I used to be associated. Indeed the hospital secretary comes along and helps.
So already one has teamwork between what one might call the voluntary side and those who are remunerated. Provided there is this spirit of co-operation, I do not think that the fears of the noble Lord, Lord Wallace of Coslany—who has had, I know, vast experience in this field, and his speech was one of the greatest importance—should really materialise. For example, to take another sphere, again in the hospital with which I was associated and of which my noble friend Lord Grenfell, so revered in this House, was a very respected chairman of the hospital management committee, Queen Mary's Carshalton, there were cricket matches every summer between the patients and the staff and the hospital officials, the hospital boards; there was nearly always a raffle or something. They raised funds and they certainly gave pleasure to all concerned.
We hear a lot of complaints, I think quite rightly, about the entertainment of very important persons at hospital functions which have to be borne at the expense of the hospital and ultimately by the National Health Service. Particularly in the hospitals in the grey areas where there may not be the funds available, where the league of friends with all their efforts perhaps will not be able to raise the money; let there be (and clause 5, as I read it, will enable this) co-operation between the league of friends and other voluntary bodies and the secretary and officials of the hospital, if I may use that rather dogmatic term. This would fulfil the needs of this clause, about which I must say I am not happy, chapter and verse. I think the principle of the clause is right, in that at a time when raising money by voluntary means is far from easy it will enable albeit a relatively small sum of money to be raised in some areas. Provided it is properly supervised, provided it is kept within the ambit of the law, it will help the financially ailing parts of the National Health Service.
§ Lord SANDYS
We have had a very interesting debate on this important clause. I should like to begin my remarks with a reference to the speech of my noble friend 1351 Lady Young at Second Reading, in which she said that as we originally saw this provision it was one of the more minor ones, important but not as important as other clauses in the Bill. She pointed out that authorities already have power to receive, hold and administer trust funds. This point was referred to by the noble Lord, Lord Wallace. These include unsolicited donations and expressions of good will, and the noble Lord referred to gratitude gifts by patients, the results of the work of Leagues of Friends and similar bodies. Although this income is small in relation to central funds, my noble friend suggested that these contributions have an importance out of all proportion to their relative size. Even small sums or items of equipment can be of great value at local level. Fund raising also brings the local community closer together with its hospital. This point was constantly referred to by noble Lords on all sides of the House.
I should like to point out that although the noble Lord, Lord Wallace, ended his remarks by saying that the clause was useless and unnecessary, he paid considerable currency to the value of fund raising in its present context. The Government's contention is this. It is a permissive power, and I think the noble Lord agreed with it. He also agreed that there was no sense expressed in the Bill that local health authorities would be compelled by pressures of one sort or another to make use of it. The Government's contention is that it is supplementary and I think that as such it is a very useful supplement.
The new power is a modest extension of existing ways in which the NHS can draw on voluntary funds. The reaction to this clause—or as we see it, from the Government's point of view the overreaction—of the Party opposite in another place in Standing Committee probably illustrates, better than any other part of the Bill, the differences between us. However, I think that the discussions in your Lordships' House have been of a more fruitful nature. This debate has demonstrated that we all want to see the NHS thrive. The difference between us is the means by which that should be done.
Although the Party opposite remains opposed in principle, noble Lords opposite 1352 have been rather more restrained than some of their more vocal colleagues in another place, remembering of course, that discussions in Standing Committee "G" occupied a considerable part of the procedures. I have spent considerable time examining this matter and I shall refer to one particular passage later.
There are two main reasons why we are giving authorities power under this clause. The first is to enable the NHS to supplement its existing resources; the second is to allow authorities to make better use of the present voluntary funds. I should like to refer to the speech by my honourable friend the Parliamentary Secretary in another place at column 569 of the Official Report for Standing Committee "G" on 13th March. My honourable friend Sir George Young said:A main reason for giving authorities a direct say in fund raising is to enable them, if they need, to deflect appeals for ordinary funds away from glamorous appeals for equipment for acute services. But it is not sensible to restrict their discretion to use the power only to assist with any of their functions. That would be cumbersome. We must allow authorities the maximum flexibility".That is the Government's intention. We believe that in that sense authorities will be able to make better use of funds and to avoid the problem referred to in Standing Committee; namely, the problem of the purchase of white elephants.
I am sure that noble Lords have seen in the Official Report of the Standing Committee the particular examples that were given, and I need not go into that matter any further. At a time when public expenditure is necessarily being curtailed it would be foolish to do otherwise. As my honourable friend the Parlimentary Secretary said in Standing Cornmittee "G" at column 739:The demand for health care is infinite and resources are not. No Government ever has been or ever will be able to find all the resources to meet the needs of the Health Service. Voluntary funding is a useful supplement to central resources".We recognise the reality of all this, and this clause is a modest measure designed to help the NHS close the gap between resources and demand. It in no way undermines our commitment to see the NHS properly funded. On this point I can do no better than once again to quote my honourable friend in Standing Committee when he said, at column 542: 1353We hope that substantial sums will be raised, but that in no way undermines our commitment to see the NHS properly funded, any more than the present power to accept and use voluntary contributions has undermined any previous Government's commitment to the NHS".Nor will the raising of funds under this power be used to reduce centrally allotted funds. Here I come to the point made by the noble Lord, Lord Winstanley, and I was very glad that he raised the point.
In his closing speech on Second Reading, my noble friend Lord Cullen of Ashbourne reiterated the categorical assurance given by my honourable friend Sir George Young in another place that money allocated from the centre would not be reduced by amounts raised under this power. I should like to repeat that assurance. The precise reference, for the noble Lord, Lord Winstanley, is column 710 of the Official Report for Standing Committee "G", where it says:I would make it absolutely clear that I, the Minister of State and the Chancellor of the Exchequer have no intention of reducing the amount of money allocated to the Health Service by the amounts raised under this new power".I feel sure that that will satisfy the noble Lord.
It would clearly be completely counterproductive to make such reductions. There would be no incentive if it were known that for every pound raised by voluntary means a further pound was taken off by the centre. The power is there if local health authorities want to use it: no one, as I said earlier, will compel them to use it. We are merely saying to authorities: if you want to draw directly on local good will then you are free to do so.
Much of the discussion on this clause has centred on the activities in which authorities are likely to engage when they use the power. There was some wild speculation on this matter in another place which I would not dream of dilating or digreesing upon. Perhaps I may draw your Lordships' attention to particular aspects which have been raised in your Lordships' House. The question of lotteries was raised, and I think that the noble Lord, Lord Wallace of Coslany, would like some guidance on this matter. Perhaps it would be more useful if I were to begin by mentioning that the Government will be issuing guidance to health 1354 authorities regarding the exercise of their fund-raising power. I can give the noble Lord, Lord Wallace, the assurance that guidelines are currently being prepared and will be made available to the House in due course. I can give noble Lords an indication of the subjects to be covered. The guidelines will explain our intention behind this provision, emphasising our belief that voluntary funds are a valuable supplement to Exchequer funds and we think that health authorities should have power to engage in voluntary fundraising using the usual types of methods adopted by fund raisers.
The guidance will set out very clearly what fund-raising activities are permitted, and that will cover advice on three main types of activity: first, those not included in the type permitted in the clause—that is to say, moneylending, property speculation or trading activities; secondly, those such as large-scale lotteries, bingo evenings and gambling which are barred by other legislation—and I shall come to that aspect in a moment; and thirdly, those which, although they do fall within the general type set out in the Bill, are considered unsuitable for the NHS. Where there are difficulties they are likely to occur in relation to the third category. But whenever an authority is in any doubt about the legality or suitability of any activity, we shall suggest that it consults us or legal colleagues. The Secretary of State's reserve power to prohibit any activity which he considered unsuitable will be explained. I do not know whether your Lordships would like a lengthy explanation on lotteries. I shall certainly give such an explanation if the noble Lord wishes.
§ Baroness PHILLIPS
Before the noble Lord moves to that matter, does he know whether these activities would be subject to all the other restrictions which other people have to undergo; for example, having to pay VAT on tickets for an entertainment? There is also the question of produce. If they are going to sell jams in order to raise money for the hospital, that may be condemned by the public health authorities. But I suppose that that may be one way of stimulating customers in the hospital. The matter is not simple at all. Any of us who indulge in money-raising know that you suddenly run into many different regula- 1355 tions and, indeed, laws. One wonders whether, because this is an official authority, they will be subject to the same problems. Perhaps the noble Lord does not know, but it is a very valid point for anybody trying to raise money.
§ Lord SANDYS
I am glad that the noble Baroness, Lady Phillips, has raised these matters because they are very practical and important matters. In general terms there will be no exemptions because, of course, much prior legislation covers the matters which she has raised. A question was specifically asked in your Lordships' House—and I do not have the reference under my hand—in regard to jam, which I think my noble friend Lord Cullen of Ashbourne answered a short time ago; he dealt with that important matter.
With regard to lotteries, I think that it would be useful at this point to say this. We shall be considering separately whether to give health authorities power to run "large" lotteries. The main legislation is the 1976 Act, and if health authorities were to have this power, it would be done via amendment to this legislation, the House having the opportunity to consider it in the proper context. The Home Secretary already has the operation of the Lotteries and Amusements Act 1976 under review, following the report of the Royal Commission on Gambling, which the House debated on 29th October 1979. This is a complex Act, and it seems right that its scope should not be extended while the review is in progress. Health authorities may, of course, benefit from the proceeds of lotteries organised by hospital leagues of friends and other bodies who may register as societies under the 1976 Act. I should like to pause in my argument on lotteries and thank my noble friend Lady Macleod of Borve for all her remarks on behalf of the league of friends of which she is, of course, the national president.
§ Lord SANDYS
Of course, I beg my noble friend's pardon. It is very important that all the comments made by the leagues of friends in this regard are taken into account. I should like to turn 1356 to bingo and gaming, because this has been mentioned both here and in another place. The clause would permit bingo and gaming machines only where these were merely a small part of a larger activity or entertainment and not the main attraction. These activities or entertainments are what are defined as "exempt entertainments" in the Lotteries and Amusements Act 1976. One of the main conditions for bingo at exempt entertainments is that it is not the only or only substantial inducement to persons to attend. We can see no objection to bingo in these circumstances.
This Bill does not, therefore, give authorities power to instal fruit machines en masse or permanently to run bingo evenings. Health authorities and statutory authorities can only do that which the legislation allows. The legislation which deals with gaming and bingo requires those who want to do either to form themselves into societies or clubs and then apply for a licence. In other words, it corroborates my earlier remark that the normal restrictions apply.
I have dealt with gambling at some length, and I hope that I have clarified, to a limited extent anyway, the queries raised by noble Lords. We shall also give clear advice on the potential pitfalls in fund-raising; in particular we shall emphasise the unsuitability of any sponsorship of events by companies concerned with cigarette manufacture. Reference was made earlier to strip-tease dancing and go-go topless dancing. I do not know whether the noble Lord, Lord Wallace of Coslany, would like me to say a little more on that subject.
Lord WALLACE of COSLANY
Please do not. It is highly embarrassing. I do not want to be involved with it. I was just pointing out that in another place the Minister gave great assurances, which I am sure will upset some Members, although they will not upset me.
§ Lord SANDYS
I hope that the assurances were clear. In the case of strip-tease dancing, perhaps I may say that this activity will not be used either directly or indirectly by health authorities or by agents acting on behalf of health authorities as a method of raising funds 1357 or as a method of attracting members of the public to attend fund-raising activities. Perhaps I have said enough in that regard.
The guidelines will deal at length with the question of National Health Service staff involved in fund-raising. I think that that point was raised by the noble Lord, Lord Wallace, who felt that officials might be spending time, either unnecessarily or time which could be better used in other spheres. We shall make clear that while preparation of fundraising events may become part of the normal functions of some staff, no member of staff should be under any obligation to participate in fund-raising activities as such. We shall also advise on the need for tact and discretion in any involvement of patients or their relatives. Activities such as ward collections will not be permitted. There was a reference to that in another place, which I think caused some anxieties, and I should like to give that assurance now.
The guidance will explain in detail the technical provision relating to the raising and administration of funds. It will emphasise the need for the aims of any appeal to be clearly stated at the onset, along with any secondary purposes. This should give a clear indication of the use to be made both of any excess funds raised and of funds raised should the appeal fall short of the amount needed for the main purpose.
I hope that my reply has been sufficiently full. Equally, if it has been too full, I apologise to those whom I have wearied among your Lordships, but in view of the interest expressed in it in another place and in your Lordships' House, I think that it was justified.
§ Lord PARRY
As the noble Lord is about to sit down, despite the fact that his full reply was very full, may I remind him that he did not give an assurance that the Government had considered the efforts of major fund-raising sources which are already making contributions to the health service. I am sure that the reply he has given has assured my noble friend, Lord Wallace, that his fate will not become a fate worse than death. I should appreciate an answer to my question.
§ Lord SANDYS
In reply to the noble Lord, Lord Parry, I am afraid that I can- 1358 not give him the assurance he seeks because competition will almost inevitably take place between fund-raising activities undertaken by health authorities and other bodies. As he will well know, it is very difficult to co-ordinate both dates and events within a pattern within the existing structure. Very often national charities are concerned with quite different purposes, other than hospitals. I agree with him in the particular case that the need for some local liaison or co-ordination would be highly desirable, but I cannot give him the assurance he seeks.
I should like to press the noble Lord a little further on the point I raised with him and to which I know he referred. In quoting Ministers in another place, I understood him to say that there was no question whatever of funds allocated to the National Health Service being reduced in respect of funds raised in this way. That I fully accept. My question was a rather more specific one. If an individual health authority is unusually successful and raises a large amount of money itself as a result of its own initiative or the generosity of the people who live in the area, is there any question whatsoever that that particular health authority might be penalised in its requests for funds out of the gross allocation to the National Health Service? This is a slightly different and much more specific point.
§ Lord SANDYS
It is clear that the situation as I have described it is fulfilled. The noble Lord may be referring to the activities of the Resource Allocation Working Party in this particular context. I think I can give him the assurance that money raised in the particular context we are discussing under Clause 5 will be sacrosanct.
§ Lord PLANT
Could the Minister give us an assurance that very specific guidelines will be issued to hospital management committees and local authorities who are running lotteries that they should not put undue pressure on patients, and in particular patients in emergency wards or out-patients, to purchase tickets and to make subscriptions to these money raising funds?
§ Lord SANDYS
I do not know whether the noble Lord, Lord Plant, was in your 1359 Lordships' House when I mentioned this particular aspect. I apologise to him if I did not make it sufficiently clear. I am quite sure that the guidelines will be sufficiently specific for his purpose and will express those sentiments.
§ Baroness MACLEOD of BORVE
May I ask my noble friend to specifically tell us that the Minister will also issue guidelines to authorities asking them specifically to consult all the voluntary bodies when they are asking for local money?
§ Lord SANDYS
The noble Baroness made her case with the adverb "specifically" twice. I will certainly pass on her suggestion to my honourable and right honourable friends and hope that this will give satisfaction.
§ 6.2 p.m.
§ Lord WELLS-PESTELL
The only thing I can say about this clause is that in my view it is a most unfortunate one in this particular Bill. I understand it—by that I mean that I understand its inclusion, because it follows and flows from the philosophy of the Government. The philosophy is that if you can get money in order to reduce expenditure, then do so by all means.
I know that the noble Lord has said that his right honourable friend the Under-Secretary of State in another place has given an assurance that in no circumstance will any money obtained from any activity that one finds mentioned in the clause be used in such a way as to—shall I say?—cause the Government to give less money to the particular authority. But I must remind the noble Lord that we cannot trust the Government. We cannot trust the Government's word. The Government, before the election, were going to increase child benefit. They were going to do a whole lot of things which they have not done.
§ Baroness YOUNG
I am sorry, but that is not true. The Government are going to increase child benefit from next November.
§ Baroness YOUNG
If I may return to the question of child benefit, which is rather wide of the Bill, it was increased in the April immediately preceding the time when we came to office in the succeeding May, and the increase in child benefit of 19 per cent. will keep up with the rise in prices.
§ Lord WELLS-PESTELL
That was done by a Labour Government. If the noble Baroness will look at some of the election promises, she will find that there was a promise made that it would be increased either last November or last April. That promise was not fulfilled. It was not the only one. If I am a little sceptical about the assurance that has been given by the noble Baroness's right honourable friend in another place, then have every reason.
However, it is not so much that which concerns me. It is that we, on this side of the Committee, believe that this should be the responsibility of the people, as personified by the state. The health service should be provided by the people through the Government. I see in this, if not immediately, an attempt to make local hospitals, not self-supporting—they will never be that—but to some extent contribute eventually towards their own support. It may well be that it is not the intention of the Government to do so immediately, but that is the intention and we shall be moving backwards to the time of the voluntary hospitals, as this country has gone back to the 1930s since we have had this Government. This provision will lend the opportunity to do so.
I want to deal with one or two specific points. First, if health authorities are going to raise money for special types of equipment, who is going to lay down what those special types of equipment should be? We know that a number of local hospitals are raising enormous sums of money to buy scanners. This is perhaps a highly desirable thing to do. But what they forget, or what they do not take into account, is the enormous upkeep of a scanner; the amount of money that has to be found to maintain it and work it in the course of the year. It is not so much buying the initial machine, it is its upkeep. I want to know who is going to lay down what kind of equipment can be bought.
1361 There is a tendency these days for hospitals to want to enter the field of some kind of dramatic surgery. When I was appalled to find how few consultants who are specialists in rheumatology have merit awards, and yet there are probably far more people in this country suffering from one form of rheumatism or another than from any other disease. It is not one of these dramatic things. It is not one of these things which bring you a lot of advertisement. There is no glamour attached to it. I am concerned about who is going to lay down the type of equipment that is bought and who will make those decisions.
I am concerned also about another side of it. I was glad that the noble Lord went at great length into the question of lotteries. He said that there will be no intention of putting in a large number of fruit machines. The implication of that is that the Government will approve of some being put in.
Lord SAN DYS
I wonder whether I could just quote what I said, and put the noble Lord right here. What I said was that this Bill does not therefore give authorities power to install fruit machines en masse or permanently run bingo evenings.
§ Lord WELLS-PESTELL
It does not give the health authority power to put in fruit machines en masse, which by implication means it can put in some. There is a serious principle here, and that is the whole question of gambling,with which the Government ought not to be associated. It is one of the worst possible social evils that we have in this country today.
A noble Lord: Bingo!
§ Lord WELLS-PESTELL
I did not say bingo; I was talking about gambling and, in particular, fruit machines and the like. It is highly undesirable that the Government should allow themselves to enter that particular field. When they come to consider what they will permit and what they should not permit, they certainly ought not to permit anything which can really come under the term of gambling as it is understood at the 1362 present moment. I am not talking about buying five tickets for a shilling for a bottle of whisky. I am talking about the more serious forms of gambling, with which I do not think the Government ought to be associated.
Another point is this. What if the income from trusts and lands and that kind of thing is so great that it mounts and mounts? Have the Government thought of that? Hospitals may be situated in fairly well-to-do areas, where people may leave a tremendous amount of money on trust to them, and a good deal of property that brings in a fair amount of money which cannot be spent. That situation could well arise and the money accumulates and accumulates. What happens to that? I am not saying that the income will ever exceed the needs of the hospital, but it could provide a colossal sum of money. Are we to understand that the Government will not step in and say, "Well, this was raised on behalf of the National Health Service, albeit for your hospital, but as there is so much money to spare and it will not be needed, then it goes into some central pool?"
I hope that the Government will look very carefully at this clause, because I believe there are more difficulties associated with it than would appear on the surface. I believe there is a very serious and important principle involved here in the Government associating themselves with some forms of what I would call pernicious gambling.
§ Lord SANDYS
Of the two points the noble Lord has raised, first of all I should like to clear up the question of the administration of trust funds. In my opening remarks, I quoted my noble friend Lady Young in this regard, because in her speech on Second Reading she pointed out that authorities already have power to receive, hold and administer trust funds; so this would be handled in the normal way. In regard to the special types of equipment, I made a specific reference to the problem of unsuitable purchases and I mentioned white elephants. One reason why we are giving power to authorities is because it is they who know whether they can afford the consequences of their purchase. In this context, the noble Lord, Lord Wells-Pestell, mentioned the cost of maintaining a scanner. As I have said, 1363 this will avoid white elephants, and I think it is an important point that expensive equipment should lie idle, collecting dust. I am very glad the noble Lord raised this matter. We believe that it is catered for. There will be no specified list of equipment. The authority itself will decide what to appeal for, and we believe it will be the best judge of what is needed, what it is best able to look after and how best to adjudicate between conflicting claims in this context.
In reply to the very serious strictures which the noble Lord made in regard to bingo and gaming, I would point out that I said in my remarks that bingo and gaming machines will form merely a small part of a larger activity or entertainment. These gaming machines will form only a part and will not be the main attraction, and I think it is important to mention it in this context. Also in this context, in reply to the noble Baroness, Lady Phillips, I said that the existing legislation would apply.
Lord WALLACE of COSLANY
As I moved the deletion of the clause, I think in common fairness and respect to the Committee I should reply. Noble Lords need not look surprised; that is how I see my duty. We have had a very good debate on this; it has been a very useful debate. We take this very seriously. I will make no reference to another place. They have their own peculiar customs, particularly in Committee stages, as some of the former Members of another place know. I see a former Chairman of Ways and Means facing me at the present time. Now that we have had this debate, I am more convinced than ever that the clause is ridiculous. I would call it a "silly-billy" clause if there were such an expression to use. The noble Baroness, Lady Macleod, spoke about some large sums being obtained from wealthy people. She said that people were donating large sums of money.
§ Baroness MACLEOD of BORVE
I hope I did not quite say that. What I did say was that chairmen of large hospitals are asking for large sums to keep their hospitals going. They have not been given them yet, but with this Bill they will have the power to do so, which they have not had so far.
Lord WALLACE of COSLANY
They have the power, and money is still being given. The Bill does not make any difference so far as that is concerned. If there is a wealthy businessman here who wants to give a large sum to a hospital, there is nothing to stop him; so it can be done now. That is my point. All these things that we have been talking about can be done now, except, of course, the provisions for bingo, et cetera. I want to point out to the Government that it is already evident from the ministerial replies that this clause lays a minefield of difficulties and risks for the future. There is no doubt about that. It is proved by the fact, which I welcome, that the Government are to provide guidelines. They will certainly need them, and they will want some very good legal advice in the preparation of those guidelines. I hope the Committee will give them thorough consideration.
One very important point was made by the noble Lord, Lord Auckland, when he pointed out—and I entirely agree with him—that officials, including senior nursing officers and so on, sit in with leagues of friends now; there is no doubt about it. They spend much of their spare time, such as they have, doing it willingly and happily; so why disturb that? The other point is about the white elephant business. This happens with the friends that I know. Before a league of friends purchases equipment, it consults first of all with the consultants, who are always demanding something extra special, and then with the officials, not only of the hospital but usually of the district health committee as well. They come to a conclusion about what is the best thing to buy with the money they have available. Then it is done, with all the questions of maintenance taken into account.
What worries me today—my noble friend Lord Wells-Pestell has also stated this—is the possibility of the Government probably taking powers for larger lotteries. The little bit of gambling that goes on at the present time in connection with leagues of friends is nothing, but larger lotteries provide a tremendous problem. In a sense, this is a moral problem. It will offend a lot of decent, progressive people who think that it is wrong that we should introduce gambling in order to safeguard people's lives in a 1365 hospital. They are right in thinking that. I think it is a dangerous thing for the Government to get involved in, especially involving area health authorities, regional health authorities and so on. I believe we have to think again about this; we have got to think about it seriously. This clause was said to be a minor list of things, a minor clause. It is not; it is a major clause of principle. I will not divide the Committee. We have had a very good debate, and it may be that some of us might be able to provide some amendments to the clause at another stage.
In conclusion, I should like to thank all the noble Lords and noble Baronesses who have spoken on this. The clause is far more important in its moral effects than some people think, and for the sake of the voluntary services I hope that no precipitate action will be taken by officials to upset the spirit of voluntary service that still exists, and must exist. Thank God it does exist, because it has a great effect in the community.
§ Clause 5 agreed to.
§ Clause 6 [Provision of public money for, and financial duties of, health authorities, Health Boards, etc.]:
§ Lord PITT of HAMPSTEAD moved Amendment No. 8:
Page 12, line 35, at end insert—
("(d) to hospitals which carry special clinical units agreed with the medical profession sums allotted or further allotted by him to those hospitals to enable them to provide those agreed special clinical services in that year.").
§ The noble Lord said: The purpose of this amendment is to introduce into the debate the question of central funding for certain special services. During a recent debate on the NHS I instanced the cost of the haemophilic unit at the Royal Free and said it was absurd that such costs should fall on the North Camden district. I gave that illustration then, but it holds good for most kidney units and organ transplants and for things like bone marrow transplants, and it will hold good if all the suggestions about Interferon turn out to be right.
§ The Government should accept that certain forms or treatment agreed with the medical profession should be centrally 1366 funded, not through regional, area or district authorities. This would have an advantage from the Government's point of view in that it could be rationalised. My view is that all forms of treatment that are available and known should be available under the NHS. They cannot all be available at district hospital level; certain forms of treatment are specialised and can only be given in specialised units. It is my view that those specialised units should be centrally funded, and it is in that spirit that I beg to move.
§ Baroness MASHAM of ILTON
I support the amendment because had the National Spinal Unit at Stoke Mandeville been nationally funded, it would not now be in its state of ill-repair and be nationally funded by the voluntary sector. Many people who have worked in and been patients at Stoke Mandeville Hospital's spinal unit—which, after all, has served most of the country and all the services, including many people from overseas—would have benefited had national funding been available. We must consider closely whether we are to have a regional or a national health service. National funding for centres of excellence would save money and, as the noble Lord said, it is too expensive to have a specialised service in every region.
§ Lord MACKAY of CLASHFERN
It is quite plain that the ultimate source of the money for the specialised services to which the noble Lord, Lord Pitt of Hampstead, and the noble Baroness, Lady Masham of Ilton, have referred is with the Secretary of State, and the question is whether it should go directly to a particular specialised unit or come down through the regional authority. The difficulty is that people concerned with a specialised unit have concern that they should get what they consider that unit requires. Local managers and authorities, on the other hand, have pointed to the fact that you can get too many costly specialised units which are difficult to control and which tend possibly to interfere with other priorities; and, accordingly, to get a balance between spending on specialised services and spending on more general services, you must, in our view, have proper local decision-making.
1367 That does not, of course, mean that decisions about individual projects should not be influenced by what takes place at the centre. The important thing is that the money which is allotted from the centre takes account of the balance of the specialised services. Our view is that the present system, from that point of view, is desirable, because the method of calculating regional shares of resources already makes allowance for services serving populations from one or more other regions or for existing specialties. To take the example given by the noble Lord, Lord Pitt, although ultimately the money comes out of the North Camden district, the money which goes to the North Camden district takes account of the fact that the money will go out from there to the specialised unit, and accordingly our view is that for these practical reasons this is the better system.
There are some what might be looked on as legalistic difficulties about the amendment which perhaps go deeper than mere legalism. Hospitals as such cannot receive funds; they would have to go to some authority. Whether a hospital should establish or continue to house some specialised clinical service is a decision not for the Secretary of State to agree with the medical profession; it is for the health authorities to reach decisions on such matters within agreed national planning machinery. The medical profession—although I think we all recognise what it is—is not a very precise term in this context.
Who is it with whom this agreement is to be made in relation to a specialised unit? We would say that decisions of that kind are better taken by the authorities, of course within a national planning framework, Accordingly, it looks as though the amendment, put into effect, would make it extremely difficult to make the necessary calculations to enable this form of funding to go through, and, indeed, create a special bureaucracy to deal with this aspect. Accordingly, while I entirely understand the concern which has been expressed, our view is that the better system is the one presently proposed, and I invite the Committee not to accept the amendment.
§ Lord PITT of HAMPSTEAD
I regret that the Government are taking a negative 1368 view about this subject and I beg them to think again about it. There would be from the Government's point of view several advantages which they have obviously ignored. The first is the one I mentioned, that of rationalisation. It is not possible to have, say, haemophilic units everywhere in the country, and therefore when such a unit is established it must serve several regions.
I do not think that, if there was central funding, the Secretary of State would be presented with any difficulty in having discussions with representatives of the medical profession, because the Government are frequently in conference with such representatives. I recognise that the noble and learned Lord the Lord Advocate, being a lawyer, sees legal loopholes, but I do not think that he need be so legalistic about this point, bearing in mind what I say about the Government frequently being in conference with representatives of the medical profession. This is common practice.
I always thought that the amendment might need to be more tightly drafted, and I am not too bothered about that. I hope that Members of your Lordships' Committee also will not be too bothered about that. If the amendment needs more careful drafting, I hope that people more capable at drafting than I am will do that. I should like the Government to think again about this question on that score.
I do not agree with the noble and learned Lord about the difficulty of calculating. If it is agreed that the country should have a certain number of units to deal with certain types of illness or to provide a certain type of treatment for a common illness, then it would not be too difficult to decide where these units should be located. In fact, usually such a question solves itself. At this moment, for example, most of the advanced treatments are carried out by hospitals through specialists receiving trust funds. The selection takes place in that way. All that my proposal would entail would be the Government agreeing to take on and fund this role as part of the National Health Service. That is all I am asking for.
I know that in the allocation of funds to regions, areas, and districts the question of special expenditure is taken into 1369 account. But this question of taking into account special expenditure—and in the eyes of those who have to do the job it is not quite being taken into account—has caused some of our problems. Putting aside the question of whether funding regionally and locally is a better method, the central funding of the special projects would be a marked improvement over the present situation and would prevent some of the problems that have arisen so far.
I never intended to divide the Committee on this amendment. I had hoped that the noble and learned Lord who replied for the Government would see that they gave it careful study. I am still asking for that. I am not asking for more than that, but I shall return to this question at the Report stage, because I regard it as of the utmost importance. I beg leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ On Question, Whether Clause 6 shall stand part of the Bill?
§ 6.34 p.m.
§ Lord WELLS-PESTELL
We come to a rather important clause, which deals with the provision of public money for, and the financial duties of, health authorities, health boards, and so on. I wish to confine myself to one aspect of the clause, relating to the Government's intention to impose cash limits on health authorities. If I understand the clause correctly, not only will the Government impose cash limits on health authorities, but the limits will be legally binding. This matter exercises my mind rather more than do some of the other aspects. If the limits are to be legally binding, I would ask the Minister how the requirement will be enforced. How does one set about legally enforcing the cash limit if a health authority overspends? What are the penalties? I am not being facetious about this. I really do not know how this situation is to be dealt with.
It is reasonable to expect the Government to be in control of public expenditure. We may disagree with the Government about how they do that, but we suggest that, if measures need to be taken against a health authority that has overspent, it would be much more acceptable if they were taken in an administrative, rather 1370 than a legal, manner. I am not unaware of the fact that in the past some health authorities have run into financial difficulties, and have overspent. I am also aware, as will be other noble Lords, that the present Secretary of State took what some of us felt was unnecessarily drastic action against one authority when instead he could have used existing powers.
I regard the clause as most unsatisfactory because it suggests a course of action without giving any indication as to how it is to be implemented. It is one thing to look at the scope, function and responsibility of a health authority from the remote situation of the office of a Secretary of State, or an office in the department. On the other hand, it is almost impossible for a health authority to make arrangements in advance to cover every financial crisis, contingency, or emergency likely to arise. There are day-to-day problems on which decisions must be made, involving the spending of money, and one makes such decisions because one thinks that they are right.
I remember that when I was at the department a situation arose relating to the City and East London Area Health Authority, which was likely to be overspent by about, I believe, £600,000. Given its problems, the authority was finding it very difficult to comply with the requirements of its budget. Such a situation is not at all surprising. Many area health authorities have such experiences. On that occasion my right honourable friend Mr. Roland Moyle, the then Minister of State, after much discussion came to the conclusion that the right thing to do was to allow the AHA in question to carry the amount into the next financial year. That was done, and I believe that the matter was satisfactorily resolved.
I can well understand that it may not be possible to take action such as that on every occasion. However, I do not like the recourse to some form of legal action. Surely the Government realise that if we are to have an efficient National Health Service, there must be co-operation and understanding between the theoreticians at the top and those people who are providing the service and coping with the day-to-day issues. I do not think that the kind of sanction proposed in the Bill is likely to foster the kind of relation- 1371 ship which should exist, and which I am sure the Secretary of State himself would want to exist, between him and those doing the day-to-day work.
As I said a short while ago, I think this clause is really very unsatisfactory. In our view it will result in concealed cuts, because you could get a situation where a health authority, fearing that it might run into the red, that it might overspend, will underspend continuously throughout the year in order to avoid overspending and therefore will perhaps finish up with not having spent the money that it was given to spend in the first instance—and, if I may say so, we have had underspending. I think this could affect the services; that we could find it a threat to the services; in other words, that it could result in a cut in medical services.
It would also give rise, I think, to a lack of flexibility, and it is not now possible to run a large concern unless there is a measure of flexibility. So I feel that this threat of some legal action may cause inflexibility; I think it will cause some sort of under-spending; and, of course, it must cause a great deal of uncertainty on the part of those people who are administering the health authority. I do not know whether the noble Baroness the Minister will feel that anything can be done about this. Perhaps I ought to content myself with some kind of explanation as to what is meant by legally enforceable "or" legally binding", and I should be grateful to have that information.
§ Baroness YOUNG
I am sorry that the noble Lord, Lord Wells-Pestell, should feel that this is a very unsatisfactory clause, but I can assure him that in this we are not seeking any new, draconian powers. Health authorities have always been expected to conduct their business within the financial resources allocated to them, and the introduction of cash limits on public expenditure required us to change our methods of financial management. It might be helpful if I explained in a little more detail why the new procedure is necessary.
The vast majority of health authority funds are money voted by Parliament to the DHSS. Like all other Government departments, the DHSS must not exceed 1372 the sums voted by Parliament; and this, obviously, is a basic rule. Under the existing provisions of the 1977 National Health Service Act, the Secretary of State has a duty to advance to health authorities such sums as they need to meet approved expenditure. As the Minister for Health explained in Standing Committee in another place, it is clear that we have a mismatch here. Health authorities are to be judged by how much they expend: the DHSS by how much it advances. As he said, authorities could legitimately build up their stocks or reduce the amount they owe to creditors, and still keep within the approved expenditure ceiling; but the DHSS could, as a result, overspend because, by the letter of the law, it had to advance the cash to finance these transactions.
This situation began to cause problems only when the previous Administration introduced cash limits. Before then, the DHSS could seek supplementary estimates to adjust the relationship between approved expenditure by the NHS and the actual cash requirements on the DHSS that this expenditure would generate. Cash limits, however, placed a ceiling on the amount which could be sought by way of supplementary estimates, and eliminated this sort of adjustment. Noble Lords will therefore see that it is necessary to relieve the Secretary of State of his duty to advance sums needed to meet approved expenditure and replace it with one to make a predetermined quantum of cash advances. This is what is achieved by the new Section 97.
As I have indicated, the old system of approving expenditure involved the submission of estimates for approval. We believe this is now unnecessarily bureaucratic, since the distribution of resources is now guided by the RAWP mechanism. However, the Secretary of State has no formal machinery for ensuring that certain money is spent according to national policy. The Minister quoted joint financing as a example where, as a national policy, we (the Government) earmark part of health authority funds for this purpose. To cover this, we have provided that in place of calling for, approving or modifying estimates, the Secretary of State should have a simple power of direction relating to the application of funds by health authorities in the new Section 97(3).
1373 The noble Lord asked a quite specific question about how a cash limit can be legally enforced, and I would try to explain in this way. If a cash limit is overspent in year 1, the overspending will be taken off in year 2. This happens at present. But if the authority persistently overspends, we must embark on our RAWP powers on the ground that it has not complied with its duty. This is the new duty imposed by this clause.
I hope that this makes it quite clear, but perhaps I should say, further, that if a health authority ask for more money because they have over-committed themselves, the Secretary of State can obviously say only either "No" or"Yes", with the DHSS as a consequence exceeding the estimate voted by Parliament and having to answer to the Public Accounts Committee. To avoid this sort of situation, the new Section 97A places a duty on health authorities so to conduct their business as not to exceed their income. Such a statutory duty on health authorities is rather a blunt instrument. Overspending can occur because of inadequate financial control as well as by deliberate act. The new Section 97A(4) introduces a power of direction relating to this duty. This will enable us to prescribe minimum standards of financial control, budget arrangements, et cetera.
I hope that as a result of this explanation the noble Lord will feel that this is a sensible provision. It is the kind of provision which I think would have become necessary—and he would have recognised it—once cash limits were introduced, as they were, of course, under the previous Administration, when he himself was a member of the Government; and he will perhaps have had experience of the kind of difficulty that might have arisen. It is included in this Bill, not to raise any fundamentally new principles but to enable us to have tighter financial controls because of the cash limits, obviously, as the name implies, on National Health Service spending. I hope I have made the position clear. If, on reflection or on reading anything that I have said, the noble Lord would like any further explanation, I should of course be very happy to write to the noble Lord on it.
§ Lord WELLS-PESTELL
I do not want to press the noble Baroness the Minister tonight; I really want this for my own information. As I understand it, cash limits can be legally enforceable. I merely asked, in what way? The noble Baroness said that if they did it a second year then action could be taken. I want to know what kind of action is possible under the clause. In point of fact, what would that action be, and what would be the penalties? I know this matter is very complicated, and I will not press it tonight. I do not know whether the noble Baroness feels that I could get a specific answer to this by letter before the Report stage, but I should be quite happy about that.
§ Baroness YOUNG
I shall try to give a more detailed answer, and then, if it is not as full as the noble Lord would like, I will of course write to him further. He is probably thinking how the new powers that we have in this Bill would have avoided the situation last year, when a health authority overspent its money. There is a power for the Secretary of State in the proposed Section 97A(4) to issue directions to ensure that authorities comply with their new duty. We anticipate making general dirctions under these powers. One such direction will specify that area health authorities should submit to regions a profile of their expenditure for the forthcoming year showing how much they expect to spend each month and in total. If the profile submitted is more than the sum allotted plus other income, then, if reason does not prevail, the region can ask the Secretary of State to issue a specific direction to the area health authorities seeking a reduction in forecast expenditure to the required level. Similarly, general directions will provide for actual spending to be reported and compared with the profile. If the trend of actual expenditure exceeds that forecast on the profile, then, failing reasonable explanations, the regional health authority may wish to ask the Secretary of State for a specific direction requiring the rate of expenditure to be reduced.
Once specific directions with time scales have been issued but not complied with, it will be clearly possible for the Secretary of State as a last resort to invoke the default powers in Section 85 of the Act. I should make it quite clear that we hope 1375 it will never be necessary to issue specific directions to authorities. It is quite alien to the tradition of relationships between DHSS and health authorities under successive Governments for recourse to be had to the law. Nevertheless, if we are to discharge our financial duty to Parliament, we believe that this power must be there in the background.
§ Lord WELLS-PESTELL
I will not trouble the noble Baroness to write to me. I should like to read this and perhaps raise the matter with her privately if necessary.
§ Clause 6 agreed to.
§ 6.52 p.m.
§ Baroness MASHAM of ILTON moved Amendment No. 9:
§ After Clause 6, insert the following new clause:
§ ("Provision for payment of dependants of doctors for work done in the practice
§ —(1)The Minister shall make regulations under section 29 of the Health Services and Public Health Act 1968 (Regulation of financial arrangements of hospital authorities and other bodies) to provide that payment may be made to—
- (a) the wife; and
- (b) any dependent
§ (2) Claims for payments under subsection (1) above shall be submitted to the Family Practitioner Committee which shall determine, after consultation with the local medical committee where necessary, whether the payments are reasonable having regard to the nature of the work performed.").
§ The noble Baroness said: I beg to move the amendment standing in my name and in that of the noble Lords, Lord Winstanley and Lord Pitt of Hampstead. During the Second Reading of the Health Service Bill, I brought to the notice of your Lordships the question of the provision for payment of the dependents of doctors for the work done in the practice. Before explaining the present situation and what this amendment sets out to do, I should like to say that it has all-party support. The noble Lord, Lord Hunt of Fawley, told me that he would support this amendment but he cannot be present today; he is in Newcastle being awarded the gold medal of the British Medical Association, one of the Association's 1376 highest honours. The noble Lord has made an outstanding contribution to the improvement of general practice.
At the moment general practitioners are reimbursed for the major part (70 per cent.) of the expense of employing paid ancillary help. It applies only to staff directly employed and paid by the doctor, the partnership or the group. It does not apply to the wife or other dependents living in the residence of the doctor or of his or her partner. A single doctor can employ a secretary or receptionist and be reimbursed. If he marries her, he can still employ her but he is no longer reimbursed. This seems to me to be discriminatory against wives. Doctors and their wives in the rural areas feel very strongly about this injustice. It is important to raise the morale and to give the dependents of doctors the chance to work for the practice as there is now a great deal of frustration. I think that this applies mainly to the practice where the doctor is single-handed or where there are only two partners. I should like to quote from a letter that I received from a doctor in Kent yesterday:
I practise from my own house in a rural partnership running an appointment system so that my wife is working not only for me but for my partners. I am the only resident doctor in the village where we have lived for over 30 years. The obvious step would appear to be for my wife to resign as secretary-receptionist but it is quite simply impossible to find anyone to take her place. For the appointment system to run efficiently, the telephone is in almost constant use from 8 a.m. to midday and again from 4 p.m. to 8 p.m. These are what I would call office hours and are the basic times for which my wife would claim payment".
§ When a doctor is on call, so is his wife. If he is out on a call and someone telephones or calls with an emergency, it is the wife who in most cases has to take the message or deal with the patients. Primary health is so important that the telephone may ring at any time at night or in the early hours. We do not want to lose the goodwill of doctors' wives; they can make all the difference especially when dealing with distressed and anxious relatives or patients. I understand that doctors can now be reimbursed for employing their wives if they are trained nurses. It can often be more difficult to find good and reliable secretaries, especially in rural areas.
§ In the second part of the amendment, there is a safeguard should doctors and 1377 their wives try to abuse the system. Payments would be submitted to the family practitioner committee which would determine, after consultation with the local medical committee, where necessary, whether the payments are reasonable having regard to the nature of the work performed. I understand that Members of Parliament as of right (and, in many instances, in practice) employ their wives as their secretaries for parliamentary purposes. Is it not a convenient and sensible thing to do in some cases? To me, this seems to be a similar situation to doctors employing their wives or dependents. I am also told by a right reverend Prelate of this House that Bishops and vicars can take advantage of this, too. I hope that this amendment will be considered with care. I think that it is the first time that this subject has been before your Lordships for a decision. I hope that the Government will accept it and, if not, that your Lordships will support it so that Members have a chance of discussing it in the other place.
Perhaps I may be permitted, before the noble Baroness, replies, to say a few words in support of the noble Baroness, Lady Masham, who moved this very necessary amendment. Perhaps I may say a few words about the history whereby we have arrived at this absurd, well-nigh Gilbertian situation under which a doctor or a group of doctors or a partnership can employ a receptionist or secretary or nurse and can now gain something like 70 per cent. reimbursement of expenses of that employment from central funds. But if one of the doctors displays an interest in that receptionist beyond a professional one and finally, as the noble Baroness has said, marries her, then suddenly the practice must pay the whole of the cost. That is an absurd situation.
Noble Lords will recall that, going back, we had a situation under which the general practitioners were remunerated out of a pool on a capitation basis and they paid all their own expenses. That necessarily meant that the doctor who gave the best service and employed a receptionist, a secretary, a nurse or whatever, was inevitably worse off than the doctor who provided an inferior service. In order to encourage doctors to employ ancillaries and to provide a better service 1378 for patients, arrangements were made whereby doctors could obtain reimbursement of necessary expenses if they incurred them. But the person left out was the wife. That person is still left out. It really is an absurd situation.
Briefly, we are not talking about arrangements whereby a GP employs his wife to answer the phone at home—an arrangement about which he can persuade the Inland Revenue to accept that she is employed. We are talking about a person doing a full-time active job for which often there is a training course run by the family practitioner committee, a post over which there is ample supervision. This is not for a nominal employment of a wife, but a wife working very long hours doing a very real job. If the receptionist is not the wife of the doctor then he gets reimbursed as to 70 per cent. of the cost. If the receptionist becomes the wife of one of the doctors, then suddenly the practice or the partner has to pay the lot. That is a situation which should end and end quickly.
Lord WALLACE of COSLANY
I should like to support the amendment of the noble Baroness. There is a parliamentary precedent for this: Members of another place employing their wives as secretaries get an expense allowance. Apart from that, the case put by the noble Baroness for the rural areas is a strong one. I know there are difficulties, but it is a case that deserves careful consideration and support.
§ Lord AUCKLAND
This is an important amendment. There are many wives who are first-class secretaries. They can deal with patients who may be nervous about seeing the doctor. The wives can give comfort, help and assurance which often a receptionist—no matter how qualified she may be—may not have the skills to do. She may not be as mature as the wife who may have a family of her own. I never realised—and I do not suppose many Members of the Committee realise—until I saw this amendment, that this anomaly existed. It seems to me—and I, like many Members of the Committee, have a wife who is a fully qualified secretary—that such people could do an excellent job and improve substantially the quality of a doctor's practice and be of enormous help. This is one of the most vaulable amendments to the Bill.
I know very little about this matter. I am not a married man, I am not a doctor, and I am not a politician. With great respect, although I would have voted against many of the previous amendments, if this one is put to the vote I am inclined to vote for it on the grounds that it seems to me unfair that if I had a secretary or assistant to whom I was already married I would not be entitled to financial reimbursement. This would also apply if I later married my receptionist or secretary.
I am sure that the noble Baroness will have arguments against this; but this seems to be a reasonable amendment which could do no harm and could do good. Speaking as a bachelor, a non-doctor and a non-politician, who therefore does not have a wife (who has learned shorthand in order to be of assistance), I am in favour of the principle of this amendment.
§ 7.4 p.m.
§ Baroness YOUNG
I recognise the strength of the feeling of the Committee and it is an issue, as the noble Baroness quite rightly said, which she raised during the Second Reading debate. I say right away that the Government recognise the case which has been put most forcefully this evening that many GPs are assisted in their practice by their relatives, particularly by their wives, and that some are employed in this way on a regular basis. There is no legal impediment to this. The Government are also keenly aware of the strength of feeling among GPs and relatives working with them about their exclusion from the reimbursement arrangements for non-related ancillary staff employed by GPs. This exclusion is of long standing—it goes back to the start of the ancillary staff reimbursement scheme in 1966, which was agreed at that time with the representatives of the medical profession.
Under that scheme, a GP can claim 70 per cent. of the cost of employing ancillary staff on approved duties—these are secretarial, receptionist, clerical, nursing and dispensing duties—up to a maximum of two whole-time equivalents per doctor. It was not thought possible to include reimbursement of salaries paid by GPs to wives or other dependants because, in their case, the need for GPs to meet 30 per cent. of the cost would not be an 1380 adequate restraint on the demand for the payment from public funds—a risk was seen of excessive salaries being paid and that the normal safeguards which ensure that employees work their contracted hours would be less effective. This exclusion of wives and other dependants has been a matter of concern to the profession and to successive Governments since 1966 but no satisfactory way has been discovered of bringing them into the scheme on the same terms as non-related staff.
As an alternative approach, in 1978 an experiment was begun under which single-handed general practitioners in rural areas became eligible for payment of an allowance where they satisfied a visiting team from the family practitioner committee and local medical committee that they employed their wife or other dependant relative on at least a half-time basis. This arrangement—known as the related ancillary staff scheme—has worked reasonably well and has been recently extended for a further two years. More importantly, the Government have also recently announced an agreement with the representatives of the profession that the scheme should be significantly widened so as to bring in any GP where the wife or other dependant relative he employs is a qualified nurse undertaking some nursing duties. They recognise that this will still leave outside the scheme some wives who are doing valuable work in the practice. But I hope the Committee will realise it is a step in the right direction and there are severe financial limitations on the rate of progress the Government can hope to make in this as in other fields where they would like to see much more done. There will be a further review of the position with the profession in 1982, when no doubt the possibility of further extension will be considered.
The noble Baroness and the noble Lord, Lord Wallace of Coslany, mentioned the allowance for Members of Parliament. There is a difference between the allowance which a Member of Parliament receives for his secretary and when he uses his wife as his secretary and what would be allowed for doctors in this situation. The chief difference between a Member's allowance and the ancillary staff scheme is that the Member's allowance has a maximum ceiling on payment, 1381 whereas under the scheme reimbursement is at 70 per cent. of whatever the GP actually pays.
The difference is, of course, that there is a ceiling on the expenditure that is given for allowances to Members' wives, and the difficulty in this situation is that there is not a ceiling on the amount that the general practitioner pays. Therefore, if he is reimbursed at 70 per cent., there is no ceiling on the 30 per cent. that he would have. In these circumstances, I hope that the Committee will realise that there is certainly no disagreement between us about the desirability of trying to right what must appear as an injustice to many wives who act as secretaries, and who are not getting the money. I hope that the noble Baroness will see that we have tried to move step by step under successive Governments to meet this particular case.
The difficulty about this amendment— to which I am very sympathetic, as are my colleagues—is that it involves a further expenditure of money. That is the difficulty here. At the moment, we have not the resources to say that we would bring it in. I have given an assurance that we shall be looking at this position again. We hope that we shall be able to do this in 1982 and review the position with the medical profession. I hope very much that when that time comes we shall be able to extend the provisions in the way that the noble Baroness and the noble Lord, Lord Winstanley, would like. In the meantime I think I have gone as far as I can in trying to explain the position, but I am afraid I cannot accept the amendment.
§ Lord UNDERHILL
Before the noble Baroness sits down, could she explain this to me? She mentioned the possibility of extra cost, and therefore there must be a limitation; but if general practitioners employed secretaries who were not their wives apparently there would be no difficulty in paying the costs. Is that so?
§ Baroness YOUNG
The difficulty is that at the present time a general practitioner who employs someone who is not his wife is reimbursed by 70 per cent., and there is this 30 per cent. Because of this contractual relationship with somebody outside who is his employee, it is much easier to keep a check on what is 1382 actually happening. It is much more difficult, when it is a relative or a wife, to prevent abuse. That is why there is the possibility of considerably larger amounts of money being spent. This is not an absolutely insoluable problem and it is one that we hope we shall be able to resolve, but the noble Lord, Lord Underhill, will recognise that if the scheme is extended it will inevitably involve more public expenditure, and that is the difficulty in this particular case.
§ Lord DONALDSON of KINGS-BRIDGE
Before the noble Baroness finally sits down, could I ask what the objection is to the opportunity presented by this Bill of inserting a ceiling? I see no problem whatever except the will.
§ Baroness YOUNG
I am sorry if I may not have fully understood the point made by the noble Lord. The problem is that it would involve increased expenditure.
§ Lord DONALDSON of KINGS-BRIDGE
So the reason is not that there is not a ceiling but that, even if there were, you would have to pay up to that ceiling—is that the problem? In other words, the doctor's wife is not to be paid at all on any basis. I understood the noble Baroness to say that they could not do this because there was no ceiling, whereas with M.P's wives there is a ceiling, quite properly in my view. This seems not to be the case. Would the noble Baroness kindly explain it again?— because I do not understand it, on what has been said.
§ Baroness YOUNG
I am sorry: I will try to explain it again. As I understand the position, a GP can employ someone as his secretary and claim 70 per cent. of the cost. What such a person pays for his help will vary inevitably from one part of the country to another. That is quite unlike the M.P's secretarial allowance, which I believe is related to what is, as it were, the going rate in London, which he would have to pay. Therefore, as I say, there would be variations between one part of the country and another. There is no ceiling on this because, clearly, what is required in one part is different from what is required in another part, but it is perfectly possible to keep a check on the total 1383 amount of money that is spent. I am assured that if we were to extend the scheme further than it is now and bring in another group of people it would inevitably involve more public expenditure. At the moment this is not something that we could consider. I am not unsympathetic and I am not trying to put difficulties in the way, because I think we all agree that it is desirable that we should meet what is widely felt to be an injustice to wives who act as secretaries to their husbands in this particular way. But it would mean extra money and, for that reason, we cannot accept the amendment as it stands now.
§ Lord DONALDSON of KINGS-BRIDGE
I do not want to go on too much about this, but the noble Baroness seems to be saying that the whole argument about a ceiling is entirely irrelevant. The Government are not prepared to pay it, ceiling or no ceiling. I think it was misleading—I know not whether deliberately or not deliberately—that that should have been brought in as an argument.
§ Baroness YOUNG
I am sorry: I did not wish in any way to mislead the Committee. The noble Lord, Lord Donaldson, practically suggests that I was "pulling a fast one" to mislead the Committee about this. I was asked why we could not do what is done for M.Ps' wives. In that case there is a ceiling on what can be spent, because the amount of money given is related to secretarial allowances in London. There are two issues here. There is the question of a ceiling and the accountability, because, as I understand it, the amount of money varies from one part of the country to another and it would inevitably involve more expenditure. Therefore the two things are different; but the whole case does not rest on the analogy with M.Ps' wives. In fact, in the case of the scheme that we recently brought in—and it could apply, I think, to the case raised by the noble Baroness, Lady Masham—under the related ancillary staffs scheme there is a ceiling because there is an allowance system; but we cannot widen that scheme right away for financial reasons. That is ultimately the difficulty about accepting the amendment.
§ Lord MOTTISTONE
Do I understand from my noble friend that if the doctors do not marry these girls, their secretaries, and so on, the Government will pay happily? In that case, the Government are not really saving money but encouraging the doctors and their girls to live in sin! And they cannot guarantee they will save money because perhaps the doctors may not want to marry their secretaries. So, if I may say so, it is a ridiculous argument.
§ Lord PITT of HAMPSTEAD
I must say to the noble Baroness that there is already a ceiling. The regulations say that you can employ the equivalent of two-full time people. That is a ceiling. The ceiling is there, and whether or not one of them is the doctor'swife is irrelevant. Therefore the argument that there is no ceiling really does not hold water.
Another point I wanted to make is this: the noble Baroness has already sold the pass, so to speak, in terms of this question of control by accepting that if the wife is a nurse she can be so employed. If you cannot control her when she is a secretary you cannot control her when she is a nurse, and if you can control her when she is a nurse then you can control her when she is a secretary. So those arguments really are no good, and I would much rather the Government decided to look at this matter again. What is happening at the moment is that the profession feels there has been discrimination against the wives of doctors who are not nurses. That is a grievance and it is one that should be remedied.
§ Baroness YOUNG
I would agree with the noble Lord, Lord Pitt, that there is a discrimination against wives and that they have a legitimate grievance about it, but, as I understand it, what has happened is that gradually the amount of money that has been allowed for people employed by G.Ps has been increased. The noble Lord, Lord Winstanley, took us through this step by step. First, certain categories of people were allowed for quite specific elements of help. Then the provisions were extended to allow a wife who is a qualified nurse to receive the benefit. What has not happened—and I quite see that it may sound very odd to my noble friend Lord Mottistone, but I think there is a difference—is that the wife who is not a qualified nurse but who helps her 1385 husband in his practice, as many wives do, does not get this payment. No one is pretending that this is either right or perfect. What I am saying to the Committee is that it does involve increased expenditure of money and I think the Committee must recognise that it is for that reason that it is not being extended now.
In view of the strength of feeling that has been expressed on this matter I will certainly take it back and have another look at it, but I must make it clear that it is most unlikely that I can satisfy your Lordships at a later stage because it does involve more Government expenditure. I will take advice on exactly the amounts of money we are talking about, in recognition of the very strong feelings of your Lordships. But I never like to pretend to people that I can deliver something which will be difficult, and this is going to be very difficult as it involves increased Government expenditure.
As the noble Baroness, without any undertaking or commitment, has undertaken to look at this subject again, might I ask her to look at one particular point while she is doing that? She said that efforts are being made to assist in rural areas where a GP is on his own and his wife is the only person he can get to help him. Would she bear in mind that, not only in rural areas but in cities and urban areas, the vast majority of doctors work in groups or partnerships and in such groups or partnerships there is inevitably a very firm discipline exacted by the other members of the group or partnership as to how much is paid to the wife of any particular doctor? This is a discipline which exists and I think it should be borne in mind. In the vast majority of cases, if doctors employ their wives, they are people doing full-time jobs on behalf of a group of doctors. If the person happens to be married to one of the doctors, the whole practice is penalised by not being able to claim reimbursement. Will the noble Baroness look at that factor and bear in mind that a fairly firm control is exerted by the other people in the partnership, who will not allow an individual doctor to overpay his wife merely because she happens to be his wife, when she is just one of a number of employees of that practice?
§ Lord PITT of HAMPSTEAD
May I, again, say to the noble Baroness that there is a fallacy in this argument about increased expenditure. As things are, every doctor is entitled to employ up to the equivalent of two people. If one of them is his wife, then he employs somebody else. If she is a nurse, that means that he can employ only one other person. If the noble Baroness agrees that if she is a secretary she can be accepted, then he can still employ only one other person. So the argument about increased expenditure is a hollow one.
§ The Earl of SWINTON
I wonder whether, if my noble friend is taking this matter back, she can consider this at the same time. I have obviously been under a strong personal lobby for the past few weeks about this point, and I still feel, at the end of this debate, that doctors are doing jolly well out of this. I am thinking of rural areas, where there is perhaps a clergyman and a solicitor, who does a lot of work under legal aid. They do not get a 70 per cent. grant for having a secretary. Would it not remove discrimination entirely if we did away altogether with the 70 per cent. grant, and then the wives would be in the same position as everybody else?
§ Baroness YOUNG
I do not think I am going to follow my noble friend down that line of argument. However, I will take note of the point which the noble Lord, Lord Winstanley, and the noble Lord, Lord Pitt, have made. I will certainly draw it to my right honourable friend's attention and consider this matter between now and the next stage.
§ Baroness MASHAM of ILTON
I should like to thank all noble Lords for their support. I am a little worried, because the noble Baroness did not give very great hope that, if she does take it back and look at it again, she will be able to say anything different. I think, in my heart of hearts, I know that the noble Baroness will not be able to give us any more hope at the Report stage. I am a little sad that the Government do not consider that the family practitioner committee and the general practitioners are a highly responsible body of people. We are not dealing with irresponsible people here. We are dealing with very responsible people.
1387 I may not be here at Report stage, because my children are on holiday and I have to look after them. Also, I know that there is so much frustration among the general practitioners' wives in rural areas throughout the country. They have waited for years and years. I think that there is probably enough support in the House, if noble Lords would look very carefully into their minds and ask themselves whether their GPs and
§ Resolved in the affirmative, and amendment agreed to accordingly.
§ Baroness YOUNG
I beg t the House be now resumed.
Moved accordingly, and, on Question Motion agreed to.
§ their wives are responsible people. Do they need support and are they helpful to them? With that, I think that I should like to divide on this amendment.
§ 7.24 p.m.
§ On Question, Whether the said amendment (No. 9) shall be agreed to?
§ Their Lordships divided: Contents, 71; Not-Contents, 41.1387
|Ardwick, L.||Glenamara, L.||Phillips, B.|
|Auckland, L.||Gordon-Walker, L.||Pitt of Hampstead, L. [Teller.]|
|Aylestone, L.||Hale, L.|
|Barrington, V.||Hall, V.||Ponsonby of Shulbrede, L.|
|Beaumont of Whitley, L.||Hatch of Lusby, L.||Ritchie-Calder, L.|
|Bernstein, L.||Henderson, L.||Robson of Kiddington, B.|
|Bessborough, E.||Irving of Dartford, L.||Rochester, L.|
|Blease, L.||Janner, L.||Ross of Marnock, L.|
|Boston of Faversham, L.||Leonard, L.||Savile, L.|
|Brockway, L.||Lindsey and Abingdon, E.||Stamp, L.|
|Brooks of Tremorfa, L.||Listowel, E.||Stanlev of Alderley, L.|
|Caithness, E.||Llewelyn-Davies of Hastoe, B.||Stone, L.|
|Chelwood, L.||Lloyd of Kilgerran, L.||Strabolgi, L.|
|Collison, L.||Lovell-Davis, L.||Swinton, E.|
|Croft, L.||McGregor of Durris, L.||Taylor of Mansfield, L.|
|Davies of Leek, L.||Macleod of Borve, B.||Tweeddale, M.|
|Diamond, L.||Marley, L.||Underhill, L.|
|Donaldson of Kingsbridge, L.||Masham of Ilton, B.||Vaux of Harrowden, L.|
|Donnet of Balgay, L.||Monson, L.||Wade, L.|
|Dormer, L.||Morris of Kenwood, L.||Wallace of Coslany, L.|
|Ferrier, L.||Mottistone, L.||Wells-Pestell, L.|
|Galpern, L.||Mountevans, L.||Whaddon, L.|
|Gisborough, L.||Newall, L.||Winstanley, L. [Teller.]|
|Gladwyn, L.||Oram, L.||Wynne-Jones, L.|
|Abercorn, D.||Ferrers, E.||Margadale, L.|
|Alport, L.||Fortescue, E.||Mowbray and Stourton, L|
|Avon, E.||Gainford, L.||Murton of Lindisfarne, L.|
|Bellwin, L.||Godber of Willington, L.||Northchurch, B.|
|Belstead, L.||Gowrie, E.||Nugent of Guildford, L.|
|Blake, L.||Greenway, L.||Orkney, E.|
|Craigavon, V.||Gridley, L.||Renton, L.|
|Denham, L. [Teller.]||Hanworth, V.||Sandys, L. [Teller.]|
|Dundee, E.||Harvington, L.||Selkirk, E.|
|Ellenborough, L.||Hornsby-Smith, B.||Strathclyde, L.|
|Elliot of Harwood, B.||Hylton-Foster, B.||Trefgarne, L.|
|Elton, L.||Long, V.||Westbury, L.|
|Faithfull, B.||Lyell, L.||Young, B.|
|Falkland, V.||Mackay of Clashfern, L.|