HL Deb 10 July 1980 vol 411 cc1399-435

8.17 p.m.

House again in Committee.

Clause 7 agreed to.

Clause 8 [Repeal of provisions relating to withdrawal of pay beds and dissolution of Board, etc.]:

Lord WELLS-PESTELL moved Amendment No. 10:

Leave out clause 8 and insert the following new clause:

"Establishment of Health Services Protection Board

(8. —(1) There shall be established a Board to be known as the Health Services Protection Board, which shall consist of a member nominated by the Trades Union Congress, a member nominated by the British Medical Association and an independent chairman with legal qualifications.

(2) The Health Services Protection Board shall have the duty of considering all evidence submitted to it including oral evidence in so far as it relates to an authorisation which could have been granted under Part Ili of the Act of 1976 and report with its recommendations to the Secretary of State and it shall be the duty of the Secretary of State to give effect to the Secretary of State to give effect to the Board's recommendations forthwith.

(3) In reporting to the Secretary of State under this section the Health Services Protection Board shall, in considering each individual application for an authorisation which could have been granted under Part III of the Act of 1976 and in addition to the matters which Part [If of the Act of 1976 authorised the Health Services Board to consider, be under a duty to ensure that health services provided within relevant hospital premises shall not exceed those services as they exist on the commencement date with an addition of a further number of beds with supporting services, employees, accommodation and equipment equivalent to the number of beds in the National Health Service authorised for the use of private resident patients on the commencement date.

(4) It is the duty of the Secretary of State and of any individual or body corporate having ownership or control of any premises within or without the National Health Service to furnish the Health Services Protection Board upon its request with such information as a Board may require or the discharge of its duties under this section.").

The noble Lord said: I beg to move Amendment No. 10, which stands in my name. Clause 8 deals with the establishment of a health services protection board and we, on this side, have put down the amendment because we note that the Bill will end the activities of the Health Services Board. We believe that, because of the importance of that Board and the contribution it has made, there should be something to take its place.

I am not unmindful that Clauses 9 and 10 have some relation to Clause 8, inas- much as they deal with the treatment of private patients in the National Health Service, but I am mainly concerned with the effects of Clause 8. I think it would be helpful if I were to quote from the Notes on Clauses, which admirably set out the intention of Clause 8. I do so by quoting what the Notes on Clauses have to say at page 47 about Clause 8: This clause lifts the restriction on the Secretary of State's power to authorise, under sections 65 and 66 of the Act of 1977 and sections 57 and 58 of the Scottish Act of 1978, the use of health service hospital facilities for the treatment privately of patients and repeals the provisions relating to the withdrawal of such authorisations (and consequential matters). It also, together with Schedule 2, abolishes the Health Services Board and its Scottish and Welsh Committees, and transfers the functions of the Board and those Committees to the Secretary of State or to persons appointed by him".

I suggest that this clause really does cause us some concern.

Your Lordships are familiar with our views on the matter of pay beds and private practice: it is a ground that we have been over time and time again. If I restate our views briefly I would say that we wish to see the complete separation of private practice from the health service but the right of the individual to be able to choose. That is important. Secondly, we have expressed ourselves from time to time on the unfair queue jumping, and, thirdly, on the large number of pay beds that are never used.

I move this amendment because the last Government made a genuine and sustained attempt to find a real solution to this problem. I believe that the last Government succeeded. Through the good offices of the noble Lord, Lord Goodman, who managed to find a compromise between the medical consultants and the Labour Government, we set up a Health Services Board. The responsibility of the board was to phase out the pay beds from the National Health Service and to regulate the development of private hospitals so that they did not pose a threat to the National Health Service hospitals.

The composition of the board is probably well known to most noble Lords. Its chairman was the noble Lord, Lord Wigoder. If anybody ever proved and established that he could be independent, it certainly was the noble Lord, Lord Wigoder. He served this committee and the department, if I may say so, extremely well. He had on the committee two members nominated from the British Medical Association and two from the trade unions. It has always been a source of amazement to me that he managed to get agreement among all four. So far as I know, there was no difficulty at all. During the time they functioned, the number of private beds in National Health Service hospitals was reduced from 3,444 to 2,553. That does not take into account the 1,000 pay beds which were withdrawn by my right honourable friend David Ennals when he was Secretary of State and had the power to do it before the setting up of the Health Services Board.

A great deal was in fact achieved. What was achieved was done by agreement of the members, which, in itself, was no mean achievement. What was even more important, their decisions were binding on the Secretary of State. I want to emphasise that because I wish to come back to it. Their decisions were binding on the Secretary of State; in other words, the then Secretary of State who agreed to this procedure—in fact suggested it—having done so, left no doubt in people's minds that he himself was not responsible. It had been left to an entirely independent committee. That is important.

Clause 8 of the Bill puts an end to all that. If your Lordships read it you will see what the position is. We regard it as essential that if the Secretary of State is sincere in wanting to preserve a proper balance between the private sector and the public sector of medicine, then the Health Services Board should be allowed to continue its work; work which was done to the great credit of its members. Does it seem fair in the sense of being just, and does it seem right that the Secretary of State—and I refer to the present Secretary of State, wedded, as I think he is, to the private sector—should have the final word on the place of private beds in our National Health Service and the development of the private sector? I am sure that we shall be told that the Secretary of State will appoint some committee or other to advise him on these matters, but the fact remains that he will have the making of the final decision, and the procedure for deciding these matters was much fairer, in my submission, under the previous Government. I ask the Minister to consider whether the present Secretary of State would not be well advised not to have the final decision, when we all know his views on the private sector.

I believe that the Government have stated that services for private patients should not prejudice services for the National Health Service patients. I hope that the noble Lord the Minister will confirm that. I believe that the Secretary of State has in fact come to a six-point agreement with the medical profession on this matter. I have not seen it published; I have not seen it advertised. I do not know whether the noble Baroness will want to tell us about the six-point agreement which the Secretary of State has come to with the medical profession.

I gather that the Government are of the opinion that pay bed authorisations are expected to remain roughly at their present level. I would ask the Minister whether she could say on what basis that statement was made. If the Secretary of State does appoint a committee to advise him, I would expect it to be entirely independent with a broadly based membership. If he agrees—and I do not suppose for one moment that he will—he could do no better than reappoint the Health Services Board, which has shown itself beyond any doubt to be completely impartial and independent.

In considering the private sector I would remind the Minister of the comments of the Royal Commission on the National Health Service, and I shall quote from paragraphs 18/28 and 18/37 of their report: Private practice does not pay the full share of the costs which are incurred in their sharing National Health Service premises".

This seems to me to be quite disgraceful. If we are going to have, as I am sure we are—and I accept the fact that it is probably inevitable—the private sector working to some extent alongside the public sector, then I feel that there has to be exercised in the future, as in the past, a control of pay beds.

There has to be also a control of private development in terms of private clinics and private hospitals. I think that the records show that the private sector has developed beyond anyone's wildest dreams. Nevertheless, the Health Services Board was able to control the development because the cardinal principle was that not too many private hospitals should be allowed to be erected near a National Health Service hospital if they were going to prove a threat to the public sector. If they are allowed to develop haphazardly, then they do pose a threat. Obviously they must get their nursing staff locally. They must get a good deal of their other staff locally. So far as the medical staff are concerned they could be by various salary scales and so on seduced from the National Health Service. We are told that the Government want to see an effective National Health Service, able to cope more effectively than at the moment with those who want medical services. I suggest that it is impossible to do this unless there is rigid control.

I do not know whether the noble Baroness the Minister can say what the Secretary of State is prepared to do in this matter. In the Bill there is a reference to his power to appoint a committee or committees. I should like to know quite definitely, because he ought to have made up his mind by now. This Bill has passed through the Commons and it is pretty well half-way through your Lordships' House, and he ought to have made up his mind what sort of set-up he is going to have to advise him about the development of the private sector and pay beds. I would have hoped that it was possible—although I do not think it is possible—to persuade the Secretary of State to give consideration to what we are asking. We feel it is essential to have a health services protection board and my justification for that is the unqualified success of the previous Health Services Board. I beg to move.

8.31 p.m.


Before we move further, I should like to clarify this amendment. There are really two amendments here. One is that Clause 8 stand part, and the other is the amendment the noble Lord has moved. Before I reply I should just like to point this out to the noble Lord, Lord Wells-Pestell.


Yes, leave out Clause 8 and insert the following new clause. It is part of this amendment.

Baroness YOUNG

I wonder if the Lord Chairman could help us. This is really a procedural point, to know how we should best proceed. We have not yet had the Motion that Clause 8 stand part, and the amendment would be to take out Clause 8 and put a new one in. I think it would be helpful to know how we should proceed on this.


My only instructions on this are that if Amendment No. 10—that is this one—is agreed to, it is necessary to put the Question that the new clause stand part of the Bill. Therefore, as I understand it, this is a substitution for the existing clause. A decision having been made on that, I then confirm that by inviting the Committee to agree that the new clause stand part of the Bill.


I hope we are in order, and with the assurance of the noble Lord the Lord Chairman I will now proceed.

The noble Lord, Lord Wells-Pestell, referred to the compromise which the noble Lord, Lord Goodman, produced on the scheme. My first comment upon the argument of the noble Lord, Lord Wells-Pestell, is this. Of course, it is perfectly true to say that a major achievement in negotiation was achieved by the noble Lord, Lord Goodman, but in our submission it was in no way true that the compromise was for a neutral consideration. We believe that from the very beginning it was assumed that the board had a particular task to perform and it performed it in the way which he described. I do not think he can claim other than the very excellent performance by the noble Lord, Lord Wigoder—a claim of impartiality on behalf of the board. Of course, its members performed their task in an exemplary manner.

I should like to begin my remarks by drawing your Lordships' attention to two things. The first amendment would delete the whole of Clause 8 and the second would provide a new body proposed by the noble Lord to deal with applications made under the 1976 Health Services Act for the development of large private hospitals. It was not very clear from what was drafted precisely what the noble Lord, Lord Wells-Pestell, had in mind, and I am grateful to him for clarifying the position. However, whatever the precise arrangements would be, one thing is very clear from the second amendment; that is that what is proposed is an overall ceiling on the level of provision of services for private practice. This is a very important policy step on the part of the Opposition. It goes far beyond anything in the present legislation. I shall come back to this in a moment. First, I would like to deal briefly with the provisions of Clause 8 which the noble Lord would have us omit.

Clause 8 serves as an introduction to the following six clauses of Part II—Clauses 9 and 10, which deal with private practice in the NHS, and Clauses 11 to 14, which deal with the private sector developments. It is the foundation for what follows. Under it, the provisions of the 1977 Act, and their Scottish equivalent, which provide for the compulsory phasing out of existing pay beds, are repealed and the restriction on the Secretary of State's power to authorise new pay beds is lifted. Clauses 9 and 10 build on this. Clause 9 tidies up the legislation to make sure there is no duplication of powers to allow private practice in the NHS. It also removes the provisions which allowed for private patients needing specialised treatments to continue to use NHS facilities. With the restoration of the main power to authorise pay beds these are clearly redundant. Clause 10 provides for restrictions on the restored powers. Clause 8 also abolishes the Health Services Board, as the noble Lord himself has mentioned. One of the Board's functions is to propose revocations of pay beds. Its other function is to exercise the powers in Part III of the 1976 Act. The noble Lord quoted from Notes on Clauses, but this is placing the explanation in a slightly different context. Clause 8 transfers these powers to the Secretary of State. Here, too, the clause paves the way for Clauses 11 to 14, which amend the transferred powers. This is a complicated situation but I hope that my explanation has been satisfactory.

I think we should look at Standing Committee G to reassure the noble Lord in regard to the question he put to me over the six principles which were enunciated by the Secretary of State. The noble Lord may know that my honourable friend the Minister for Health, Dr. Gerard Vaughan, sent them to the health authority chairmen in March of this year. He will be aware that the principles were referred to in Standing Committee G, and perhaps I might be permitted to quote the Parliamentary Under-Secretary of State's comment on them, because it is very interesting in this context. It comes at column 822. He said this: The six principles are designed to ensure the equitable operation of the National Health Service private practice, both as an end in itself and as a way of helping to ensure that the continued presence of private practice does not cause unrest among other staff. The agreement should go a long way to reassuring those who genuinely believe that private patients prejudice NHS patients. The profession's acceptance and public endorsement of the principles is seen by us as clear recognition by the profession that it accepts the pay bed privileges have associated responsibilities. These principles are a clear statement of our view that it is totally unacceptable that the treatment of an NHS patient who is seriously ill or who needs urgent medical care should be in any way prejudiced because priority has been given to a private patient in less need".

I could quote further from what was said on that occasion, but I think it would be more valuable to place on record what the six principles are, and at the risk of wearying the Committee, I will enunciate them because I do not think they are on public record.

The six principles are as follows: first, the provision of accommodation and services for private patients should not significantly prejudice non-paying patients; secondly, subject to clinical considerations, earlier private consultation should not lead to earlier NHS admission or to earlier access to NHS diagnostic procedures; thirdly, common waiting lists should be used for urgent and seriously ill patients as at present and for highly specialised diagnosis and treatment. The same criteria should be used for categorising paying and non-paying patients; fourthly, after admission, access by all patients to diagnostic and treatment facilities should be governed by clinical considerations. This principle does not exclude earlier access by private patients to facilities especially arranged for them if these are provided without prejudice to NHS patients and without extra expense to the NHS; fifthly, standards of clinical care and services provided by the hospital should be the same for all patients. This principle does not affect the provision on separate payment of extra amenities, nor the practice of the day-to-day care of private patients usually being undertaken by the consultant engaged by them; and sixthly, single rooms should not be held vacant for potential private use longer than the usual time between NHS patient admissions.

Those are the six principles about which the noble Lord asked me, and I hope I have satisfied him that they have been in the hands of the health authorities. They were discussed at some length in Standing Committee G, and the noble Lord may have seen references to them in other official documents. As for private sector developments, the proposals for dealing with applications for private sector developments were set out in a letter by the DHSS on 31st January and that was made available to Members of the Standing Committee. It proposed that the Secretary of State would need independent advice to advise him on applications, and I will, with permission, quote paragraph 17 of that letter: From time to time, the Secretary of State will need independent advice in dealing with applications for increases in pay beds or for authorisation of private sector facilities. This would be necessary where applications raise unusually difficult or contentious issues which the Department is unable to resolve. It is proposed that an expert panel be appointed, from which individuals could be drawn to advise the Secretary of State as and when necessary; the members of committees to hold public hearings could also be drawn from the panel. The panel would include a range of various types of expertise; covering medical, nursing and other NHS staff, health authorities and the private hospitals. It is felt that a panel of this nature would give a greater measure of flexibility than a permanent committee with a fixed membership, and would enable advice to be readily available".

I hope the noble Lord, Lord Wells-Pestell, is reassured on this matter.

The amendment seeks to overturn the basis of the Government's policy which I have attempted to set out, and of course the policy was stated in our manifesto and was explained to your Lordships' House and to another place and elsewhere on many subsequent occasions. Perhaps one of the best occasions of this was when the noble Lord, Lord Hunt of Fawley, initiated a debate on 19th March this year, and the noble Lord, Lord Wells-Pestell, will be well aware of that occasion. In that debate, Lord Hunt quoted two very eminent authorities in the medical profession. If Lord Wells-Pestell does not pay much attention to my statements, here we had the president of the Royal College of Physicians, Sir Douglas Black, being quoted by Lord Hunt, who said: The president of another, the Royal College of Physicians, Sir Douglas Black, supports the continuance of a strong private sector which, in his own words, 'makes a most valuable contribution to medical care in this country … it is no kind of threat to NHS standards'".

The noble Lord a little later quoted another eminent authority, no less a person than the president of the Royal College of Surgeons, Sir Reginald Murley, who had said: The private sector is an encouragement to raise standards of personal service, as well as proper costing and economical use of resources". —(Official Report, 19/3/80, col. 221.)

Those two quotations are of real value because those very eminent medical authorities, widely accepted in this country, stand right outside the political field, and I hope that adds reassurance to the noble Lords that the Government's policy is on the right lines.

Our policy on pay beds is quite simple. We believe it was wrong to phase them out and we shall allow them where they are wanted, subject only to their not interfering with services to NHS patients. I think the six principles make that clear. To ensure this, we have a statutory provision, and the six principles to which I have referred have been agreed with the medical profession; and this we shall no doubt discuss when we come to the amendment to Clause 9 standing in the name of the noble Lord, Lord Wells-Pestell.

Apart from the argument of principle on pay beds, they also are a very useful source of income. No less than £45 million is expected to come from this source in 1980–81. I believe that, as a source of income, it is a growing one, because on 19th March, when the noble Lord, Lord Hunt, referred to it, he spoke of an income of £30 million. So if the rate of progress from this source of income is possibly to be anticipated, I think it will be a real source of satisfaction to medical provision in this country.


I am grateful to the noble Lord, Lord Sandys, for his contribution. I am aware of what is in the Bill and I am familiar with what the clause intends to do in relation to the Secretary of State's statement about the appointment of committees or a panel.

The noble Lord said that the amendment seeks to overturn the Government's intention. That is precisely why it has been put down and is now before your Lordships' Committee. I am not impressed by the quotation from two learned members of the medical profession. That was precisely what I should expect them to say. I should imagine that they are both—no, Sir Douglas Black is a scientist, if I remember rightly, not a member of the medical profession.


Sir Douglas Black is president of the Royal College of Physicians.


I should be very surprised if people who make that kind of utterance are not themselves very heavily involved in private practice. I would go so far as to say that if they were Members of your Lordships' House, speaking in your Lordships' Chamber, they would have to declare an interest before they spoke. So I am not at all impressed by that aspect.

I raised the question of the six principles because no mention had at any time been made of them in your Lordships' Chamber; there may not have been an opportunity. I am familiar with them. I have a copy of them in front of me. Since the noble Lord has been good enough to bring them out into the open, so that they will be recorded in Hansard, I hope that noble Lords will read them, and read them very carefully. What worries me about the first principle is that it says that the provision of accommodation and services for private patients should not significantly prejudice non-paying patients—which surely implies that it will, but not very much. What does "significantly prejudice" mean? If it is not going to prejudice, there is no need to say "not significantly". It is obvious that it will do. The Secretary of State, I grant, was being honest. What he was saying in effect was that it will prejudice, but not very much—


Perhaps one should look at the total number of beds in National Health Service hospitals. The noble Lord quoted the reductions, and the Committee will be grateful to him for doing so. The present total of beds in question can surely amount to a proportion that is little more than 1 to 1½per cent. of the total number of beds in the care of the National Health Service.


The noble Lord misses the point. There is a point of principle here so far as we are concerned. It is not a question of a ratio; it is a question of principle. Let us get back to the principles. The fourth principle states that after admission access by all patients to diagnostic and treatment facilities should be governed by clinical considerations. This principle does not exclude earlier access by private patients to facilities especially arranged for them—I emphasise the phrase "especially arranged for them" —if these are provided without prejudice to National Health Service patients without extra expense. I think that that is contradictory in that it permits for private patients treatment that would not he available to National Health Service patients. What facilities was this clause intended to cover?

Baroness YOUNG

Will the noble Lord give way for a moment? On the first point of the six principles that have been agreed, I believe that we are talking somewhat at cross purposes, because the first is in fact a statutory safeguard. The statutory safeguard in the Bill is that the Bill retains the legislative provision that pay beds will be authorised only where this does not significantly prejudice National Health Service services. That is the reference in the first of the principles, and this is provided under Clause 9, which links the sections in the Act referred to, which provide for authorisation of facilities for private patient use with Section 62, which contains this restriction on the use of the power. We shall discuss this matter under Clause 9. But that is the reference, and it is a legislative one.


Yes, but it does not alter the fact that the word "significantly" is used.


The noble Lord has twice made this point and perhaps he would like a rendering in regard to the word "significantly". I understand that "significantly" is taken from the noble Lord's own party's 1976 Act in relation to private sector developments and Section 59 treatments. The word is used in Section 62, which stems from the 1976 Act.


I should have to look at the Act; but, after all, noble Lords opposite have always said that the Labour Party was wrong. I see that there is no point in pursuing these six principles. I think that on the whole there has been something of an achievement, but I do not think that the principles are as good as noble Lords opposite make out. I take the view that the fourth principle suggests that certain facilities are not available to National Health Service patients, and the fifth principle makes it clear that private patients will be able to monopolise the personal time and expertise of their consultant. One point that irritates many of us—and I have spent very long periods in hospitals—is that where there are private beds, the consultant spends an inordinate amount of time looking after the patients in those beds, while his registrar or houseman comes along and looks after me and other National Health Service patients. I am not quarrelling with that situation, because in my experience the consultant popped in occasionally, so that I did not forget him. But the fact remains that this has been one of the complaints of junior doctors—


May I ask the noble Lord whether it would not be worse if the consultant was functioning in a private hospital, miles away from the National Health Service? In that case he would not even be on National Health Service premises while looking after his private patients, whereas otherwise if there is an emergency in the National Health Service section while he is attending his private patients, then at least he is on the same premises and is therefore more easily available.


If the noble Baroness is to argue along those lines, I, too, shall argue on the same lines by saying that if there was no private practice, we should have more consultants and doctors in the public sector. But neither argument is of very great value. I do not want to say anything more, other than to add that I move the amendment.


Before the question is put, there is one point that I should like to address to the Minister. We are talking about private beds, but what is the position about amenity beds? Amenity beds still exist in hospitals and are to some extent different from private beds. Do the Government have amenity beds and private beds in mind in relation to the same purpose in the Bill, or are amenity beds still being kept separate?

Baroness YOUNG

To the best of my knowledge, the amenity beds will remain as they are now within the National Health Service. If I should add something further to that, I shall let the noble Lord know later in the proceedings, or write to him.

On Question, amendment negatived.


The Question is that Clause 8 shall stand part of the Bill?—and if my noble friend Lord Sandys is in doubt about this procedure, I would call his attention to page 13 of the Deputy Speaker's guide.

Clause 8 agreed to.

Schedule 2 agreed to.

Clause 9 [General power to make accommodation and services available]:

8.55 p.m.

Lord WELLS-PESTELL moved Amendment No. 11:

Page 20, line 5, at end insert— ("( ) Section 65 of the Act of 1977 shall be amended by the insertion after the second "and" in paragraph (a) of subsection (1) of that section the words "in particular he shall direct a health authority to admit private resident patients to a health service only if he is satisfied that—

  1. (i) all potential private resident patients have been placed on the same waiting list as comparable National Health Service patients in the care of the same consultant and that the consultant concerned is ensuring that all patients selected by him for admission to such a hospital and all patients on the said waiting list are being so admitted for treatment and moved along the said waiting list in accordance with common criteria;
  2. (ii) in applying such common criteria the consultant concerned is applying social criteria where such criteria are relevant among others to admission to hospital and to progression along the waiting list but not to such an extent as may give either the class of private patients or the class of National Health Service patients 1414 an advantage in terms of the length of time on the waiting list over the other class of patient;
  3. (iii) a potential private patients' place on the waiting list is being determined by the date upon which he was first referred to a hospital outpatients clinic or for a private consultation by the patient's general practitioner;
  4. (iv) the District or Area Health Authority is ensuring that the provisions in subparagraphs (i), (ii) and (iii) of this section are being properly applied and that statistical monitoring has been instituted by the relevant health authority to ensure that paragraphs (i), (ii) and (iii) above are being so applied;
  5. (v) sub-paragraphs (i), (ii), (iii) and (iv) above are being applied to diagnostic and other medical services; and".")

The noble Lord said: I beg to move this amendment to Clause 9, which deals with the treatment of private patients in National Health Service hospitals. The amendment seeks to lay down certain stipulations. It is a simple amendment, expressed in very simple language, and we ought not to run into any difficulty about it. It seeks to lay down that all private resident patients in National Health Service hospitals should be placed on the same waiting list as National Health Service patients, and should move along the waiting list in rotation. It will be for the consultants to see that their patients take their turn. This will eliminate queue-jumping, which has been a bone of great contention among the public. The amendment also seeks to make certain that neither class of patient would be at an advantage over the other.

The new sub-paragraph (iii) states that the place on the waiting list, whether private patient or National Health Service patient, shall be determined by the date that the patient was referred to the hospital out-patients' department or, in the case of a private patient, when he or she was referred to the consultant by the patient's GP. The new sub-paragraph (iv) places a responsibility on the District Health Authority or the Area Health Authority to see that these conditions are complied with in regard to reference to the National Health Service for diagnostic and other medical services. The same procedures apply.

This is a sincere attempt to overcome misuse and unfairness by the private sector when using National Health Service hospitals. No one on this side of the Committee would want to deny National Health Service facilities to the private sector as and when necessary. The National Health Service already provides many facilities, as was recognised by the Royal Commission on the Health Service, and I should like to ask the Minister to confirm that the Government have changed the policy with regard to private patients using National Health Service beds to include capital charges for pay beds. I should also like to ask whether it is the Government's intention to extend that to the other services involving particular equipment where capital costs and maintenance are high. This, I believe, is not being done at the moment. I accept that some contributions that are asked for from the private sector meet certain expenses, but not all expenses take in the overhead expenses. I beg to move.

Baroness YOUNG

The effects of this amendment would be to provide for statutory common waiting lists for all National Health Service and private patients, and for local monitoring of the arrangements. The Secretary of State would be required to direct a health authority that private patients could be admitted only if he was satisfied that the authority were operating on this basis. I assume that the amendment is designed to instigate a debate on the whole question of "queue-jumping" and common waiting lists, and the Government's own six principles, which we have already discussed.

The amendment seeks to provide for common waiting lists for all National Health Service and private resident patients. It is argued for on the basis that without it private practice leads to abuses. We do not accept this argument, and therefore we cannot accept this amendment; but perhaps it would be helpful if I reiterated some of the points that we have already made about the way in which we have provided that pay beds do not operate to the disadvantage of other National Health Service patients.

As your Lordships will know, our policy is to encourage private practice, both within the National Health Service and outside. For the National Health Service that means allowing private patient use of facilities. As I have said, we are concerned to ensure that this is not at the expense of National Health Service patients. We said in the consultative letter which the Minister of State sent out shortly after we came into office that we were concerned that the arrangements for private practice in the National Health Service should operate, and should be seen to operate, fairly, and we have kept that promise.

There are two safeguards, one statutory and one non-statutory. The statutory safeguard, as I have already indicated on the previous amendment, is that the Bill retains the legislative provision that pay beds will he authorised only where this does not significantly prejudice NHS services. This is supplemented by the non-statutory safeguards—that is, the agreement that the Secretary of State has reached with the medical profession on the six principles, which we have already discussed.

The noble Lord asked a question about matters of urgent treatment, and I would say to him that we have extended common waiting lists, where they are needed, to include not only those who are seriously ill and/or those who are in need of urgent treatment but also those requiring highly-specialised diagnostic or treatment facilities. We do not believe, however, that it is objectionable that a patient who has chosen private treatment should be admitted earlier (or later, for that matter) than he otherwise might have been as an NHS patient provided that—and I cannot emphasise this too strongly— he does not thereby prejudice the position of NHS patients who are in need of urgent or highly specialised treatment or diagnosis.

This is the extra provision that we have made about which, I think, the noble Lord was concerned. I hope that that answers the question that he has raised, and has explained our general policy with regard to common waiting lists.


Is the noble Baroness the Minister in a position to give any indications as to how in fact these things are monitored? Who has the responsibility to see that they are in fact properly applied? That, of course, will also go for the six principles when they come into being, if they have not already come into being.

Baroness YOUNG

So far as the question of monitoring is concerned, there will be no formal monitoring system of the sort provided for in this amendment. I think I must say that. The main check will be by medical colleagues—what has been called the peer group. Health authorities will be asked to ensure that private practice is conducted in accordance with the principles. I hope this explains how we would see this operating.


I am bound to say, on what the noble Baroness the Minister has said, that I think it is highly unsatisfactory and open to a good deal of abuse.

On Question, amendment negatived.

Clause 9 agreed to.

Clause 10 agreed to.

Baroness ROBSON of KIDDINGTON moved Amendment No. 12: After Clause 10, insert the following new clause:

("Charge on private health hospitals

. The Secretary of State shall require private health hospitals annually to levy a charge upon themselves to be fixed after consultation between the Secretary of State and the hospitals for use as a contribution by the private health hospitals for the education and training of medical, dental, and nursing staff within the National Health Service")

The noble Baroness said: I am aware of the fact that an amendment was moved in the other place at Third Reading attempting to achieve what my Amendment No. 12 is attempting to achieve here. It was moved as a new Clause 8 in another place, and I have chosen to put it in as new Clause 11 because I believe that it follows naturally in the arrangement of the Bill since the preceding clause deals largely with the responsibilities that the NHS has towards the private sector. I am the first to agree that, having private sector medicine in this country as well as the NHS sector, it is very necessary that we co-operate for the benefit of all the patients; but it appears to me that the Bill itself concentrates rather too much on the responsibilities of the NHS towards the private sector rather than the other way round. I was also very concerned at hearing the Minister of Health's recent statement that he foresees the possibility of private medicine growing until it accounts for 25 per cent. of patient care in this country. Today, private medicine accounts for less than 5 per cent. of patient care, but nevertheless the drain on NHS-trained staff is already appreciable.

In the debate on the preceding amendments, somebody mentioned that the NHS benefit to the tune of £45 million income from private patients. It sounds to be a large sum of money. Can I try to tell your Lordships something of the cost of training staff for the NHS and the private sector?—because the NHS is basically the only training ground for the staff that services private medicine as well as its own. So far as I know, there are only five private hospitals which carry on a limited amount of nurse training. There are one or two voluntary and private hospitals which give training facilities to one or two registrars and senior registrars. Apart from that, on the whole the training for health service personnel, whether private or NHS, is done by the NHS.

To give some idea of the kind of burden that this places on the NHS on its limited budget, I can tell your Lordships that the cost of training undergraduate medical students on the SIFT formula in my region—and I have only one teaching hospital in my region—is £6,069,000. That is the sum required to train 324 medical students and 157 dental students; and that is the cost for one year. The cost to my region of re-training and bringing back into service married women who had left because they have had a family is half a million pounds a year. The cost of training nurses in my region is £3,235,000 per year. The cost of postgraduate training for nurses is £274 million a year, and the cost of postgraduate medical and dental education is £458 million a year. I have not totalled those figures but one can do that on reading Hansard tomorrow. It gives one some idea, if one multiplies the total by the 14 regions in England and Wales, plus whatever happens in Scotland, of the cost of training medical personnel for the use not only of the NHS but also of the private sector.

I have put forward an amendment in quite different terms from the amendment which was put forward in the other place. I have done this deliberately, because I believe that it leaves the possibility of working out on what basis a levy should be charged to the private sector towards the cost of education. I have talked to many people involved in the provision of private medicine in this country and they are fully aware of the debt that they owe to the NHS. I do not believe that there is any resistance on behalf of the private sector to helping with the cost of education of nurses, doctors and dentists. If we pass an amendment which leaves to the Secretary of State and the representatives of the private hospitals, the working out of the procedure, I believe that we might achieve something worth achieving. I believe that the private sector would feel better about carrying out their responsibilities and that the NHS would benefit enormously. The idea is not a new one. In most industries that deal with both the private and the public sector we have industrial training boards to which everybody pays a levy. I believe that if we did that, the relationship between the private sector and the NHS would be immeasurably improved. I hope that the noble Baroness, the Minister, can accept this amendment. I beg to move.


I should like to support the noble Baroness. This is an eminently sensible and just amendment. It will be attractive to the Government because it will bring finance into the National Health Service. I am sure that the Government, who are so keen to save money, cannot but accept the amendment. We have been discussing private beds. The noble Baroness is quite right: we train in the National Health Service people who become consultants. I think that I am correct in saying—and I have sat on one or two appointment boards—that we appoint consultants. It is the consultants who, in the main, benefit from private pay beds. There is every element of justice in this. It is an attractive amendment for the Government and they will be throwing money down the drain if they do not accept it.

Baroness MASHAM of ILTON

I, too, should like to support this amendment. It seems only fair that these hospitals which cater for people on insurance schemes pay their contribution to the National Health Service. For example, the long-term sick and disabled are not accepted by insurance schemes. They have no choice. But when they work they contribute to the National Health Service. They feel that these hospitals which are outside the Health Service should contribute.

9.16 p.m.

Baroness YOUNG

It is very helpful that the noble Baroness, Lady Robson of Kiddington, has raised this matter so that we can discuss it fully in the Committee. The question of the private medical sector's contribution to staff training has been discussed both in our House and in another place on a number of occasions in the past months. It was raised during our own debate in March. It was first raised by my right honourable friend the Secretary of State for Social Services during the Second Reading debate last December in another place. The Secretary of State said then that although the State trained many people who then went to work in the private sector—and there was an argument that there was no reason why the private medical sector should make a contribution to training—there was a good case for saying that in the case of health personnel the position was different. Where the NHS was short of qualified staff, and where the training was expensive, then the private sector should help by training more of its staff to meet its own needs. The Secretary of State mentioned that there already was some private sector staff training; the Government thought there could be more and their policy was to help the private sector increase its contribution. This was in effect a challenge to the private sector to do more.

We believe that the private sector has accepted this challenge and the responsibility for doing more to meet a greater proportion of the training costs of its own staff. That was a point made by the noble Baroness, Lady Robson of Kiddington. She said, quite rightly, that the private sector would like to help in this matter. To help them see what the possibilities are the Department of Health has had a number of meetings both with individual private sector groups and with a sub-group of the joint liaison committee for independent health care. Next week my honourable friend the Minister for Health will be discussing this with the joint liaison committee itself. So far discussions have concentrated almost ex- clusively on nurse training, but there is no reason why they should not go wider than this at a later stage. I think the Committee will agree, however, that nurse training is the most important area on which to concentrate. I think the noble Baroness made this point herself. Good progress has been made. We now have a much clearer idea of the amount of staff training which already takes place in the private sector. This is often provided in collaboration with the NHS. It takes the form primarily of in-service and developmental training, but there are a number of formal nurse training courses, both basic and specialist, provided in private hospitals.

We have also got a clearer idea of some of the problems in the way of a larger contribution. The cost of setting up a basic nurse training facility in the independent sector would not only be very expensive; but, more important perhaps, there are also problems in finding the necessary teaching and clinical experience. These problems are exacerbated by the fact that the private sector, unlike the NHS is made up of a number of very different groups, varying in size, services provided and staffing needs. These differences will affect individual hospitals' degree of involvement in a training programme. Basic nurse training within the private sector is of course not the only area where a contribution can be made. I think that the noble Baroness, Lady Masham of Ilton, made this point. In our discussions with the private sector we are looking at other areas where a contribution would be just as valuable.

If I might indicate just briefly some of the possible options, there is a sponsorship of existing NHS basic and post-basic training. This would be done by sponsoring places in nurse training schools both in NHS and independent hospitals. Alternatively, students from independent hospitals might be sponsored or seconded to attend training schools. There is also the question of direct financial contributions which might be made to support and expand existing training facilities, again in both the NHS and the private sectors. There are also a number of universities which are offering nursing degree courses and students on such courses are funded by local education authority grants, as are other undergraduates. These courses provide graduate nurses of a high calibre for the common pool of nursing staff. Resources might be injected into those courses by the independent sector by the endowment of professorial chairs ch lectureships. These are just some of tht. options we are exploring and I give them only as examples of what might be pos sible. I have mentioned some of tilt: difficulties and particularly the difficulties in the way of more basic nurse training but, as noble Lords will appreciate, these are not things that can, or should, be done overnight. They will take some time.

I hope I have said enough to indicate that there is general agreement between us on the principle of this and that we are looking actively at it. In view of what I have indicated and the discussions which are currently taking place, I may say we have not ruled out completely the idea of a voluntary levy. During the Report stage in another place, when a similar amendment was tabled, the Minister of State said that we did not have a closed mind on the idea of a levy and thought that some form of agreed rate of voluntary contributions to a central pool might be made. We do not think that an amendment to this Bill at this stage which would introduce a compulsory levy would be very desirable in view of the discussions we are having. Before we did introduce a compulsory levy we would have to think it through very carefully indeed. For example, the levy would be imposed in all private hospitals and it would be completely non-selective and there would be implications of this. Would there not be any exemptions?

As this amendment stands, unless the definition of a hospital was carefully drafted, it could embrace such premises as those looking after the terminally ill. It would include voluntary and religious hospitals where many of the patients are admitted without any charge at all. I do not in any way use these arguments as a debating point, but I would say quite simply that it would be difficult to accept the amendment on the levy as it stands, because it needs thinking through. I give the assurance to the Committee that, as a matter of principle, this is something that the Government are looking at.

I hope I have said enough to assure your Lordhips that we are looking at a series of propositions with the private sector and meetings are currently taking place. If I have any further information available by the time we reach the next stage of this Bill, I will of course give it to your Lordships. In the meantime, I hope that I have given enough reassurance so that the noble Baroness may feel able to withdraw her amendment.


It is gratifying to hear the noble Baroness say that her right honourable friend the Minister of State is considering this matter with the private sector, but, bearing in mind that the private sector is going to exist for some years on people who are already trained—that is, nursing staff, medical auxiliaries and doctors—and that they have been trained at the expense of the State, does her right honourable friend the Minister of State rule out the possibility of getting some kind of levy for the staff they have already got?

Baroness YOUNG

No, we do not rule that out as a possibility. I hope I made that clear: this is one of the things that are being discussed.


I thank the noble Baroness very much for her reply and for her open-mindedness on this question. I have some reservations. The noble Baroness said it would be very expensive for the private sector to set up a training programme of their own. I realise that, and that is why there is no hope that this will happen. That is why I have introduced an amendment for some levy to be paid by the private sector.

The noble Baroness also referred to the problems of different hospitals, the size of hospitals, terminal care and all kinds of difficulties that might occur in raising a levy from the private sector. This is exactly the reason why I have left my amendment so wide, and why I say that consultation will take place between the Secretary of State and the private sector. All it says is that, as a basic principle, a levy should be charged. I should be quite happy to accept the result of consultation between the Secretary of State and the private sector, and I hope that this will be kept in mind when the consultation proceeds along the lines that the noble Baroness has suggested.

In view of her statement on the consultation, I am happy to withdraw the amendment today. But I will re-table it on Report, because I do not accept that this is not the time or the Bill in which to introduce it. I believe that this is exactly the Bill in which to introduce it. Having read the report of what has been said in reply today, and after consulting my colleagues, I might easily re-introduce the amendment on Report, but today I beg leave to withdraw it.

Amendment, by leave, withdrawn.

Clauses 11 to 14 agreed to.

Schedule 3 agreed to.

Clause 15 agreed to.

Schedule 4 agreed to.

Clauses 16 to 24 agreed to.

Schedule 5 [Amendments of the Act of 1977 and the Scottish Act of 1978 relating to exemptions from charges for certain services and appliances]:

9.27 p.m.

Baroness ROBSON of KIDDINGTON moved Amendment No. 13:

Page 54, line 33, at end insert— ("After paragraph 1 of Schedule 12 to the National Health Services Act 1977 there shall be inserted the following paragraph— 1A. No charge shall be made under section 77(i) above in relation to the supply of any drug, medicine or appliance to any person who is in receipt of Invalidity Benefit.".")

The noble Baroness said: I very much regret that my noble friend Lord Winstanley is not here to move Amendment No. 13, but unfortunately he had to leave in order to catch a train. As your Lordships know, the amendment deals with the exemption from prescription charges for all people in receipt of invalidity benefit. To look at the case for this, we have to look at the figures of those to whom it applies. I believe that at 3rd June 1979 there were 557,000 people in this country who were in receipt of invalidity benefit, and of those about 80,000, or 12 per cent., were exempt from prescription charges, because they were over retirement age or receiving supplementary benefit. Then there are a large number of people who are in receipt of invalidity benefit, and who are exempt because they have a specified condition. Those conditions include cancer, heart disease, spina bifida, cystic fibrosis, multiple sclerosis, mental illness, chest disease and arthritic condition.

In the discussion on this Bill in the other place on 9th June 1980, it was stated by the Under-Secretary of State, Sir George Young, that information was not available for any of the other exemption categories; in other words, the number of people who are exempt under those categories. But there is evidence that many people who would be exempt under those categories do not apply, because either they do not want to go through a means test or they are not aware that they can apply.

The argument of the present Government is that somebody who is in need of repeated prescriptions can get a season ticket, but for somebody who is in receipt of invalidity benefit this can cause quite a lot of hardship. If you are to get the maximum benefit from buying a season ticket, you ought to buy it on a yearly basis—it costs £12 at the moment, and in future it will cost £15—but it will be very difficult for somebody who is caught in the poverty trap (and many of the invalidity beneficiaries are) to have to pay out that sum of money, particularly since they will say to themselves: "I may not be in need of prescriptions for the whole of the year; it may be only in the winter that I shall need a great number of prescriptions".

Neither the Government nor anybody else has been able to tell me how many people are not exempt now. All we know is that 80,000 people are exempt on the grounds of age or because they are receiving supplementary benefit. We do not know how many people are exempt because they suffer from a specific disease. The Government estimate that the cost to the health service if we introduced exemption from prescription charges for invalids would be £21½ million, based on the average prescription per person, and that, taking into account that an invalid would perhaps need more prescriptions than the average person, the maximum cost would be £4 million. These people are already suffering from the abatement of their benefit and from other measures contained in the Social Security (No. 1) Bill and the Social Security (No. 2) Bill. I believe that it is incumbent upon us to make certain that people in this category are entitled to free prescriptions.

There is one extra point to be made. Very often general practitioners prescribe a drug or a medicine to make the life of an invalid pleasanter and better in some way, although it is not necessary for his physical health. They will refrain from doing this because they will know that the invalid will have to pay the extra prescription charge. The saving to the nation is so small, that I believe this to be one of the meanest things that we are trying to do. Therefore I hope that the Committee will agree to accept this amendment.

9.33 p.m.

Baroness MASHAM of ILTON

I spoke on this point at Second Reading. As old age pensioners and war pensioners are exempt, it seems to me to be reasonable that invalidity pensioners should be exempt if they become yet another category. Already there are six categories. I would not agree if they were to take the place of some of the people in the six categories. I believe that the very severely long-term sick and disabled should be exempt. They include people with muscular dystrophy, spina bifida, multiple sclerosis, kidney disease, continual skin disease like psoriasis, heart disease, chest disease—all sorts of disease.

I have discussed this with the noble Lord, Lord Campbell of Croy, who is himself war disabled. He tells me that it is quite simple for the medical profession to categorise severely disabled people. Therefore, I implore the Government to look again at this category of severely disabled people. It really does seem appalling that this country cannot help these severely disabled and long-term sick people, some of whom have cancer and who may be going to die. Only last week I heard of somebody who has cancer who has hesitated in taking up her season ticket because she feels that she may not live for a whole year. It really is an appalling situation. In fact, as I meet so many disabled people and I really see them at this level, I feel that the country should do something about this situation. Since Second Reading I have discussed this with many members of the public, and they were appalled because they did not realise that these very badly disabled people were not exempt.


I do not want to prolong this debate, but this is a matter which is causing considerable concern to the people who are working in the field of those who could be described, to a large extent, as being deprived. It has imposed a very severe burden on them. I do not want to go over the same ground as that covered by the noble Baroness, Lady Robson, because she has done it in such an excellent manner. What I want to ask the Minister is this. Is it true that the Department of Health and Social Security has already investigated the possibility of granting exemptions to more groups with specified illnesses, but that this was rejected because it was unacceptable to the representatives of the medical profession because of the risk of argument between doctor and patient?


I think we have had a very useful debate on this most important subject, and I am sure that despite the fact that the noble Lord, Lord Winstanley, has been unable to be with the Committee on this occasion the amendment so ably moved by the noble Baroness, Lady Robson, has interested the Committee very much. I think it would help the Committee if I were to go over in a little greater detail the present arrangements.

Your Lordships may or may not be aware that the present exemption arrangements are based broadly on medical and financial need. Exemption on medical grounds is based on the fact that all persons suffering from one of the exempt medical conditions are virtually certain to require prolonged continuous medication. This is not necessarily the case with all invalidity recipients, many of whom may not require a lot of prescriptions. Exemption on grounds of financial need is given to recipients of supplementary benefit, family income supplement and to others, whether working or not, whose financial resources are not much above supplementary benefit levels. Invalidity benefit is not a means-tested benefit; therefore many recipients will not be in financial need.

While recipients of invalidity benefit as a whole do not qualify for exemption from prescription charges, many of them do not in fact have to pay for prescriptions as they qualify for exemption under the present arrangements; that is, because they are suffering from one of the specific medical conditions or because they are in receipt of supplementary benefit or family income supplement or because their income falls below a certain level. The qualifying level for low income exemption was raised when prescription charges were increased in July 1979 and on 1 April this year, thus extending entitlement to more people. As was explained in another place, the existing exemption arrangements will continue when the prescription charge increases to £1 on 1st December this year. The low income qualifying levels will again be raised at that time.

The noble Baroness referred to figures in June 1979, and I am a little mystified about them because the figures quoted in another place at col. 90 were 130,000 recipients of invalidity benefit—that is for Great Britain, in 1978—who were known to qualify for free prescription on age grounds or because they were in receipt of supplementary benefit. I regret information is not available for any of the other exemption categories.

In June 1978 recipients of invalidity benefit totalled approximately 708,000. This figure includes those in receipt of contributory invalidity benefits, non-contributory invalidity pension and housewives' non-contributory invalidity pension. I have not been able to reconcile the noble Baroness's figures. I am sure they are very accurately quoted, but I have had insufficient time to reassure myself as to their particular source.

The cost of exempting invalidity benefit recipients would be, for those who are not otherwise exempt from the present 70p prescription charge, in the region of £2.5 million. Apart from the cost there are conflicting claims of the various groups including people who suffer from serious medical conditions, such as cystic fibrosis, glaucoma, chronic bronchitis, emphysema, multiple sclerosis and muscular dystrophy, who in terms of prescription needs and numbers would seem to have a much stronger case. Some other examples of people who feel that the exemption categories should be extended to them include people involved in early retirement, dependent wives of pensioners and widows.

I re-read with interest the speech of the noble Baroness, Lady Masham, on Second Reading at column 1407. She was of this opinion—I quote her words: All I am asking the Government to do now, as prescription charges are going up, is to extend the exemption to some more categories who are severely disabled and need prolonged treatment by the use of any drug, medicine or appliance". The noble Baroness slightly varied her argument this evening, but I think we can take it the two are not inconsistent with one another.

In the present circumstances I think it would be profitable to take up another point raised by the noble Baroness. She specifically mentioned the problem of a particular case of a sufferer from cancer—and I am sure the House was much moved by it. I think the noble Baroness mentioned that the sufferer did not think it would be worth her while purchasing a season ticket, a certificate for 12 months, at a cost of £12. I would remind the House that there is another option of taking up a four-monthly certificate at a cost of £4.50, which would entitle the holder to obtain as many prescriptions as he or she needs during the four-month period. I think there is a point here. By introducing the four-monthly certificate, to replace the previous six-monthly one, the Government hope to have made it easier for people who have to budget carefully, to find the money to buy a prepayment certificate. A prepayment certificate is currently worthwhile for anyone who needs more than six items on prescription during a period of four months, or more than 17 items during a period of 12 months.

When the prescription charge increases to £1 per item on 1st December 1980 the cost of certificates will also be increased. This increase will be less, proportionately, than the prescription charge increase and thus make the purchase of a prepayment certificate a more attractive proposition. The new prices will be £15 for an annual certificate and £5.50 for one for four months. Certificates issued with a starting date before 1st December will remain valid for their full period. I hope that that information may assist the noble Baroness and I hope that I have answered the questions of noble Lords.

Baroness MASHAM of ILTON

Before the noble Lord sits down, I should like to thank him for what he said about the season ticket which can be paid by four-monthly instalments. There are many people who do not know about it and it would be good if the Government could give it some publicity. That would be very helpful, especially to cancer patients. Having said that, I still think that the very sick and disabled should be exempt.


I am grateful for the reply that has been given, but I am not happy about the answers because I feel that there are such grave doubts about what the Government are trying to save by not allowing this amendment. What worries me is that the noble Lord who replied cannot tell me the number who are already exempt. However, despite that we have a statement saying that if we exempt everybody it will cost £2.5 million, or maybe £4 million. It seems to me to be a very vague statement and that we need more concrete facts.

It also seems to me that someone in the state of physical health which qualifies one for an invalidity benefit is someone who should be entitled to free prescriptions, especially as the saving to the nation is something about which we are not quite certain—the cost might be very much smaller than the amount stated. However, I shall ponder the subject and decide what to do on Report. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness ROBSON of KIDDINGTON moved Amendment No. 14:

Page 55, line 14, leave out paragraphs 3 and 4.

The noble Baroness said: I seem to be working overtime. I have tabled this amendment to Schedule 5 to leave out paragraphs 3 and 4 on page 55, line 14. I followed with interest the debate that took place in another place when in this schedule the qualifying age for free dental treatment was raised from the age of 16 to 18, whereas previously the exemption age was 21. I realise that there can be an argument for saying that somebody aged 18 now has the right to vote, he or she is an adult human being and there is no reason why we should carry on with this particular benefit.

However, in my view it is absolutely wrong at present to stop treating young people free. The economic situation of this country is such that a mass of our young people are leaving school and not earning any money. They arc in the unemployment queue. I am one of those who believe that it is desperately important that people should look after their teeth up to the age of 21; because if we do not look after the teeth of the young people in this nation, we shall only cause ourselves greater expense looking after them later in life. Healthy teeth have an impact not only on the teeth themselves; they have an impact on the whole health of a person.

We in this country certainly have a rotten record over healthy teeth, which is perhaps only surpassed by the people North of the Border. I happen to have been born in a country where teeth are considered to be important; and we take a pride in keeping our teeth to the age of 70, 80 or 90, or of dying with them. I think that we should have that same principle in this country. I believe that it is very dangerous for a young person who, for the first time probably is on his own, or who leaves his family also to have the added disadvantage of having to pay to go to his dentist. If the treatment were free, we might persuade that young person to get into the habit of going to the dentist every six months to ensure that his teeth are in order. He would have had a year or two before reaching the age of 21 in which to get into the habit. I do not believe that the cost of carrying this out would be enormous, and I believe that it would do an enormous amount of good for the young people of this nation, particularly until this Government, with the last Administration, get down to sorting out who has the ultimate responsibility for putting fluoride into our water supply. This is a problem that has not been solved at all. Until we solve it, at least let us look after the teeth of the young people until they are 21 years of age. I beg to move.


I should like to support this amendment. I am very much aware of the financial problems of the National Health Service and also of the directives from the Treasury. I am also aware that the dental profession has been successful in already having had Schedule 5 of this Bill amended, changing the age for charging for dental treatment from 16 to 18, and I think that that is a good thing.

Although there is no dental significance attached to the age of 21, it is a fact that between the ages of about 15 and the middle 20s there is a higher incidence and often an onset of many of the aspects of dental disease. My colleagues and I feel that any discouragement to seeking treatment at this age may have far-reaching effects which may ultimately cost the National Health Service much more.

However, I was at the centenary celebration this morning of the British Dental Association, and was delighted to hear my right honourable friend the Secretary of State announce the setting up of a dental strategy review group to look into the future management of dental services and to report as early as the spring of 1981. I was most encouraged to hear that one of the points of reference will be an investigation into the basis of patient contribution towards the cost of dental treatment. It is my hope that the present fixed charges—whether they be payable at the age of 18 or 21—will be reviewed in some way so that the actual charge towards the cost of treatment will bear some relationship to patient co-operation with preventative measures and a commitment to a programme of continued care.


I am sure that the Committee was very glad that when the noble Baroness introduced her amendment she spoke with such feeling from her native country on this interesting subject. The Committee will be grateful that my noble friend Lord Colwyn, a practising dentist himself, was able to add such a weighty contribution to the debate.

The Government, I regret, oppose these amendments which would have the effect of reducing the planned revenue from patients' charges and causing difficulty over the implementation of the proposed extension of the exemption arrangements for appliance charges. May I deal with the revenue point first. Paragraphs 3 and 7 of Schedule 5—which of course this amendment refers to—provide for the upper age limit for exemption from dental treatment charges to be reduced from 21 to 18 in the case of young people who have left school. It is estimated that this will produce increased revenue from patients' charges of some £7½ million in 1981–82 in Great Britain at Survey 79 prices. The amendment provides, however, for the status quo to continue, with, of course, a consequential loss of planned revenue which the Government would have to make good in some less acceptable way—probably by other increases in NHS charges or by reductions in services. In our view this is undesirable.

In framing Schedule 5, we have endeavoured to ensure that we get the balance of exemptions right. We have had regard, for example, to the arguments put to us that it would have a damaging effect on the dental health of young people to reduce the age limit for exemption below 18 (noble Lords may recall that our original intention, outlined in the latest expenditure White Paper, was to lower the age limit to 16). My noble friend Lord Colwyn referred to this a few moments ago. Similarly, we have provided for full-time students to continue to be exempt until the age of 19. Those patients who cannot afford to pay charges will be able to claim remission on low income grounds, as they can now. The existing arrangements for free dental examination also remain unchanged, as do the exemptions for expectant mothers and those who have borne a child within the previous year. With all these safeguards we do not feel that young people's dental health need suffer as a result of the provisions of paragraphs 3 and 7 of Schedule 5.

Turning now to paragraphs 4 and 8, the definition of qualifying full-time education is required not only for the implementation of paragraphs 3 and 7 but also for paragraphs 1, 2, 5 and 6. What we are doing in these paragraphs is to remove the anomaly whereby the existing exemption arrangements for dental and optical applicances and for appliances supplied to hospital out-patients are restricted to young people under 16 years of age or receiving "full-time education in a school". It is the phrase "in a school" which creates the anomaly because, as many noble Lords will be aware, the pattern of secondary education in many parts of the country is now such that a considerable number of young people follow A ' level and other comparable courses not in schools but in colleges of further education or similar institutions which do not fall within the statutory definition of the term "school". As a result, students at these educational institutions are denied the exemption to which their counterparts in schools are entitled.

Schedule 5 removes this anomaly by extending the exemption arrangements so that they include all those under 19 years of age who are pursuing a course of full-time education. The interpretation of "qualifying full-time education" in paragraphs 4 and 8 is a necessary part of this extension of the exemption arrangements. I hope that my reply, if it has not satisfied the noble Baroness, will at least have explained the Government's position.

Baroness MASHAM of ILTON

Before the noble Baroness, Lady Robson, replies, may I say that she has a very interesting amendment? My country of birth is Scotland, where I think we have the worst record for teeth. I wonder whether she could tell us what they do in Sweden, which I think is her country of birth. Perhaps we can learn from her.


That was a very searching question, considering that I have not lived in that country for some time now and 1 am not 100 per cent. up to date on the legislation in that country, but in the days when I was a young person we did get free dental treatment up to the age of 21. But I am not certain, and I should not like to say, that this is so at this moment. I shall have to check up, and I will let the noble Baroness know when I have checked with the Swedish Embassy. What worries me in particular about the noble Lord's reply is that he implied that by levying charges we should receive an income of £7½million.Did I understand that correctly?




That is correct. I presume this is on the assumption—and this is what worries me about the schedule—that all these young people went on and had their six-monthly check and looked after their teeth. What concerns me about it is that I do not believe they will. These are young people who are let out of their family surround- ings; perhaps their mother and father are no longer there telling them to go to the dentist. If they are short of cash because they are not finding suitable employment, the last thing they are going to spend money on is a visit to their dentist. I believe that it is a short-sighted measure, and I hope the Government will have another look at it before we come to Report stage. But I withdraw the amendment for the moment.

Amendment, by leave, withdrawn.

[Amendments 15 and 16 not moved.]

Schedule 5 agreed to.

Schedules 6 and 7 agreed to.

Clause 25 agreed to.

House resumed: Bill reported with the amendment.