HL Deb 23 June 1980 vol 410 cc1370-434

3.3 p.m.


My Lords, I beg to move that this Bill be now read a second time. This Bill includes a number of different provisions. There are some common central themes linking the Bill's main provisions on the local administration of the health service contained in Clauses 1 and 2, voluntary fund raising contained in Clause 5, and private practice contained in Clauses 8 to 15. But before turning to these central themes I should like to deal briefly with other minor provisions of the Bill.

At the outset I should like to say how pleased I am that the noble Baroness, Lady McFarlane of Llandaff, is making her maiden speech on this Bill. We shall greatly look forward to hearing what she has to say. I must also apologise to the House since I may not be here at the end of the debate as I have a long-standing engagement early on this evening. My noble friend Lord Cullen of Ashbourne will be winding up the debate for the Government, and I shall of course read Hansard tomorrow should I have missed any of the speeches.

Clauses 3 and 4 deal with two aspects of co-operation between the National Health Service and local authorities. These are provisions which bring the legislation into line with the ways in which this co-operation has developed. Section 26 of the National Health Service Act 1977 and its equivalent Scottish provision allow the Secretary of State to supply goods and services to local authorities. These arrangements can include the services of NHS employees. However it is often necessary to use the services of persons who are not employees as such of the NHS (for example, general medical practitioners who contract to provide NHS services). Such arrangements have been covered since 1975 by a non-statutory scheme authorised by the Estimates and confirming Appropriation Act. Treasury agreement to this arrangement was given on the understanding that an early opportunity would be taken to obtain statutory authority. Clause 3 provides for this.

Clause 4 similarly makes statutory the present informal arrangements for joint financing under which health authorities contribute to personal social services projects run by local authorities. Joint financing was started by the previous Administration and has been successful in many areas in fostering collaborative planning between health and local authorities. The arrangements are now firm features of the health and personal social services. Authority for joint financing rests at present, with the approval of the Treasury, on the Estimates and on the confirming Appropriation Acts and again we are fulfilling an obligation, acknowledged at the time the arrangements were introduced, of providing a statutory basis for the scheme. In the plan for NHS spending for next year, we are providing £61 million for jointly financed projects, a 15 per cent. increase in real terms over last year's allocation.

Clause 6 gives statutory expression to the existing arrangements for financial control of the health service. I believe your Lordships' House will welcome this. It is imperative that the Government operate arrangements which are clearly on all fours with the statute. The clause removes any possible ambiguity between the cash limit arrangements first introduced by our predecessors and the underlying statutory basis. Under the present provisions in the National Health Service Act 1977 (Section 97) the Secretary of State is under a duty to advance sums to meet whatever a given approval of expenditure might require. This is not compatible with the cash limits system and it is necessary to change this duty to one whereby health authorities are given advances not exceeding a pre-determined sum, which is compatible with the department's own cash limit. The clause also places a clear duty on health authorities to contain their expenditure within the sums allotted to them, together with any other sums they receive—pay bed revenue for example.

Clause 7 dissolves the Central Health Services Council. I am sure the immediate reaction of many of your Lordships will be to regret its passing and I should like to spend a few moments explaining why we feel the council is no longer necessary. The council was established in 1948 as a way of ensuring that Ministers responsible for the service in England and Wales should receive appropriate professional advice. The council has played a very valuable role over the last 32 years. However, the various professional interests reflected in its membership have increasingly developed their own direct links with Government and the decision to wind it up has been taken in the interests of rationalising the number of separate and often overlapping channels through which Ministers are advised. For example, Ministers have found it increasingly necessary to appoint ad hoc committees to give advice on particular topics. The Joint Committee on Vaccination and Immunisation is a very good example of this development. Many former council members will, I think, recognise that the council no longer provides an essential source of advice. It has done good service hut it has outlived its role.

I turn now to the miscellaneous clauses in Part III of the Bill. Clauses 16, 17 and 18 of the Bill deal with three aspects of the General Practice Finance Corporation. At present the corporation has power to borrow money, and to lend it to doctors, to buy, improve or build surgery premises. It has without doubt been of great help to GPs over the years. The corporation has now committed the £25 million that it is entitled to borrow under 1966 Act, and Clause 17 raises the borrowing limit to £40 million and gives power to increase this by order to £100 million.

Clause 16 contains a new power to allow the corporation to own premises and lease them to GPs for their surgeries. We believe—and both the corporation and the profession support this—that this will particularly help doctors in the inner cities, where high building costs and high rents can make it difficult for them to find suitable premises. Clause 18 is a minor provision which enables the corporation itself, instead of the Secretary of State, to pay its members fees and allowances.

Clauses 19 and 20 deal with two aspects of pharmaceutical services. I think noble Lords will find Clause 20 of particular interest. This clause is provided to enable the Government to implement the recommendations of the National Joint Committee of the Medical and Pharmaceutical Professions, which was chaired by Mr. C. M. Clothier, on the dispensing of NHS prescriptions in rural areas. The usual arrangement for the supply of medicines to NHS patients is for dispensing to be carried out by pharmacists. However, in rural areas access to a pharmacy can be difficult and a regulation enables doctors to supply medicines direct to patients who live more than a mile from a pharmacy. There are, however, disadvantages. Sudden changes can occur, either because a doctor starts or extends NHS dispensing or because a pharmacy opens. This can result in a substantial loss of income for whoever is already dispensing in the area, and the possible closure of a rural pharmacy or the termination of a doctor—dispensing service; in either case the patients suffer. The lack of stability in the arrangements has marred relationships between the medical and pharmaceutical professions for many years.

The Clothier Committee's main recommendation was that significant changes in dispensing arrangements ill rural areas should be regulated by an independent, statutory body. This body would have power to refuse an application from a pharmacist to start dispensing NHS prescriptions or from a doctor to start or extend such dispensing, but the only grounds for refusal being if, in the committee's view, the service to patients in the area from doctors and pharmacists would be adversely affected. The medical and pharmaceutical professions have accepted the recommendations and have jointly asked the Government to submit to Parliament the legislation required.

Clause 19 enables hospital dentists to have urgent prescriptions dispensed by High Street pharmacies after hospital pharmacies are closed. At present, these pharmacies are permitted to dispense for hospital dentists only the limited range of "listed" drugs that they can dispense for general practice dentists. This clause will enable them to dispense any drugs for hospital dentists.

The other provisions—covered by Clause 24 and set out in Schedule 5—to which I should draw attention are the amendments to the provisions in the 1977 Act relating to exemptions from charges for certain services and appliances. The existing exemption of school children from charges for appliances is extended to include all full-time students under 19 years of age, while the age limit for exemption from charges for dental treatment is lowered from 21 to 18, except in the case of full-time students under 19 years of age. No Government likes to have to extend the scope of charges, but we believe that if charges have to be levied for certain services—and all Governments have found this necessary—then they should fall on those who can best afford to pay. Patients who cannot afford dental charges can claim remission on low income grounds.

I now turn to the main provisions in the Bill; local structure, private practice and fund-raising. At the outset I mentioned common themes. The main theme is the Government's intention to work towards a more local and more flexible NHS that is better designed to meet the needs of patients. This is true not only of the reorganisation provisions in Clauses 1 and 2, but also of the clauses dealing with private practice and local fundraising. I will deal with the latter first. I was tempted to list Clause 5—the fundraising power — among the minor provisions. That indeed is how we saw the clause when we first put it in the Bill. Authorities already have power to receive, hold and administer trust funds. Compared with Government expenditure on the NHS, the amount of NHS non-Exchequer income is small; in 1978–79 it was some £14 million in voluntary donations and another £14 million in dividends on funds built up from past donations. These figures of course exclude donations in kind by leagues of friends, local firms, et cetera, but, although small in relation to central funds, these contributions have an importance out of all proportion to their relative size. Small sums or items of equipment can be of great value at local level. Also, by helping with fund-raising, the local community is brought closer together with its local hospital. It helps to make it "the local hospital", which the local community not only cares about but also supports in a practical way.

There is, therefore, nothing new in the NHS using non-Exchequer funds to help to provide services. We see the new power as a modest extension of existing ways in which the NHS can draw on voluntary funds. Furthermore, we believe it would be absurd, when the NHS is hard pressed to meet the demands made on it, to deny it help from other quarters, in this case the voluntary sector. We do not see voluntary funding as an alternative to central funding of the health service: it is not. Nor does it become such under this clause. Voluntary funds may be small compared with total NHS expenditure—and we do not anticipate that vast sums will be raised under this power—but they are a useful supplement which can make a tremendous difference locally, and there is the intangible benefit: we believe the NHS can only be strengthened by the closer involvement with the community that such voluntary help generates.

Finally, I should like to say a few words to reassure those who, while they have no objection to this new power, wonder how it will fit in with the very valuable work already done by leagues of friends and others. I can say quite categorically that the new power in no way supersedes or usurps the role of existing voluntary groups. This would clearly be completely counter-productive. The new power supplements the work of such bodies. There may, for example, be items which are beyond the scope of any single local fund-raising body, and the simplest way of co-ordinating an appeal and keeping it going over a long period of time might be for the health authority to take the lead. The new power will also help voluntary bodies to give better help to the NHS. Although voluntary bodies usually make a point of consulting with health authorities before launching appeals for new items of equipment to make sure that these are wanted, this does not always happen. There have been cases where authorities have received items of equipment that they either do not need or cannot afford to run. This is a tragic waste of resources and very damaging to local good will. The new power will enable such existing bodies and health authorities to work more closely together to avoid that sort of situation.

I mentioned the need for more local involvement in the NHS. This is one of the main themes of the consultative document Patients First. Clause 1 contains the new power to create district health authorities. We have learnt the lessons of a single, large-scale reorganisation. We propose therefore to take only a permissive power to appoint district health authorities. Clause 1 confers on the Secretary of State a power to appoint such authorities, but it does not require him to do this. The provisions do no more than allow greater flexibility for Ministers to determine the most appropriate health service structure to suit the needs of different parts of the country. They do not seek to lay down any particular structure and do not require that there should be any change at all. They will simply enable the implementation of the proposals we have put forward in our consultative paper Patients First, if these are confirmed as policy later in the summer.

The consultation period on Patients First ended on 30th April and we are now very carefully considering all the representations we have received. Our impression so far is that there is very wide agreement on the main thrust of our proposals: to establish in England a pattern of operational authorities on similar lines to the existing single district area health authorities and to strengthen management at the hospital and community services level. The proposal to retain existing arrangements for the administration of family practitioner services, provided for in Clause 2, is an indication of our intention to keep what works and change what does not.

Finally, private practice is dealt with in Clauses 8 to 15 of the Bill. I mentioned the importance of voluntary sector help for the NHS. We believe the same is true of the private medical sector. We debated the private sector's contribution to the health care of the nation in March in a debate instigated by my noble friend Lord Hunt of Fawley. We had a very good debate and discussed a wide range of issues, and we on this side said we would keep our comments on pay beds for the time when we debated this Bill. On this occasion I restrict myself fairly closely to the provisions of the Bill, but I should like to remind the House of a general point made by my noble friend Lord Cullen of Ashbourne on that occasion. He said: Our approach to private medicine is based on two beliefs; one is a fundamental principle, the other is based on observation of practice. The first, the fundamental principle, is that there is absolutely nothing wrong, morally wrong, with the existence of private medicine. The second, the practical observation, is that private medicine poses no general threat to the NHS. It neither threatens the concept of the NHS nor prejudices its ability to function. Indeed … we believe that the reverse is the case: that the existence of the private sector can strengthen the NHS, not weaken it. Our commitment to the NHS is in no way undermined by our belief that there is a place for private medicine and private provision and that both should be facilitated and encouraged".—[Official Report, 19/3/80; col. 251.] I think that your Lordships will see that that commitment to the National Heath Service, going hand in hand with the desire to encourage private medicine, is evident from the provisions in this Bill.

The main provisions in this Part of the Bill deal with two aspects of private practice: NHS pay beds and the controls over private sector hospitals development. The two are linked at present in the Health Services Board, which is responsible for removing existing pay beds from the National Health Service and for exercising the controls. Under Clause 8 the board is abolished, the compulsory phasing out of pay beds is ended, the Secretary of State's power to authorise new pay beds is restored and the powers of control are transferred from the board to the Secretary of State. Before I proceed, I should like to add my tribute to those paid in another place and elsewhere to the work of the noble Lord, Lord Wigoder, and his colleagues on the board. They have performed a difficult task supremely well and have earned the respect of all sides. It is no reflection on them that we are proposing the abolition of the board.

Clause 9 restates the Secretary of State's general power (in Section 58) which allows National Health Service services to be provided for non-NHS purposes, but it repeals the Section 59 use of that power. This allowed for continued private patient use of specialised NHS services and was provided by the previous Adminstration as part of a compromise on pay beds reached by the noble Lord, Lord Goodman. A separate power to allow specialised admissions is no longer necessary once the main pay bed power is restored.

Clause 10 does two things. First, it provides that the Secretary of State cannot revoke existing pay bed authorisations, unless there are alternative facilities for the private patients who use them. That is a sensible safeguard. Its effect will be that any future Secretary of State will have to come to Parliament, in the same way as we have had to, if he wishes to remove existing pay beds. We believe that it would be wrong for all facilities for private practice to be removed without full parliamentary discussion. This provision ensures that by placing this one limitation on the Secretary of State's discretion.

Secondly, Clause 10 links the pay bed powers in the National Health Service Act 1977 to Section 62 of that Act. This section provides that nothing may be done which would significantly prejudice services to NHS patients. This is a statutory safeguard to protect the National Health Service; private practice will be allowed, but only w here it will not so interfere with services to NHS patients. Moreover, this statutory safeguard is supplemented by the agreement the Secretary of State has reached with the medical profession on "six principles" to be followed in the arrangements for private patient use of the National Health Service. My noble friend Lord Cullen of Ashbourne listed these principles when he spoke in March, so I shall not reiterate them here. But my noble friend said at the time: The principles are designed to ensure the equitable operation of private practice in the NHS, and have been endorsed and accepted by the medical profession. This agreement is a notable achievement by the Government. It goes beyond what the previous Administration achieved. It is a product of co-operation and negotiation ".—[Official Report, 19/3/80; col. 257.] Finally, I turn to Clauses 11 to 14. It is a clear indication of our commitment to the National Health Service that we have retained these powers. We think it right that, when a large private development is proposed, there should be a check on whether it will interfere with the provision of National Health Service services, and I remind the House that the only grounds for not allowing a development is if there will be such an interference. These powers are a sensible safeguard for the NHS—not an arbitrary control on the private sector. The clauses amend the powers.

The main changes proposed are that a hospital will have to provide 120 or more beds before authorisation is required, and further increases to premises already above this level will be excepted from the need for authorisation where the increase in beds is less than 20 per cent in a three-year period. The Bill also includes a new reserve power enabling the Secretary of State to designate areas where all private hospitals would need authorisation. This is designed to meet the point made by the Royal Commission on the NHS that a number of small hospitals could jeopardise the NHS as much as a large hospital could. Before an area is designated, and before any development is prohibited, there will have to be firm evidence that such a danger to the National Health Service exists.

Our policy is clear. We believe that there is a place for private medicine both in the National Health Service and outside. We believe that the National Health Service benefits from this. Pay beds bring in income. The private sector relieves pressure on the National Health Service. It would be difficult to believe that the National Health Service could cope with the extra burden of providing for the patients who now use the 35,000-odd private hospital and nursing home beds. However, we are also concerned that the expansion of private medicine does not harm the NHS. We do not think that it will, but where there is the possibility of harm, then we have the safeguards which I outlined a few moments ago. Our policy is quite simple: "Yes" to private practice and safeguards where they are necessary. We totally reject the idea that there should be any arbitrary, doctrinaire ceiling on private provision. As I said at the beginning of my speech, the main themes of the Bill are local structure, private practice and fund raising. I hope that I have outlined them. I commend the Bill to your Lordships and hope that you will give it a Second Reading—


My Lords, before the noble Baroness the Minister sits down I wish to refer to the fact that she referred to the six principles, which I understand have been enumerated by the Secretary of State and have been accepted by the British Medical Association. Is the noble Baroness in a position to say whether the principles have yet been implemented, or whether they will not be implemented until this Bill gets on to the statute book? Can she say what is the present position?

Baroness YOUNG

My Lords, to the best of my knowledge they must wait until this Bill goes on to the statute book, but if I am wrong in the information that I am giving the noble Lord, my noble friend Lord Cullen of Ashbourne will correct the point when he winds up. My Lords, I beg to move.

Moved, That the Bill be now read 2a.—(Baroness Young.)

3.28 p.m.


My Lords, first, I wish to thank the noble Baroness, Lady Young, for the rather quick, but quite clear manner in which she presented the details of a Bill which is in fact far more complicated than she suggested. I appreciate what the noble Baroness said about her having another engagement; indeed the House appreciates the extreme pressure to which the noble Baroness is subject in her ministerial office. What amazes me, and I am sure all the other Members of your Lordships' House, is the remarkable stamina and grasp of detail that the noble Baroness shows. I look forward, as indeed does the whole House, to the maiden speech of the noble Baroness, Lady McFarlane of Llandaff, and to hearing what she has to say on this vital subject.

This is an administrative Bill. Certainly, for a health service Bill, it is somewhat unusual in that the patient and patient care do not feature anywhere in it. The previous reorganisation of the health service, under a Conservative Government, has been responsible for much of the lowering of standards in the hospital service and the decrease in morale of staff. Remote control and increasing bureaucracy have created a situation in which further reorganisation is necessary, and it is somewhat appropriate that another Conservative Government are now taking action to put right some of the disastrous effects of Sir Keith Joseph's policies on the National Health Service.

A Labour Government would have had to take action in the course of time, but it is fair to point out that to have carried out further reorganisation too quickly would have seriously harmed this service. As it is, the reorganisation will have to be carried out with extreme care, particularly where it affects staff, some of whom inevitably will be casualties. In this connection, in the phasing out of staff, patient care must be taken into account. However, I must state that the general effect of Clause 1 is welcome as far as it goes, but I rather feel that the Minister should have greater powers. The establishment of district health authorities should do much to bring back the element of local control which was so evident in the old management committee days. Membership of the new committees will, of course, have to be carefully selected, based on local experience and balanced with some staff representation.

Care must also be taken to avoid unnecessary amalgamation of present health districts; otherwise this would only continue the remote control of area health authorities. May I give an example of an area with which I and possibly some other noble Lords are familiar? The Greenwich and Bexley area health authority has two health districts—Bexley and Greenwich—both high populated areas and completely different in character. To amalgamate these would be completely at odds with what I feel is the objective of Clause 1—more local control—and would only continue the defects of the present system in maintaining remote control.

There is a further point, and here I have often been at odds with my regional health authority. Regional health authorities at the present time possess sweeping powers. Do the Government intend to extend the responsibility of district authorities to enhance the desirable extension of more local control? It would seem that behind every Bill the Government introduce lies a financial motive, and I may be excused for thinking that that may be the case in this particular Bill. However, will there be any cost saving behind Clause 1 and, if so, can the Government say how much?

Behind the proposals in this clause lies the difficult problem of staff reorganisation. The previous reorganisation, or, as I have often preferred to call it, disorganisation, created many problems regarding staff, and many capable officers were lost to the service. I understand that the Whitley management side have sent to regional, area and district administrators three documents on protection of pay and terms and conditions of service; on compensation; on redundancy; on premature retirement and arrangements for staffing the reorganised National Health Service. It is true that in a sense they are discussion documents. The staff side have yet to negotiate and accept, and it is obvious that this is going to be the start of a long and difficult period of negotiation at national, regional and local level.

What arrangements have the Government in mind to deal with these extremely difficult and sensitive matters? What steps are being taken to ensure that patient care is not adversely affected by staff reorganisation? What is the cost of the Whitley management side proposals; and what is the estimate of eventual net saving, if net saving there be? It would seem desirable that the Government set up a commission to oversee the whole set of negotiations and its effect on the National Health Service. Reverting to local interest and control, I am sure that although there have been difficulties and differences of opinion it will be agreed that community health councils perform a useful function. It is desirable that they continue to carry out their functions as consumer watchdogs, without restriction of their present narrowly prescribed duties and powers. I ask the question for a clear answer at the end of the debate: will they continue?

The proposals in Clause 2 dealing with family practitioner committees need to be examined with a great deal of care. There is a case for continuing those established on a joint basis for two adjoining districts within a present area health authority area and proved to be efficient. But to extend it further would completely negative the principle of more local control. Family practitioner committees provide a vital and efficient service and the proposals in Clause 2 are far too sweeping in effect.

Now I become controversial. I turn to Clause 5, the so-called "Bingo Clause"—a term which I feel rather cheapens a very serious matter and ignores what is being achieved already. The clause itself is not necessary. It suggests reversion to the old days of nurses begging for cash in the streets on flag days and professional lottery promoters reaping a harvest in the name of charity. In any case, lotteries promoted by local authorities with professional help are proving a flop. The proposals provoke the suspicion that here is an idea to reduce state aid by relying on local collections, fetes and flag days. It will also—and this is a point we must bear in mind—benefit wealthy areas at the expense of poorer areas where the need is greater. It is wrong that health authorities should have to use staff and time on such activities when already organisations exist for fund raising efforts.

It is true that the noble Baroness paid tribute to leagues of friends, but what seems to be ignored is the invariably enthusiastic work for hospitals of leagues of friends and bodies such as rotary clubs and many others, in wealthy and poor districts alike. The impression seems to be held in another place that they are the do-gooder providers of little comforts and extras that ease the stay in hospital. That may possibly be true of the situation a few years ago, but certainly it is not so today. As an example I quote from the balance sheet of the Friends of Queen Mary's Hospital, Sidcup, of which the noble Baroness, Lady Hornsby-Smith, is patron and of which I am a life member. I have the balance sheet here should any noble Lord like to examine it. For the year ending 31st January 1980, comforts and extras amounted to £2,329, which the friends paid for. Medical equipment was £9,211. Commitments, also for further medical equipment, as at 31st January of this year amounted to £5,340. So medical equipment is being provided by these organisations.

Such organisations, together with many others, mobilising as they are local voluntary workers and local enthusiasm, are already actively providing urgently needed equipment that regional imposed cash limits will not provide. May I indulge in a slight commercial? My league of friends are holding their fete on Saturday next, the 28th, and any noble Lord or noble Baroness is welcome to come along provided they stuff their wallets with £5 notes. I shall be glad to see them all. Why undermine all this excellent work and voluntary effort by this stupid and entirely unnecessary clause, when facilities already exist, avoiding the time and expense of health authority staff?

I now come to Clause 6. I am suspicious of this clause. It imposes legal rigid control of cash limits, no doubt to ensure that any sweeping cuts imposed by the Government are carried out. The clause is unnecessarily rigid and does not allow for exceptional cases which may arise and which justifiably call for consideration by the regional health authority for an additional grant. Here, what is needed is a more flexible approach allied to reasonable financial control.

Finally, I come to Clauses 8 to 14 which pose the problem of the private sector versus the public sector. I would accept that if people think they can obtain better treatment and priority in the private sector and part with their money directly, or through subscriptions to an organisation, to buy health care and priority, then let them do so; it is a free country and they have a free choice. But do not take action to introduce paying for priority in the National Health Service where the only priority should be the medical needs of patients, irrespective of colour, class or creed. We have had enough trouble over pay beds in the health service. Pay beds in National Health Service hospitals only irritate. They distort waiting lists, make unnecessary and excessive demands on nurses and ancillary staffs and, although costly to private patients, the financial advantage to the National Health Service is not all that great if one takes into account the additional demands on the hospital administrative staff.

What has to be achieved in this difficult field is to secure a proper balance between the private and public sectors, bearing in mind that the public sector serves the largest section of the community. To encourage encroachment of the private sector into the public sector is a political act designed to undermine the National Health Service, a National Health Service which has had worldwide admiration. Of course, financial interests are involved. That is well known; but let us keep the health service national and not make it an element in class distinction and preferential treatment. There is nothing to prevent properly balanced private and public sectors co-operating in the joint use of specialised equipment and in joint efforts, particularly in the research field.

My Lords, there is a strange coincidence about this debate. This Second Reading debate is being held in the Chamber that was used by the Commons for their debate on the original National Health Service Bill during the 1945 to 1950 Parliament. Some of us here today remember that debate. We also remember the Conservative opposition to the Bill, with the BMA aiding and abetting. Despite the opposition (which has not completely vanished over the years) the National Health Service was established as a great ideal. True, in recent years, problems and differences have emerged, including the disastrous reorganisation which has fomented trouble.

The present Government, in deciding to bring in a new bill, had a great opportunity to restore confidence and to raise standards. Instead, we have this ragbag of a Bill—based as it is on political dogma and failings on high principles—with some element of good in it but which, in the main, will undermine the National Health Service still further. We shall challenge many aspects of the Bill in Committee and the Government will be well advised to be a little more receptive to argument than they have been so far on other Bills. We have fought over the years for a full, free, comprehensive health service. It is an ideal that we cherish and it is an ideal that we shall strive to maintain and, what is more, to extend.

3.44 p.m.


My Lords, we on these Benches look forward with great pleasure to hearing the noble Baroness, Lady McFarlane of Llandaff, make her maiden speech because few people in this House are more knowledgeable about the Health Service than she is. I shall deal briefly with the Second Reading. First, as one who is involved—and I think that everyone knows that I am chairman of a regional health authority so that I need not announce my special interest—I realise that the consultation paper Patients First is not yet public knowledge and the outcome of the deliberations are not public knowledge. Therefore, I very much welcome the Government's move in putting this Bill in front of your Lordships' House at this moment so that, when the end of the consultations comes and we know the answer, we shall have the opportunity to move forward without having to wait for legislation to come to your Lordships' House. That is the desperately important thing because something we have to guard against more than anything else in any future reorganisation of the service is allowing it to take too much time. The disturbance to staff and patients that occurs in a lengthy procedure of reorganisation is something which I believe the staff of the NHS could not take for a second time. So I welcome the fact that we shall be ready to take the right steps when the moment comes.

I believe personally—and I think all Members of the House will agree—that smaller authorities by themselves must be an improvement. They are sure to facilitate members of the authority having proper knowledge of the institutions and services they have under their control—which is something that has not been possible in many cases since 1974. I welcome the smallness of the authorities, but I should like to warn noble Lords that merely changing the authorities will not help to solve all the problems of the health service. By no means. I think it will be helpful but it will not solve all the problems. By far the most important thing is to make certain that we get the right management structure in the service, that we get the decision-making within a district down to unit level and that power over budgets and in answering queries can be made at the unit level. We have lost this since 1974 and this has been responsible for most of the problems that have faced us in the health service. It is not only a matter of creating districts but of creating, too, the right management structure under the districts.

People ask: "Will this save money?" I sincerely hope that we are not going into this exercise in order to save some £30 million, which I believe is the sum that has been mentioned on various occasions. We are not going into it for that reason; we are going into it in order to create a better administration. I do not believe that the savings will be there. I think that in many cases in the Health Service we are under-managed and under-administered; and it may be that we shall not save any money. But if we improve the service it will be worth doing.

I, too, have divided what I am going to say vaguely under the various clauses, but not in the same pattern as that of the noble Baroness, Lady Young. When we come to Clause 2 and the family practitioner committees, we on these Benches would have liked to see some attempt made perhaps to integrate more deeply the family practitioner committees into the health authorities, as is suggested by the Royal Commission. But I realise also it is almost an impossible thing to undertake. We are therefore very pleased that the suggestion is that there will be no further splitting up of the family practitioner committees and that they will serve more than one district. It would have been fatal to have split them once again.

Clause 4 makes joint financing statutory. It gives powers to make grants to the local authorities and allows the health authorities to extend that right to make grants to district councils in connection with their functions under Section 8 of the Residential Homes Act. That is something we did not have before. Before that, the health authorities could, through joint finance, support the social services.

I think two questions arise. Why pick out, in particular, the Residential Homes Act 1980? Why not include in joint financing things like health education? Because this is, in the long run, a preventive method of reducing the cost to the health service. There have been various attempts to get permission to use joint financing for health education, and they have been turned down by the Department of Health and Social Security. I think that is a great pity. Equally, I think this should be extended probably to sheltered accommodation, and to No. 3 accommodation. It depends. It should be at the discretion of the health authority and the local authority, because if, together, they can see that it would be beneficial both to the social services and to the health services, then I think that the freedom for them to collaborate should exist.

Then I come to the question of moneyraising. Like the noble Lord, Lord Wallace of Coslany—and I have read the debates in the other place—I should like an assurance in this House, too, that money raised voluntarily will not result in a reduction in the grant to an authority in the following April. I should like a reassurance that the Treasury vote to each regional health authority will keep pace with inflation and demographic growth as a minimum. In addition to that, by all means let us involve the health authorities in the money-raising efforts of voluntary organisations. I have always found it a mistake for members of the health authority not to be allowed statutorily to take part in money-raising exercises; quite frequently it has resulted in a very embarrassing situation. Where, as has already been mentioned, money is raised locally for a body scanner and the revenue consequence of using that body scanner is not in the hands of the authority, it creates very bad feeling.

Further, I should like the health authorities to be involved because I should like to concentrate to a much greater extent on raising money for ongoing revenue purposes, and not always just for one project. It is easier to raise money for one project, but what we want it for, quite often, are the revenue consequences of running a home for disabled people, or some such enterprise, and that is much more difficult to do. I believe the involvement of the health authorities might help to make that more possible. Under Clause 5, in the new Section 96A(3), various specific fund-raising activities are enumerated and then it finishes up with the words, "and other similar activities". Could we have a statement from the Government Front Bench as to whether it is intended that that should include lotteries? Because if it does, I think we on these Benches would not be very happy about that.

Clause 6 is the clause which makes cash limits statutory. I think it is realised that this clause has been introduced because of the problems which existed in a certain part of London last year; but whether we are working on cash limits or on income and expenditure, one of the problems with health service finance has always been the inability to carry over substantial under-spending in years gone by. Those restrictions have been somewhat lifted, and we can carry over a small amount; but this situation makes for bad spending in the health service. It makes for spending on what one can spend the money on, instead of on the real priorities to which the money should be devoted.

I know this is a Treasury rule, but I would wish the Government to press the Treasury to relax it further. I should like to have an explanation, therefore, of the new subsection (7)(c), which could be read as giving greater flexibility on the carry-over than at present sanctioned by the Treasury. This concerns subsection (7)(c), where any money in the bank is considered as part of an authority's spending up to the end of the year. If that is meant to give greater flexibility I welcome it fully, but I should like to have an explanation of that provision.

Then we come to Clause 8, the abolition of the Health Services Board. I would join with previous speakers in paying tribute to my noble friend Lord Wigoder and his colleagues for the wonderful work they have done, because they have to a large extent taken the party political steam out of this particular question. I sincerely hope that, by abolishing them, we are not going to get party politics into this question yet again. We had a very good debate in this House, as has already been mentioned, on private practice and the NHS. I believe they can exist side by side, but it is important that the responsibilities are equal on both sides; and I should not be averse to making a contribution towards the training of staff by the private sector a statutory responsibility. Further, should we not perhaps have a look at various health insurances, and at making it statutory that they should carry through into the long-term, long-stay, provision for private patients as well?—because this is where the National Health Service has to take up the patients who were previously in the private sector, and it is a very expensive exercise. I think that perhaps we should have a look at those two things in relation to private practice.

I know that my noble friend Lord Winstanley will want to raise various other aspects of the Bill, in particular as it deals with charges for prescriptions and the lowering of the dental services, but no doubt we shall have ample opportunity at Committee stage. Let me wind up by welcoming the powers taken to create district health authorities.

3.58 p.m.


My Lords, may I first thank the noble Baroness, Lady Young, for the generosity of her remarks at the start, and couple with them the remarks of the noble Lord, Lord Wallace of Coslany, and the noble Baroness, Lady Robson. I think I am privileged to speak for the first time in your Lordships' House on a Bill affecting a service in which I have spent the majority of my working life. I worked in the National Health Service first as a nurse, then as a midwife and then as a health visitor, and subsequently I have occupied educational roles, preparing nurses for their work in the National Health Service. In my present educational role, I have felt it very necessary to remain closely in contact with the work of the National Health Service, to the extent that we have created joint appointments between the University of Manchester and the Manchester Royal Infirmary, so that we are in day-to-day contact with the reality of caring for people in the hospital service.

Add to this, in 1974 I was appointed to the Manchester Area Health Authority, which is a three-district health authority; and subsequently I had the privilege of serving on the Royal Commission on the National Health Service, where I gained tremendous benefit from the breadth of view that we could take of the National Health Service. It is from this perspective that I should first like to speak. There is no doubt that a vast weight of evidence came to the Royal Commission on the fact that there were too many tiers in the health service, too many administrators, too many meetings and too many delays in decision-making. Therefore it was our recommendation that there should be only one operational level in the health service below that of region in England. I have therefore very great pleasure in feeling that I can support at least the first clause very wholeheartedly, and it is mainly to that clause that I wish to address myself today.

Although I think that, strictly speaking, structure cannot and should not be divorced from the function of the health service, there are several pertinent considerations that we need to have before us in looking at the structure. First of all, the area health authorities were in 1974 created for a purpose, and that was to establish coterminosity with local authorities, to facilitiate the co-ordination of the work of the local authorities and the health authorities. That aim should not be lost sight of in any reorganisation at local level. It is absolutely essential if the care to the individual is to be co-ordinated that these two authorities should be enabled to work very closely together.

Secondly, I think the size of an authority which may be ideal for institutional management—that is, the management of acute services in hospital—may not be the ideal size for the management of community services. I think a hint of that is given in Clause 2 in respect of family practitioner committees, but the organisation of the community nursing services, in particular the schools health service and the services to the elderly and the handicapped, may need special consideration alongside those of the acute services.

An added point is that the removal of a tier should not be regarded as a panacea for all the ills of the National Health Service. There were complaints about delays in decision-making, and certainly removing a tier should remove one level through which the decision-making has to pass, but this will not of itself remove all the difficulties and I feel personally that there is a great need to have maximum delegation downwards of decision-making so that there can be a liberation of people such as nurses and doctors in carrying out the work at patient-care level for which they are trained. So I think we should be offering to nurses and doctors involvement in day-to-day care and responsibility and accountability for care at that level.

Sometimes we forget that the National Health Service is not a tidy structure, and we tend to want to have a tidy structure because it is administratively convenient, but the National Health Service shows all the signs of its notable origins in history. For that reason, I think we have to bear in mind the vast range of services that the National Health Service is giving and the very many different types of workers in the National Health Service, and the fact that, through a very large service, we are trying to give highly individualised care to people. We need, therefore, to have the maximum of flexibility at local level so that there can be the maximum of initiative and variation.

In the report of the Royal Commission on the National Health Service we drew attention to the difference in the kind of structure needed in places like Wester Ross and Tower Hamlets, but there is no reason why the structure in those areas should be the same, because the services required are so very different. I would therefore urge that there should be flexibility in management arrangements at local level. I would hope that there would be no bureacratic blueprint issued from above as regards management arrangements and that there will be a great sensitivity to the local needs of the health service The noble Lord made reference to the fact that many workers in the health service have already undergone consider- able trauma in successive reorganisations. You will be aware that in the nursing service we have already passed through reorganisation due to the Salmon and the Mayston Reports, not to speak of 1974, and I would agree that it was a tragedy that many valuable people were lost to the service following the 1974 reorganisation. I think, therefore, we must move into this period of reorganisation with great sensitivity, maintaining a very careful balance between the interests of patients and the interests of staff, because unless the staff morale is good the interests of patients will suffer in the end.

I think, too, that we sometimes forget in reorganisation—and I believe change must be part of any institution that we have in society—that we should always bear in mind that working in a new structure, with new relationships, is a learning experience and time must be given for learning. I know that many of us came to the Royal Commission with a certain amount of scepticism about consensus management. It was interesting that, as the life of the commission progressed, more and more positive views were coming forward about management by teams of equals, and I personally feel that the nursing service has contributed something very positive to the National Health Service in the way in which it has co-operated in consensus management.

There is, I believe, a constellation of factors which we should be bearing in mind when we look at any revision of structure. We have before us at the moment five or more different reports and documents dealing with the National Health Service. First of all, there is Patients First and the management arrangements consequent upon the structural rearrangements. Then there is the report of the working group on the organisation and management of problems of mental illness hospitals. That report made a strong recommendation for functional management, and indeed in the development since 1974 there have been notable successes in the development of functional management in the nursing service—that is, the management of entities like the psychiatric nursing service and the maternity services. I think that in our anxiety to slim the administrative structure of the service and to look at the needs of identifiable institutional managers we should not lose sight of the expertise of functional managers. That is certainly very much needed in the nursing service. Then, on top of those two reports, we have that of the Flowers Committee and the London Planning Consortium, and lastly that on the future pattern of hospital organisation in England.

All these together may give us very different views of the needs of reorganisation, and I think there is a need to take a total view of reorganisation and the impact of all these different reports on structure and function, because we may, if we are not very careful, have to take yet another stab at structure unless we get the inter-relatedness of all these aspects of the health service in line.

I do not wish this afternoon to enter into a discussion on private medicine or on any other clauses, but merely to say and to plead that there should be the maximum flexibility, certainly below district level; that there should be a consolidation of the gains that have been made—and I was most reassured by the words of the noble Baroness to this effect—and that we should have great sensitivity in our dealings with the staff of the National Health Service in the future, because in all these things the interests of patients and workers must be kept in a proper balance.

Several noble Lords: Hear, hear

4.10 p.m.


My Lords, it falls to me, and indeed it is my great pleasure, to thank the noble Baroness for her maiden speech and to congratulate her on it. Rarely do we have the pleasure of listening to somebody who has so much knowledge of the subject of the speech that she has given us this afternoon. As a professor holding the first chair in nursing she is a very rare person. She is also a very rare person in that I am told that she is the first nurse who has been made a Peer of this House.

We congratulate her most sincerely on her speech this afternoon. I am sure that it will be read with great interest by those who are not in this Chamber. She referred to the fact that she thought that nurses had contributed in no small way to the National Health Service. We did not want to interrupt her speech, but we all wanted to say, "Hear, hear" because that was obviously correct. We owe a great debt of gratitude for the part that nurses have played and are going to play in the future in the National Health Service. I thank the noble Baroness.

I welcome this Bill in its entirety. There are one or two questions that I have to ask the Minister; but I welcome the Bill in that since 1948, when it was established on 1st April, the National Health Service in this country has occasionally prospered, has occasionally foundered and has very often been altered. Nevertheless, we have all always been proud of the service that has been given to the people of our country, following the establishment of the National Health Service. We always hear that it is second to none in the world, despite some of the difficulties that it has gone through from time to time. My late husband was Minister of Health from 1952 to 1956 and had a very difficult time, because there was even less money then than there is now. I know that his heart was very much in providing this particular service. The fact that he could not move fast enough because of the lack of money made him rather unhappy at times.

It seems to me—although only the future can tell us—that this Bill has just about got it right. One hopes so; and one hopes that, as a result of the Bill, there will be more co-operation right down the line. The area health authorities giving way to the district health authorities and the family practitioner committees should be a step in the right direction. Those of us who are very low on the ground have had difficulties in the past in getting decisions made, and the fact that—as the noble Baroness said—just one stratum will be removed means that perhaps decisions will be made rather more quickly.

There are two reversals of previous Bills that are made in this Bill. The first one is to re-create private patients. One knows that vast sums are paid for private health care by people from abroad and indeed by people on insurance companies and, one has always regretted that the National Health Service has not been the benefactor from it, because in recent years there have been practically no private patient beds. I am sure that this will be a step in the right direction. But I would say this: so far as I am aware, where private patient beds still exist they are much more expensive than beds in private hospitals. Therefore I feel that it will be incumbent upon those hospitals which have private beds in the future to have a very high standard of care from every angle and every stratum within the hospital. Otherwise, I feel it is not likely that many people will use the private patient beds.

The Minister almost made me blush and was particularly kind to the leagues of hospital friends when she paid tribute to them. This is another reversal, in that, as the noble Lord, Lord Coslany, said (or it may have been the noble Baroness, Lady Robson of Kiddington; they both have so much knowledge in these matters) since the appointed day local hospitals have not been empowered to raise funds for themselves. Therefore since 1948 local voluntary organisations have had almost the sole responsibility for raising funds to help local hospitals.

I am particularly interested because I happen to be the national chairman of all the leagues of hospital friends: 1,200 leagues covering about 1,700 of our 2,000 hospitals. I am also delighted this afternoon that my friend and president, the noble Lord who is sitting on the Woolsack, is present to hear the tributes which are being paid to the work of the leagues of hospital friends. It was said in the other place that leagues of friends occasionally provide television sets, curtains and chairs, but I would remind the House that the leagues also go into capital works. In fact, within the past two or three months £21,000 has been raised at East Grinstead for the enlargement of a physiotherapy department. Twenty-one thousand pounds has also been raised by a league to provide a tea bar in the Stanley Royd Hospital at Wakefield. That is a very large 1,100 bed psychiatric hospital.

I think that the noble Lord, Lord Coslany, said that it would be difficult to raise money in poorer areas. I believe I heard him aright. I can only tell him of my experience. When I started a league in Bethnal Green and at the same time started a league in Kensington, it was the people of Bethnal Green who came up with more money and more enthusiasm than the people of Kensington. The reason I bring this point up is that I feel it is going to be very important for the hospitals, if they are going to raise money, to raise it in conjunction with the voluntary organisations, because they will be appealing to the same people. It is important that the Minister, perhaps even through a directive, should express a wish that the hospitals should raise money in consultation with the voluntary services.

I also want to know about the future of the community health councils. They made a very slow start. Many people have wondered whether they had a part to play. They are now getting going, I gather, in all parts of the country—some perhaps more than others, and perhaps some are slightly more efficient than others. They are important because they are the watchdog of the community. They play no part in the National Health Service whatsoever; they are completely separate. It is because of this that they are able to give advice to the area health authorities and the local hospitals as to what those local hospitals need and what could be done to better conditions for the patients and the staff in those hospitals.

I am delighted to see that in this new blue hook which was issued recently, called The Future Pattern of the Hospital Provision in England, great emphasis has been laid on keeping the smaller, local hospitals, because they have a very great part to play not only, as one noble Lord said, because of the pride in local hospitals, but also because the local people like to take a personal interest as well as pride in their local hospitals. It was not very long ago—perhaps six weeks ago—that I had the privilege of visiting three GP hospitals in Wales and the pride those three towns took in their local hospital, where everyone knew everybody else by Christian name, was very different from the feeling towards some of the vast organisations. Of course, we realise that they are just as vital, but they are rather impersonal now. It was marvellous to go into those hospitals and realise the great wave of goodwill and sympathy they create in the neighbourhood in which they are situated. In fact, one of them, through the league of hospital friends, has such advanced equipment that consultants come from 40 miles away to use it. I could say more, because I am particularly interested in the National Health Service, but I will close by wishing this Bill well and hoping that it will have a beneficial effect on the service.

Lord WALLACE of COSLANY: My Lords, before the noble Baroness sits down, when I referred to rich and poorer districts, I was referring to the possibility of such things as lotteries and so on, officially run. I entirely agree that, so far as the hospital leagues of friends are concerned, they embrace a large section of the community and encourage a great deal of enthusiam. I am personally very enthusiastic about their work.

The other small point is that my name is still Wallace of Coslany. Norwich would be proud to hear me called Lord Coslany but I am very proud of my family name.


My Lords, I apologise to the noble Lord.

4.23 p.m.


My Lords, I, too, would like to congratulate the noble Baroness, Lady McFarlane of Llandaff, on her polished and effective maiden speech, which I very greatly enjoyed. I am sure there will be ample opportunity in Committee to dissect the detail of this Bill and I intend to speak very briefly today, doing little more than indicating general agreement with the motives behind it and with its major provisions.

I hope very much that, in part at least, we may see it as an attempt to improve the lot of patients, for to me any measure of this kind stands or falls according to its success of failure in this respect. Far too often in the recent past I believe that our health service has been allowed to become a battleground upon which normally humane men and women have allowed themselves to become locked in conflict, to the neglect of the focal point of any system of health care. It is not the interests of this or that political party, certainly not of doctors or of nurses, of administrators, physiotherapists, porters or electricians, but the interests of patients that should he paramount at all times. During the last five years, in particular, I have the feeling that the patient has often had a raw deal, and surely it is time we tried to put this right.

The extremists at both ends of the scale, and the strife that has intermittently but repeatedly interrupted or curtailed the care of the sick, have inflicted, I believe, serious, lasting wounds upon the health service; and whether this be through the reckless pursuit of self-interest or the well-meaning but irrelevant pursuit of political dogma, conflict within the health service does harm patients and is something which today we just cannot afford. I sincerely hope, in particular, that the passage of this Bill may see at least the beginning of a new relationship between the National Health Service and private medicine. The motive is clearly there, though I could have wished that perhaps the essentials for a proper relationship has been spelled out in more detail and with greater determination.

To me, it is not enough to suggest that a separation of private medicine from the health service would be harmful. I would go very much further than that and urge that a mutually supportive link with independent medicine should be seen as a means whereby private finance, through private medicine, can provide support for the health service in areas in which available public resources are proving inadequate. Medical science and technology have advanced so far and so rapidly in the last decade, particularly in the more acute and more spectacular fields of medicine, that whether we like it or not those of us who treat patients or are involved in the allocation of health care resources are already confronted by a near-insoluble ethical problem of deciding how and in what proportion resources should be devoted. Should they be devoted to, let us say, coronary artery surgery, organ transplantation or new hip joints for the old, and how much should be devoted to the unspectacular treatment or much commoner disorders such as, in the surgical field, hernias and varicose veins, or to the relief of chronic illness, of mental ill health or of the physical effects of ageing? If at times a decision that proper provision really must be made for the commoner ailments of the community as a whole has curtailed the application of some spectacular new medical advance in clinical practice, it would surely not be unreasonable for the Department of Health to be able to examine what the independent sector of medicine could do to fill the gap—given, of course, that a good symbiotic relationship between state medicine and private medicine exists.

Since I was permitted to join your Lordships' House some two years ago, it has been a constant source of great regret to me that I have not been more successful in converting to this view the noble Lord, Lord Wells-Pestell, for whose conscience in regard to the responsibilities of us all to the sick I have the most sincere and undiluted respect. At this fundamental level, I think he and I agree so completely that I do so wish he would abandon the argument that, because in a hospital the existence together of state medicine and private medicine results, among other things, in the national health resources in some areas being used for the benefit of private patients, this should be eliminated by a forcible separation of private medicine from the health service. A more logical way of regarding this particular problem, I would have thought, is to say: "Here is an example of the way in which the health service assists private medicine", and then ask the question: Now, in what way can private medicine redress the balance by supporting the National Health Service?"

The conscience of the noble Baroness, Lady Gaitskell, is also, I believe, clearly troubled by this point, as evidenced by her intervention in my speech to this House on 19th March at col. 235 of Hansard. I would give her this same answer, that if the private sector of medicine uses national health resources, then, equally, support for the health service should be sought from the private sector, and we should now be actively examining all the ways in which this can best be effected—additional, that is, to the revenue from private beds in NHS hospitals.

Properly developed, this Bill could become the basis of a much improved system of health care in this country within which state medicine and independent medicine developing, not independently but interdependently, would be seen to place the interests of patients above all other considerations. Although much detailed examination will be necessary in its Committee stage, at this Second Reading I am glad to give it my support.

4.32 p.m.


My Lords, may I say, first, how much I appreciated the speech of the noble Baroness, Lady McFarlane? We were particularly fortunate to have as one of our speakers in this debate a member of the Royal Commission, and I know that we shall look forward to hearing her on many other occasions.

It seems to me that in some respects this Bill is an attack on the basic principles which led to the creation of the National Health Service. The most important of these principles is that the service should he free at the time of use to all members of the community, and that it should be paid for by the community through direct taxation. The Government have ignored the advice of the Royal Commission that the Health Services Board should be retained and that pay beds should be phased out of the National Health Service. Under the last Government, the number of pay beds was reduced from over 4,000 to 2,819. It seems now that, under this Government, these figures will be reversed.

I know that it is maintained by members of the Government that pay beds need not lead to private patients jumping the queue. The Royal Commission's reports does not support that view. The Coin-mission said that it had had frequent and serious allegations relating to the speedier admission of private patients, both to pay beds and to National Health Service beds, and that it deplored queue-jumping of this nature. I sincerely hope that the Government will give more thought to their pay bed policy and to the health needs, not only of the well-to-do but of all members of the community.

As chairman of the governors of a London teaching hospital for many years, I came to have great respect for the community health councils and I strongly support the Royal Commission's recommendation that their powers and resources should be strengthened. One of their most important duties is to make themselves really accessible to the community that they serve. This necessitates headquarters in a central area with ample space for their equipment, for their interviews, for office work and for undertaking many surveys of local health services. One of the most difficult problems that all CHCs must face is that the more efficiently they do their jobs, the more they become aware of all the work that there is still left for them to do. This is particularly true in relation to the CHCs' contacts with the general public. If they are successful both at public meetings and at advice centres, more and more citizens will seek their help and advice. As my right honourable friend David Ennals said in another place, CHCs speak up for the patient and the community and it would be a tragedy if they were lost. I urge the Government not only to retain the CHCs, but to allocate larger sums of money than are at present available to cover their costs and to provide adequate office accommodation for them.

May I now make a few comments on Clause 4, which gives health authorities power to engage in activities which are intended to stimulate the giving of money or other property for health service purposes? It is essential that those who raise funds for a particular hospital should be aware of the hospital's priorities in terms of its needs. Expert advice should always be obtained in different fields, before an appeal is made. It is also essential today that fund raising should make allowance for changes in the value of money. Hospital equipment costing £30,000 in 1979 may cost £40,000 a year later, and the hospital may not be able to raise the additional £10,000.

In conclusion, may I urge the Government, once again, to give further thought to their pay bed policy. In a democratic community we cannot support a policy which gives the well-to-do priority of treatment in a health service which was set up to serve all our citizens, and which is paid for by the community as a whole.

4.37 p.m.


My Lords, may I join others in congratulating the noble Baroness, Lady McFarlane of Llandaff. Those of us who are social workers, and who have always tried to work closely with others, have welcomed the tremendous help given by health visitors and nurses of her profession. We welcome her here and are very grateful for the contribution that she has made.

I feel that I have to give a testimonial of myself, because I find myself standing alone among all the other speakers, including, I regret to have to say, the noble Baroness, Lady McFarlane of Llandaff, in that I question the community health councils. I go no further than that, but I question them and wonder whether we should give further thought to their continuance.

I speak as one who has been a director of social services in a local authority where there was an outstanding medical officer of health, a hospital and general practitioner service of high quality and a committed health visitor service working closely with a committed staff of social workers. Therefore, I admit that I am focused on to Clause 4, which, as the noble Baroness has just said, is the clause on joint funding. The joint funding will be, as I understand it, as between area or district health authorities, on the one hand, and local authorities and voluntary organisations, on the other.

The Royal Commission on the National Health Service stated: We look at the important links which the National Health Service has with services and institutions outside it. Perhaps the most important of these is the relationship with the complementary services provided by local authorities". It went on to say, the most direct is with the personal social services". This joint service seeks both to prevent illness, and to rehabilitate those who have come within the orbit of the Mental Health Act, the Chronically Sick and Disabled Persons Act, the Health Services and Public Health Act—dealing with the elderly—and the various Acts concerned with children and young persons.

The members of the Royal Commission stated: There should be a policy of coterminosity, interchange of staff, joint consultation and joint financing; there should however be no radical change in the responsibilities in either the health or personal social services". With the joint financing and the need for close links between the health service and local authorities, it is questionable whether the recommended structure of administration has yet achieved the correct balance. The matter is complicated and important, and I seek information from the Minister concerning the community health councils—as indeed have many other noble Lords.

Is the Minister satisfied that the community health councils are rightly placed within the health service? They are financed to the tune of £4 million, but they have no vote on the area health or district health authority. They therefore carry no ultimate responsibility or accountabilty. Circular 5055 laid down that the councils were to represent the views of the consumers but gave little guidance as to how this was to be done. Some community health councils have done well; others have found the position frustrating. The staff of the health service is not accountable, on the other hand, to the community health councils. The Minister has said that there must be more local involvement and that involvement should be flexible.

I would submit that the community health councils are no different, for instance, from Age Concern, which represents the views of the elderly; the Child Poverty Action Group, which represent the views of those who are in difficulties with social security; Shelter, for housing, and Mind for the mentally ill and handicapped. None of these organisations is within the orbit of the Ministry or department in whose work they are concerned. In my view, if community health councils are to go on, then surely they should be—and perhaps it would be more helpful for them to be—outside the orbit of the health service.

This being so, I come to paragraph 23 of the consultative document Patients First. The Government question whether the present one-third of local authority membership is necessary. If there is to be joint financing of projects and the forging of close links between the health service and local authorities, then surely local authorities should be better represented and should realise that they are accountable to those who live in the area. I would suggest that on the area health authority there should be the chairman and vice-chairman of the social services committee, the chairman of education and representatives of housing. If the probation service were represented on the area health authority, I think that the Butler Committee's report might have got further.

Local people vote for their councillors and they go to their councillors, as the electorate go to the surgeries of their Members of Parliament. A number of people who are nominated by the Secretary of State serve well on the area health boards, but they are not known to the people who live in the district. If therefore there is to be joint financing and joint projects as between the health service and the social services providing a service in the community, I think that local councillors should serve on area health boards and should be accountable. So, from a different point of view from other noble Lords, I would ask the Minister, what is to be the role, purpose and future, as the Government see it, of the community health councils?

I would make only two more points. I come from an area with a population of 110,000, where there are seven health centres. At the health centres are based the doctors, the district nurses, the health visitors, the social workers. This means that there is a great deal of interchange of information and a great deal of cooperation, to the benefit of the patients. Furthermore, there are not more than, I think, six or seven doctors at each health centre, so there is an element of personal service to the patients.

My last point is about coterminosity. As I understand it, it will not be possible for all the district health authorities to be coterminous with the local authorities. If this is so, I hope that it may be possible for there to be a nominated doctor, known to all, who is the link between the district health board and the local authority.

4.46 p.m.

Baroness MASHAM of ILTON

My Lords, I, too, should like to congratulate the noble Baroness, Lady McFarlane of Llandaff, on her maiden speech. The noble Baroness is an excellent addition to your Lordships' House and the Cross-Benches, bringing expert advice which is much needed on the health service. I heard the noble Baroness speak at a conference on cancer a short time ago, and I am happy to say that now she has risen to the top of her profession she has not forgotten the basic ground level needs of patients.

I hope that this Health Services Bill can be amended in your Lordships' House to help alleviate the worry of some very sick and disabled people. As I drove along in my car listening to the Chancellor of the Exchequer's Budget speech, I heard that prescription charges were to be increased to £1. There was a roar of disapproval from the Opposition. I thought that Sir Geoffrey Howe went on to say that children, pensioners and the disabled would be exempt from these charges. This does not seem to be so now, so far as the disabled are concerned.

There is extreme worry from some specialised organisations who help disabled people. Unless this Bill is amended, people who suffer from serious medical conditions such as cystic fibrosis, cancer, chronic bronchitis, emphysema, multiple sclerosis, muscular dystrophy, spina bifida, Parkinson's disease and others will be subject to charges.

Chronic long-term disability is like a bad dream which never goes away and can only get worse. The general public may see a paralysed person sitting in a wheelchair and think that he will have extra expense keeping warm because oil prices have risen and because his circulation is bad as a result of restricted movement. Keeping warm is an obvious problem. So is the extra expense of getting around, not being able to use public transport. Also, there are problems of access and employment. However, the general public do not think of the hidden disabilities that there may be: the on-going urinary infections which need controlling by antibiotics; the dreaded pressure sores which have to be kept clean and dressed; the bleeding haemorrhoids which come from sitting too long and which need ointments; the evacuation manually of paralysed bowels which requires the use of plastic disposable gloves and suppositories. The medical conditions of many disabled people are varied. The on-going strain and stress on families and patients when the disabilities are severe are great. The Government may answer by saying that it is possible to get a season ticket, but the cost is to be increased, I am given to understand.

Recently, disabled people seem to have been the worst hit by inflation. They are sinking into the poverty trap. I personally think they need recognition from the Government and the medical profession and a little encouragement at this difficult time to cope with their heavy burdens. If they give up and go into residential care or hospital they have no worry about prescription charges or keeping warm. This increase in charges may be the last straw which breaks the camel's back.

I do not go along with the other place in wanting to link exemption charges with the invalidity pension. I think the present principle, which is based broadly on medical or financial need, is the best one. 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. I ask the Government to approach the General Medical Services Committee to help them to extend the exemption of medical conditions. If they do not do this I consider that squeezing the odd million pounds out of really sick and disabled people is a sorry and inhuman way of running a health service.

Instead of trying to squeeze the last drop of juice out of a dried-up lemon, which I think is what the Government are trying to do to disabled people, I suggest that they should try to tackle a far more lucrative source of saving money. Most people are unanimous in agreement that the health service in England has been over-administered. I know personally several consultants who have gone abroad to work because of the frustrations and hold-ups due to too many tiers of administration. I am glad that the Government are tackling this problem.

Another problem that I think they should tackle is that of the disgraceful thieving that goes on in our large city hospitals. I have a friend who worked in a senior position in one of London's large teaching hospitals and your Lordships may be surprised when I tell you that on average a hundred pillows disappeared from that hospital each week; large quantities of meat went missing from the kitchens. Stealing in hospitals has become a major hazard and again the patients are the unfortunate people who have to suffer. The hospitals have become too large and impersonal and there are too many people working in the service and too few people who want to take responsibility. I can assure your Lordships that there are many honest, hard-working members of the hospital staff who are appalled at this grim situation and want to see this dishonesty uncovered and stamped out.

I should like to ask the Government a question and I shall be interested to know the answer. This would help me to decide whether or not to table an amendment at Committee stage. General practitioners can employ people to help as receptionists, secretaries and for dispensing purposes, provided these people are not related to anyone in the practice. The general practitioners can claim 70 per cent. of their wages back from the family practitioner committee. They find the remaining 30 per cent. out of their own pockets: why cannot the doctors employ their wives under the same terms as other employees? In rural areas general practitioners feel that they could give a better service to the community if this restriction was lifted. If doctors are considered responsible enough to make life and death decisions about patients surely they should be able to assess whether their own wives can do a job efficiently.

I should like to end by saying that the spinal injuries unit appeal at Stoke Mandeville Hospital, which is now being helped along by Jimmy Saville and the Daily Express, and which is to rebuild a part of the hospital which fell into such poor repair as a failure of the National Health Service in its duty to provide health facilities for patients, is an example of the generosity of the public. Ten million pounds is a great deal of money to raise. I feel that the trusts and the City will have to help as well if this sort of money is to be raised, but it is most heartening to witness so much goodwill towards a hospital appeal which is being run through the co-operation of the National Health Service workers and volunteers.

4.55 p.m.


My Lords, first, I should like to thank the noble Baroness, Lady McFarlane of Llandaff for her splendid maiden speech, based on so much personal experience.

The title of this Bill has been well chosen. In it, reference is made not only to the National Health Service but also to our independent medical services—the private sector. I have been interested to read through the debates upon this Bill in another place during the last few months, especially in Standing Committee G, the reports on which took up more than 1,000 columns of Hansard. The noble Lord, Lord Wallace of Coslany, mentioned stamina and surely these meetings were a good example.

This afternoon I can comment only on a very few points which have been raised in this Bill and the debates. It is clear that most, if not all, members of the Labour Party, want to see pay beds in National Health Service hospitals reduced or got rid of as a preliminary, some of them suggest, to the abolition of private practice altogether. When I spoke to your Lordships on 19th March in a short debate on the need for co-operation between the NHS and the independent medical services—and I should like to thank my noble friend Lady Young for her remarks about what I said—I suggested that it would be quite impossible for the National Health Service to take over all the finance, administration, equipment and personnel involved in this private work carried out by so many people and organisations. These have included private consultants and general practitioners (whole-time and part-time), private nurses, dentists, psysiotherapists, chiropodists and so on, and then there is the cost of private hospitals and all those who work in them, especially the 30 private hospitals run by the BUPA Nursing Homes Trust, the King Edward VII hospital for Officers (Sister Agnes'), the Royal Masonic Hospital, the St. John and St. Elizabeth Hospital and many others. There are very many charitable organisations; and there are the 4,000 or more small private hospital beds for surgical, medical, maternity, convalescent, psychiatric and geriatric care and for terminal care. Then there is all the great help that private doctors have given to the many thousand overseas visitors who come to this country each year.

The private sector is, of course, very much smaller than the National Health Service but it is of considerable significance to British medicine. Its work is more extensive than many people think. A rough estimate suggests that it has saved the National Health Service possibly some thousands of millions of pounds during the past 30 years.

The private sector has been called many nasty things: it has been said that it is "immoral", that it "feeds like a parasite on the National Health Service". Many of these epithets are ideological slogans used by those who do not like it politically. Some of them are remarkable. Who in their senses, for instance, could believe that the Royal Masonic Hospital, St. John and St. Elizabeth Hospital, St. Dunstan's, the British Red Cross or Sue Ryder's rehabilitation centres, are "immoral" or "parasitical"? Who really believes that all who receive private care are queue jumpers?

The Wellington Hospital and other large and expensive private hospitals in London have had their fair share of brickbats thrown at them, too. Mr. Dobson in another place the other day described them as "leeches on the provision of health services in the London area". I myself was somewhat against these large private hospitals at first, but I have changed my mind now, having seen what excellent work they have done and are doing in helping out the National Health Service in treating so many of our wealthy overseas visitors, most of whom are fully covered by medical insurance and many of whom (perhaps when acutely ill) want the very best treatment and at once.

The equipment of these large private hospitals in London and the treatment they give are often quite excellent, perhaps even better than can be found anywhere else in the world. That is good for the prestige of British medicine. The patients who use them and their families bring a considerable amount of money into our country. A valid criticism of them, of course, is that they may take a certain number of doctors, nurses, paramedical workers, and domestic staff away from neighbouring NHS hospitals; but some of these workers might not be happy in the NHS and no one can be forced to work where they do not wish. It is up to the NHS to improve conditions in its hospitals so that fewer people want to work elsewhere; and it is up to the administrators to make sure that there are enough staff and equipment to supply everyone's needs.

The argument that doctors, nurses and others who have been trained in NHS hospitals should work in them for several years afterwards does not apply to other professions. Our NHS unashamedly employs many who have been trained in medical schools overseas and we do not consider that we are doing anything very wrong by making use of their services in our country now.

I am a little unhappy about some of the clinical provisions of this Bill. I am sorry in a way to see the Heath Services Board disappear. I am not altogether happy about the replacement of the NHS hospital pay beds which the last Labour Government removed. After more than 30 years of the NHS the major political parties are still at loggerheads over these pay beds. It is becoming a political battleground, which is the very last thing we want. In spite of all their advantages, which have been described very fully elsewhere, I am now coming to believe that unhappy effects they occasionally have on morale, labour relations and interpersonal relationships when NHS staff and private patients are together under the same roof, are disadvantages which may sometimes outweigh the many advantages of these pay beds. It may prove better, in future, for National Health Service and private patients to be cared for, whenever possible, in separate buildings and by separate staff. One seldom hears nowadays of serious personal clashes, or trouble with labour relations, in any of our large BUPA or other private hospitals, in which the atmosphere, so far as I see it in my work, is more often than not a happier one than in the pay bed departments of some National Health Service hospitals.

It seems clear from the debates on this Bill that the present Government is not quite sure how many of these pay beds it wants to restore. It is almost certain that the next Labour Government will act, as soon as it is in power, to remove as many as possible of these pay beds, perhaps by means of a "short sharp chop", as mentioned by Mr. Moyle in another place the other day. It cannot be often that Pooh-Bah and Koko in their duet from the first act of The Mikado are quoted in either of our Houses; but I am glad that Mr. Moyle did that; it helps to keep us human.

In spite of all that one hears said by Members of the Opposition against our independent medical services we are, on this side of the House, almost united in agreeing with the Parliamentary Under-Secretary of State, Sir George Young, when he wound up the debate in another place on this Bill by saying: Our party is united behind our policy, which is a policy based on partnership … It is a policy based on freedom of choice, not state monopoly. It is a policy supported by the vast majority of people in this country ".—[Official Report, Commons, 9/6/80; col. 252.] "Partnership" is the key word here. I myself firmly believe, with others, that the basis of the future welfare of British medicine lies in friendly and helpful cooperation between the National Health Service and all our independent medical services. It is for this liaison that we must all strive, and this Health Services Bill goes some way towards achieving that.

5.6 p.m.


My Lords, I personally wish to give this Bill my wholehearted support. I have listened with intense interest this afternoon to the many views put forward, not only by the noble Lords my medical colleagues but also by noble Lords, and, if I may say so, even more Ladies, whose lay knowledge of the health service has been unique and extremely stimulating. In this connection I, too, should very much like to congratulate the noble Baroness, Lady McFarlane, on the way she dealt so wisely and so simply with a most complicated subject. We all know her vast experience, but to be able to express the views she did so delightfully I think was a great treat for this House.

As this is a Second Reading, and as we have dealt with a lot of detail during the afternoon, perhaps I may at this stage of the debate be allowed, briefly I hope, to deal with some general principles of the Bill. It seems to me to embody three matters which are of vital importance to the health service: first of all, the need to streamline and to reduce an obviously overloaded bureaucracy of organisation; secondly (and I think this is a very important one) to emphasise the relative priorities of primary care, that is to say general practice, community medicine and preventive medicine, including, of course, health education, and in so doing provide comprehensive overall provision of medical services; and, thirdly, to use all—and I emphasise all—available means of supporting the strained and inadequate financial resources of the National Health Service, in particular, as stated in this Bill, by encouraging local individual initiative and fund raising, and, secondly, by freeing the private practice sector of medical care from the present quite illogical restrictions.

I will say just a few words on each of those, but first of all may I remind noble Lords, not for the first time perhaps, of the report of the Medical Services Review Committee, published nearly 20 years ago. Its activities, oddly enough, are very relevant to today's debate. The Medical Services Review Committee, which was set up under the aegis of the BMA and consisted of the tops of practically every branch of the medical profession, worked for four arduous years to review the operation of the National Health Service in the light of its first ten years of existence.

It was also set up to make practical suggestions from the doctor's point of view—after all, it was the doctors who were running it and making it work—and how it might be improved in the future. This it most certainly did, but for reasons never quite adequately explained—probably because it was an ad hoc body and not Government sponsored—it was, with barely minimal acknowledgment, if I may say so, shelved by the then Secretary of State, the right honourable Enoch Powell. However, as the present incumbent said to me just a week or two ago, it is remarkable how often in the intervening years it has been taken down from the shelf, dusted off and had extracted from it by interim Administrations ideas which have then become incorporated in subsequent legislation.

One of the basic suggestions of the Medical Services Review Committee Report was that the three original divisions of the profession as set out in the 1948 Act—the hospital service, the general practitioner service, and the public health service—should be amalgamated into one entity. That has now been achieved to the great betterment of the service as a whole.

Two other primary suggestions of the report in yet another shape or form are up for discussion again today and they are what interest me. First, there is the necessity of delegating authority for day-to-day management of the service as far as possible to the periphery, while retaining overall financial control in the department. After all, it is at the periphery—that is to say, the general practitioners in their surgeries, the community clinics and the hospitals—that the producer and the consumer of medical services make con- tact. It is there that the doctor/patient relationship—the essence of all good medical practice—is established and maintained. The possibility offered by the Bill at the newly envisaged district level should do much to improve and accelerate both management and administration of the service.

Secondly, the establishment of the family practitioner committee, as envisaged in Clause 2 of the Bill, serves to emphasise the relative importance of primary care in overall medical services. Health education, the recognition of illness in its early stages, the advice on and treatment of minor ailments at source, are all of vital importance not only to the patient, but to the service as a whole.

Not long ago it was estimated that something approaching 75 per cent. of all monies expended in the National Health Service were devoted directly or indirectly to the hospital services, but that these services benefited only 20 per cent. of the population—surely a most inequitable distribution of available funds. Today's trends tending to place more clinical responsibility and recognition on primary care are all to the good, especially when combined, as they have been recently, with the appreciation that a number of small, homely, strategically-placed hospitals can achieve much more for the population at risk than the massive, impersonal and relatively inaccessible buildings that have been erected at vast cost in recent years—a point well made by the noble Baroness, Lady Macleod of Borve.

Finally, there is the unnecessarily thorny question of private practice, private hospitals and private beds in National Health Service hospitals. The present position which the Bill sets out to remedy in Part II seems to me pathetically illogical. The National Health Service is woefully under-financed; it needs all the help that it can get; it is lacking essential facilities; it cannot cope with the demands being made upon it—for example, as shown by the waiting list problem—it is losing, because of unnecessary restrictions, many young doctors and some not so young who, because of their greater experience, are even more valuable. And, for all those reasons, the standards of medical practice in this country have, of recent years, very sadly, but very inevitably, fallen.

Yet in the private practice sector there stands by a staunch ally ready and willing to accept a substantial part of the load carried by the National Health Service; capable of adding a very appreciable, worthwhile sum of money to enrich its coffers; offering a stimulus in friendly competition and hence raising standards generally; and offering also opportunities of initiative and self-expression to the rising generation in the profession, so essential to the maintenance of good morale.

Yes, my Lords, the National Health Service needs all the help that it can get and the private sector in medical services can help enormously if given the opportunity to develop without petty restrictions. In my view it should be strongly supported and allowed to run as a valuable adjuvant service parallel to and complementary to the National Health Service. As your Lordships know, in some ways that is happening. There are now, in more than one place in the country, nurses' training schools which are combined National Health Service and private sector. There are also many beds in the private sector which are filled, by arrangement, with National Health Service patients.

We have surely reached the stage where we cannot be so naive or narrow-minded or ostrich-headed as to claim—or even boast as we used to—that we have the best state medical service in the world. That is just not true; otherwise, why has not one of the many countries that have instituted state medical services since ours began in 1948 copied us? They have, benefitting undoubtedly from our pioneering experience, found better ways, most of them being some variant or other of state-supported personal insurance schemes.

There is nothing wrong with the initial splendid ideal of the National Health Service. Where it has not lived up to expectations is in the implementation of that ideal. For this the profession is not to blame—it has nobly and, I would suggest, often valiantly, striven to support it, and still does so. The administrators are not to blame—they have their regulations and "theirs is but to do or die". Even the politicians are not to blame, except when they allow petty party political doctrines to influence their decisions.

The fault, quite simply, lies in the system—the inherent, and some would say insoluble, difficulty of nationalising a profession. But we have done it in some shape or form, and run it for more than 30 years. It is still far from perfect, but it has achieved much—much more than many people believed possible. I suggest that radical measures still need to be taken if we are to get anywhere near the objectives set up by our idealistic founders. These are matters of national importance—of the health and wellbeing of our people; of the prevention of illness and suffering; even of life itself. Has not the time come to sink party political differences, to stop using medicine as a shuttlecock and to unite in the grand design of making our National Health Service really the best in the world? It is possible, but that is the only way in which it can be done.

This Bill certainly serves to oil the creaking wheels of the ponderous machine that at present runs our National Health Service. I wish it great success and I hope that your Lordships from all sides of the House will feel that it demands whole-hearted support.

5.19 p.m.


My Lords, the Health Services Board is now under sentence of death and its execution will take place, as your Lordships know, when the Bill becomes law. I am sure it is within the ambit of the Addison Rules that, as the chairman of the board, I might make two very brief observations to your Lordship this afternoon.

First, it would be churlish of me not to say on behalf of the board how much we appreciate the kind remarks that have been made, both in another place and in your Lordships' House, to the effect that the board managed to carry out its task with a reasonable degree of common sense and competence. It will give me the greatest pleasure to ensure that those remarks are drawn to the attention of my colleagues on the board whose support and co-operation have been quite invaluable in the past few years; and also to the attention of our very small staff led by our secretary, Mr. Taggart, who displayed ability of the most conspicuous nature and wisdom and discretion of the highest order.

The other observation I should perhaps make is that your Lordships will recollect that originally the board was constituted quite deliberately so as to comprise members who came to it with very different attitudes and viewpoints. The board has decided that it would be fitting that we should make no comment of any sort on the legislation that is now before your Lordships.

We have, of course, had much experience of some of the matters which your Lordships will be debating, but we have come to the conclusion that the proper course is that the individual members of the board should make that experience known to the bodies who were consulted when they were first appointed, and that in that way that experience can come to the attention of both Houses of Parliament. As the person who has the task of trying to be independent, I shall seek to preserve a discreet silence. I thought that perhaps I ought to make those two observations. I hope your Lordships will understand why it is that throughout the rest of the progress of this Bill I shall sit here listening with the greatest possible interest, but taking no part in your Lordships' discussions.

5.21 p.m.


My Lords, first I wish to offer congratulations to the noble Baroness, Lady Mcfarlane of Llandaff, from everyone on this side of your Lordships' House. The noble Baroness would be entitled to think that it is a matter of form that we thank a maiden speaker for his or her particular speech, but, if I may say so, one can detect from the words used by other noble Lords and Baronesses in this House that they really meant what they said. I know that everyone will join me in hoping that the noble Baroness will attend your Lordships' House regularly and will take part in our debates fearlessly, if necessary without giving or asking any quarter. It would be a very magnificent contribution if she would do so.

I want to resist the temptation of dealing with some of the points raised this afternoon with which I profoundly disagree. I do so because I think that (and I said this on a previous occasion) the Second Reading of a Bill is mainly designed to give the Government an opportunity to set out in clear and precise terms their aims and their proposals, and to enable noble Lords to intimate their reactions to the Bill. I want to do precisely that. I do not think that this is the time to go through the particular theme which I have been through in great detail on three previous occasions, for if I attempt to do it a fourth time I shall have one or two noble Lords getting up and reciting it with me.

We are pleased in some measure with Clause 1 because of the administrative changes, but I am bound to say that I think that Clause 1 provides the only common ground between myself and my colleagues on these Benches and the Government. We are glad that the Government have been frank enough to indicate in Clause 1, by the very nature of it, that the 1974 reorganisation was something of a mistake. On 19th December 1979, at column 649 of the Official Report of another place, the Secretary of State said, during the Second Reading of this Bill, that Clauses 1 and 2: do no more than confer greater flexibility on Ministers in determining the most appropriate structure of the health service … in different parts of the country. They do not commit anyone to any particular structure". I want to ask the Government whether that means what I think it says, that when the Government have made up their mind on the nature of the structure there will be a full discussion on the proposals in Parliament. I should like to ask that question in the hope that I shall, in fact, receive an answer.

On this side, we are concerned about the position of the community health councils. We hope that the community health councils will not be affected by the change envisaged by the Government. During the Second Reading debate on this Bill in the other place on 19th December, at column 668 of the Official Report, the Secretary of State made a remark about the community health councils. It is, I think, the implication that worries a good many of us. He said: I should like to state publicly that the Government's mind on this point is absolutely open. Paragraph 26 makes that clear. Whether or not the CHCs will stay depends greatly on representations that may be made to us between now and next April. I should like that fact to be understood. I have made no decision on the matter". What concerns some of us is the reference to the representations to be made to the Secretary of State, as if he is initiating some or is anticipating some. I should like to emphasise that the Royal Commission recommended strengthening the CHCs, and I gather that they do not commend themselves to the noble Baroness, Lady Faithfull. However, I should like to emphasise that whatever role the CHCs have, which is backed either by an Act of Parliament or by some part of the Health Services Bill, they have an enormous amount of power. They have an enormous amount of power in the sense that they are the representatives of the consumer. As I understand the situation, no hospital can be closed if there is a disagreement between the area health authority and the community health council. If the matter reaches the stage where they cannot agree, then it must be referred to the Secretary of State for his decision. Where the area health authority and the community health council are in complete agreement that is all right and action is then taken, presumably by the regional health authority.

However, so great is their power that they can stop the closure of a hospital if they are opposed to the recommendations of the area health authority. I think that this is tremendously important. The noble Baroness, Lady Faithfull, will know that in the city in which she lives there was a long dispute between the community health council and one particular hospital in the Cowley Road, which I am not sure has even yet been resolved. However, it is of supreme importance that we have a kind of watchdog—a group of people made up of the entire community who can have discussions with the area health authority and the regional health authority or whatever new structure we may face in the future; they should have the right to have discussions about, say, the effectiveness of the organisation and the structure, and about all the matters that concern the ordinary patient. Therefore, I want to say to the noble Baroness the Minister that we, on this side, believe that, whatever happens, the community health councils must be maintained. We shall certainly deal with this matter, so far as we are able, at Committee stage.

Another subject which causes us some concern is Clause 5, which gives power to the health authorities "to raise money, etc., by appeals, collections" and other means for health service purposes. I should like to ask whether the Government can say at this stage what those purposes will be. Will it be for general amenities of the patients, or will it be for equipment? What kind of appeal? What kind of lottery? What kind of activity will the health authorities be able to undertake in order to raise money? The noble Baroness, Lady Robson of Kiddington, raised the question of what would happen to it. I think she asked for an undertaking that any money raised would not be deducted from the cash limits of the following year. We must have a definite answer to this.

Let me say right away to the noble Baroness the Minister that we do not trust the present Government. We do not trust them further than we can see them. It would be idle for me to pretend that we do. We know that they are bent on saving every penny. They are doing so by adopting some despicable means, as we have been through in the first Social Security Bill and the Social Security (No. 2) Bill, and I shall not go over that ground again. A million here; £12 million there. I would not put it beyond them to try to save money by getting local health authorities to raise funds by various means and then to say to them, "Yes, you have raised so much money, and this therfore will be deducted from the cash limit next year". The Government have to "come clean" about this. The Government have to give a categorical answer that whatever money is raised locally, for whatever purpose—provided it comes within the terms laid down in the Bill when it becomes an Act—will not be taken away from cash limits.

I really am, as are most other noble Lords on this side of the House, concerned about Clauses 8 to 15, which will at the Committee stage be the real battleground. As I said earlier, we have passed this way several times before and neither side has been able to influence the other. There has been no change of heart on this side, and it is apparent from this Bill that there is no change of heart on the other side.

There are many Members of your Lordships' House who see the choice between a National Health Service incor- porating pay beds and private patients, or a private sector completely separated from the National Health Service, or the abolition altogether of private medicine, leaving a National Health Service for all. My own position in this matter is quite clear—I have always made my own decision quite clear—and that is that, if we are going to have a private sector, I prefer that it should be completely separated from the National Health Service in every way, with very real safeguards for the National Health Service and the people involved.

May I refer again to some remarks made by the Secretary of State, at column 653: If one looks to the private sector outside the NHS, it is widely acknowledged that the last five years have seen the biggest expansion of the private sector since the war". There is no doubt about it in our minds that this is so, but we say that it has been at the expense of the National Health Service. It is all very well for the noble Lord, Lord Hunt of Fawley, to talk about the tremendous contribution that these private hospitals are making to people who have come from abroad to this country and pay enormous sums of money which, he says, enrich this country. They do not enrich this country. They enrich the hospital and the people behind the private hospital. It is a very good Conservative point to refer to the amount of money that this brings in, but let me say to the noble Lord, Lord Hunt, that there is something far more important than money, and that is providing a skilled, competent and efficient service to the vast army of ordinary people in this country who need it. This is the overriding, the number one, priority.

We have had in this country a mushroom growth of private hospitals, each of them drawing on the skill, competence and experience of a vast army of doctors and nurses who have been trained at public expense and are spending the greater part of their time looking after people who do not live in this country and have no allegiance to it. I am not going to say that we ought to stop that entirely. I can see that there are some benefits accruing to medicine from people coming from other countries with special diseases, peculiar diseases. I am sure that our doctors and nurses learn a great deal from them. But do let us under- stand that the overriding need of a Government is to provide an adequate health service for their own people.

Take the Wellington Hospital, which has been mentioned. I believe one is charged £900 a week for being there. I do not think that that includes the consultants' fees, be he physician or surgeon. The noble Lord, I think, was getting at me—and I do not blame him; so would I if I were in his position—when he was talking about abusing the word "immoral". There is nothing more immoral than somebody being able to go into hospital and pay £900 a week. It is terribly immoral, and there is no justification for it. That sort of situation cannot not only be justified; it cannot be maintained.

I do not want to say anything more about the private sector, but when we talk about the private sector let us bear carefully in mind the inroad that it is making into the medical skills of this country that ought, in some way or other, to be so organised that they could be given to those I have already referred to as the vast army of men and women who need them. If there is any criticism—and in my view there is plenty of criticism—against that kind of private medicine, it is not the fault of the National Health Service. It is due entirely to the fact that the private sector has brought this on itself.

I know that the noble Lord, Lord Hunt of Fawley, and others in the House who are specialists in the medical field have not approved of a good deal that has been done by the private sector in the past; the queue jumping (it has been a very real thing) and the fact that one can engage a consultant, pay his fee and then find oneself in an NHS bed in two or three days being treated as a NHS patient. It is that sort of thing that has got under people's skin and caused a tremendous amount of criticism because of the manifest unfairness which so many people have witnessed and experienced. That kind of thing must stop.

It may well be that the Secretary of State wants to make a sincere and sustained effort to do something about it. On Second Reading of the Bill in the House of Commons on 19th December he enunciated the six principles to which the Minister referred earlier. I will not quote him verbatim, but the first principle restated the undertaking that private practice should not significantly prejudice non-paying patients, and that is a good start; secondly, that subject to clinical considerations, earlier private consultation should not lead to earlier NHS admission, the point I was just complaining about; thirdly, that common waiting lists should be used; fourthly, that after admission access by all patients to diagnostic and treatment facilities should be governed by medical considerations only; fifthly, that the standards of clinical care and services should be the same for all people in all hospitals; and sixthly, if I have understood it correctly, that single rooms should not be held vacant for potential private use. I pay tribute to those six principles. This may be a sincere effort to try to come to grips with the problem, and unless something is done along those lines there will be a great deal of further difficulty and disharmony.

Finally, a word about the Health Services Board. If the Government want to make a real effort to deal with the problem of pay beds acceptable to the community as a whole, I should have thought they could have dealt with it in a very different way from the way they are dealing with it in the Bill. As I understand it, the Secretary of State will in future have the responsibility to protect the health service from the encroachment of the private sector. Can you imagine anything so open to criticism? Here is a Secretary of State who is wedded to the pay bed system and to private practice, yet who will now take over the responsibility formerly given to the Health Services Board.

When we were in Government, my right honourable friend the Secretary of State, David Ennals, was so anxious to see that the matter was dealt with in such a way as to leave no doubt in people's minds that, to ensure it would be really independent, the Health Services Board was established consisting of two members nominated by the British Medical Association and two by the trade unions under the chairmanship of an independent person. Noble Lords have paid tribute to the noble Lord, Lord Wigoder, and I do not want to paint the lily, but it really was an independent chairmanship.

When one thinks that from 21st May 1977 to 1st January of this year the number of pay beds was reduced from 3,444 to 2,533—and no one heard of a single dispute between the members of the board on the subject—it was a tremendous achievement. It is true that that is not the total number, because the then Secretary of State closed down 1,000 before the Health Services Board came into being. Now the Health Services Board is under sentence of death. Do noble Lords honestly think it right that this matter should be dealt with in future by the Secretary of State, himself a person of integrity—I accept that of course—and a person who would endeavour to be independent? It is the appearance of the thing that matters; should he be judge in this situation?

I wish to stress on the Minister that it is not too late for the Health Services Board to be invited to go on, and I hope she will get her right honourable friend the -Secretary of State to reconsider the matter. They have done a remarkable job. They have not been slow or indolent, and they have done it without any suggestion of difficulty or upset. While I take this opportunity, on behalf of my noble friends, of thanking the noble Lord, Lord Wigoder, and his colleagues for what they have done, I appeal to the Minister to see whether this decision cannot be withdrawn; or, if she prefers to deal with it in another way, I shall no doubt be tabling an amendment on this, and I might—I just might—hear her say, "We accept."

5.48 p.m.


My Lords, we have had an extraordinarily interesting debate, greatly enriched by the maiden speech of the noble Baroness, Lady McFarlane of Llandaff, who I understand has two firsts in that she is the first professor of nursing in England and the first nurse to become a Member of your Lordships' House. I hope we shall hear her speak often in future, and perhaps she will help us with the Committee stage of the Bill.

Our debate has ranged over a wide number of subjects, which is inevitable given the number of different provisions in the Bill, and I will deal with some of the main points that have been raised and questions that have been asked, which I think is my main job this evening. But first I shall make a few general remarks on the reorganisation provisions in the Bill. My noble friend Lady Young helpfully guided us through the many provisions in the Bill, but obviously she could not dwell in detail on them all.

Clearly noble Lords have found Clauses 1 and 2 of special interest, and first I should like to make one or two additional points on our thinking behind these provisions. The first point is that the changes proposed in Patients First are not a retreat from the 1974 reorganisation. We think that the administrative structure can be improved through the removal of the area tier. But, my Lords, the creation of regional and area health authorities was not the main aim of the 1974 reorganisation. It was rather the chosen way of achieving the first objective of the 1974 reorganisation, which was, as we have said in Patients First, to secure the integration of the formerly separate hospital and community services. That we believe the reorganisation has substantially achieved. Our proposals are based upon our desire to sustain and extend this achievement, not to diminish it. Surprisingly, some of those who have commented on Patients First see the proposals as a move back to a hospital-only service.

Various reasons have been advanced by those who take this view of our intentions. They argue, for example, that the references in Patients First to the need to strengthen unit management are to be taken to refer to strengthening hospital management at the expense of the community services. They also argue that the proposed move to more locally based health authorities, with, as one result, the inevitable abandonment of the one-to-one coterminosity with local authorities, is a move to more hospital-oriented authorities.

I can give every reassurance to those who argue in this way. They have, I believe, misread Patients First. While it is certainly true that the Government intend to strengthen unit management, they are concerned about the management of both hospital and community services. Indeed, the references to hospitals in Patients First are linked to the community services. It is true that in some districts the community services are organised separately from the hospital service, but there are effective links. In other districts management below district headquarters is integrated, but divided into geographical sectors. The new district health authorities will be free to choose either option when sorting out their future units of administration. The Government have no desire to subordinate the community services to hospital services. That would be a retrograde step. Nothing in Patients First calls for it, or implies that that is our intention.

Some have argued that, because our proposals are likely to lead to more district health authorities than the present area health authorities, there will be an increase in the number of administrators and of the proportion of NHS funds devoted to management costs. It is true that if Patients First is implemented, there may be 180 or so DHAs compared with the 90 AHAs; but there are 251 separate "bureaucracies" within those 90 areas: 90 area headquarters and 161 district organisations. There will be only 180 or so when, and if, the DHA pattern is introduced. Thus, there could he a reduction of 70 chief officer teams.

Our proposals are also aimed at shortening the chain of command between authority level and those at the "coal face". In our judgment a reduction of up to 10 per cent. in the cost of managing the service will be achieved, once short-term transitional costs have been met. That would represent a saving of £30 million a year at current prices.

Obviously much will depend on the composition of the new authorities and a lot of time was spent in Standing Committee discussion of the Bill in another place on the question of the membership of the new DHAs against the background of paragraph 23 of Patients First. Very briefly, the Government have suggested a district health authority membership of about 20, apart from the chairman, of whom four would represent local government, together with a consultant, a general practitioner, a nurse and a nominee from the university and from the trade union movement. The remaining members would be selected by RHAs after consultation. In Committee a range of possible constitutions, such as DHAs consisting of 50 per cent. local authority nominees, and varying proportions of elected staff and trade union members, were pressed on the Government. The merits of democratic election versus continuation of the appointment system were also debated. No final decisions on these matters have been taken since the mass of comments received has not yet been fully analysed. The comments received reflect a very wide range of views and need the most careful consideration.

The local authority associations have in particular pressed hard for retention of their current one-third representation, or more. In contrast, some, but not many, individual local authorities believe that four councillors could, as Patients First suggests, adequately cover local authority interests. The Association of District Councils also argues the case for statutory representation of non-metropolitan district councils on the new DHAs. My honourable friend the Minister for Health is sympathetic towards the association's aspiration, and said so when the membership question was debated during the Committee.

However, the views of the other local authority associations on the input of the various local government tiers to the membership of DHAs will have to be studied very carefully. Moreover, the accommodation of every non-metropolitan district council on the DHAs would not be straightforward, and would certainly require detailed discussions with the Association of District Councils. These matters will all take time. Accordingly, the Government cannot move to amend the present law through the Health Services Bill, though the possibility of a change in any later legislation has not been ruled out.

I should now like to try to answer some of the questions that I have been asked. At the beginning of the debate the noble Lord, Lord Wells-Pestell, intervened regarding the six principles and asked when they would be implemented. The six principles are to be implemented when the Bill is enacted. They will be formally promulgated to authorities in a circular, and the medical profession has agreed to communicate them to its members. However, the principles are not all new. To some extent they represent merely a writing down of the principles of equity, which are already normal practice. Mean-while, they have appeared in the medical press and the Minister for Health set them out in a letter to health authority chairmen on the 21st March.

The noble Lord, Lord Wallace of Coslany, who asked a number of questions, suggested that staff representatives should serve on DHAs. I am sorry to say that on this question we have made up our minds, as Patients First made clear. We do not believe in staff representation on authorities. In our view the way forward is through the development of joint consultative machinery between management and staff. To this end a Whitley Council agreement was concluded earlier this year. The noble Lord also asked about staff protection. The Government offers on staff protection, early retirement and filling of posts were made public recently. Negotiations in a sub-committee of the General Whitley Council are about to commence.

The noble Lord, Lord Wallace of Coslany, and a number of other noble Lords, referred to community health councils. There are arguments for and against community health councils. That is why the Government posed the question about their future in Patients First. I am unable to give the noble Lord an answer to his question about the future of community health councils. No decision has yet been taken. We are carefully analysing the evidence and I must ask the noble Lord to be patient and await the Government's statement in July.

The noble Lord also asked about family practitioner committees. The powers in Clause 2 are to be used to retain the existing pattern of family practitioner committees. The noble Lord's fear of wholesale amalgamation of family practitioner committees are unfounded. On Clause 5 the noble Lord asked a question about fund raising. He was suspicious that the power will be used to reduce NHS funds. This is certainly not to be the case. The power is about more money for the NHS, not less, or the same money from different sources. I can give the House the categorical assurance which the noble Baroness, Lady Robson, asked for. Funds raised locally will not be deducted from funds allocated to authorities. There would clearly be no incentive for local fund raising by authorities if this happened. I would remind the House that the power is discretionary and health authorities are not compelled to use it.

Noble Lords also mentioned that this power might benefit the wealthy and not the poor areas. I do not believe that this is so. I do not believe it is true of the present position. Good work is done by leagues of friends and others in all areas. I believe that the observations of my noble friend Lady Macleod on this point answered the noble Lord extremely well. She has considerable experience in two areas, Kensington and Bethnal Green.

The noble Lord, Lord Wells-Pestell, also asked a question on fund raising and I would just like to say what my honourable friend Sir George Young said in another place on 20th March: I would make it absolutely clear that I, the Minister of State, the Secretary 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 ".—[Official Report, Commons, Standing Committee G, 20/3/80; col. 710.] The noble Lord, Lord Wallace, suggested that the cash limits clause was too rigid. The purpose of the new clause is to give cash limits a statutory framework. It therefore needs to be framed in a clear and precise way and to allow for the Secretary of State to enforce it if necessary. But it is not rigid in the sense that carryover from one year to another can continue and additional grants can be made.

The noble Baroness, Lady Robson, asked whether this Bill is just to save money. That is not the intention of the Bill. It is to create a better structure more fitted to deliver effective care to patients. None the less, it is the judgment of the Government that, as I mentioned earlier, savings of 10 per cent. or so of management costs are possible. But that is not the purpose of the Bill. The noble Baroness also asked about joint financing and whether it could be used for health education. There is no objection in principle, but the purpose of joint financing is to fund functions of the social services authorities. Health education is something which the health authorities would usually undertake in its own right. Sheltered housing is financed through the housing subsidy system and would not be directly appropriate for joint finance, but the Social Services Depart- ment provide aids and other facilities additional to basic housing and these latter can be funded by joint financing.

The noble Baroness also asked what are similar activities and whether lotteries would be allowed. The purpose of the list of activities in subsection (3) of the clause is to establish a certain type of activity. Listed activities include appeals, collections, entertainments and bazaars. These are all the usual types of activity engaged in by numerous fund-raising organisations. There may be similar activities which we have not specifically identified. The form of words used is to allow such activities as well. Lotteries in the sense meant by the noble Baroness and the noble Lord, Lord Wallace, are not permitted by this Bill.

The noble Baroness, Lady McFarlane, raised the question of coterminosity. I fully agree with the noble Baroness that coterminosity between health and local authorities is important. Patients First made it clear that coterminosity should be given weight with other factors in determining the boundaries of the new DHAs. I do not think that coterminosity can be the overriding factor. If it produces a health authority which is a nonsense in terms of health care planning it would be wrong to insist on full coterminosity. But I can assure the noble Baroness that the need to ensure proper collaboration and co-operation between health and local authorities will not be forgotten.

The noble Baroness also referred to flexibility. Again, I entirely agree with what the noble Baroness said about flexibility in structure and management arrangements. That is why we propose in Patients First that the regional health authorities, in consultation with all relevant local bodies, should make proposals for the new boundaries. They will be better able to have a feel for the local aspirations than Ministers and officials in the Elephant and Castle. The Government also believe that there should be flexibility in management arrangements at local level. The noble Baroness can rest assured that we shall not produce another detailed grey book.

The noble Baroness, Lady Robson, asked about statutory requirements for the private sector to contribute to training and for insurance agencies to cover long- stay treatment. The Government do not think that either of these is a suitable subject for statute. This is not to say that we do not hope people will insure themselves for a wider range of treatment and that the provident associations will make their cover more comprehensive. We also hope that the private sector will undertake its fair share of staff training, as was said in the other place by Ministers in the course of discussion of the possibilities, with the Joint Liaison Committee for Independent Health Care, of which Sir Richard Bayliss is the chairman.

My noble friend Lady Macleod asked about community health councils. As I have already said, I cannot answer the question as to the future of community health councils. So many different views have been expressed, even in this debate today, that the fact that this is rather an evenly-balanced point has been proven once more. The noble Lord, Lord Smith, referred to the symbiotic relationship between the NHS and the independent sector. I could not agree more, and I hope there will be more and more instances in which health authorities and local private hospitals can work together to the mutual benefit of both. The noble Baroness, Lady Stewart, I think was under a slight misunderstanding when she referred to the Royal Commission's recommending the phasing out of pay beds. They did not actually do that. In point of fact they suggested that the presence of pay beds was not significant to the efficient functioning of the NHS, but they did not actually recommend their phasing out.

The noble Baroness, Lady Masham, asked whether disabled people could be exempted from prescription charges. The noble Baroness made her usual very emotive speech, which I listened to with great interest and which is something I look forward to reading again. There was not a great deal of it which referred directly to the Bill with which we are concerned; and, in point of fact, if she managed to get this exemption it would not require an amendment of this Bill, because exempted conditions are set down in regulations. However, I shall convey—

Baroness MASHAM of ILTON

My Lords, may I ask another question of the noble Lord? Why was it, then, that such an amendment to this Bill was moved in another place?


My Lords, I simply could not answer that question, but I understand it is purely by regulations that this could be altered. But, as I say, I will pass on the noble Baroness's suggestion to my right honourable friend.

My Lords, I think I have answered all the questions I can. Finally, I turn to the private practice clauses of the Bill. As expected, this section has preoccupied many speakers this afternoon, and the noble Lord, Lord Wells-Pestell, says that it will be the battleground when we come to the Committee stage. I am sorry to hear that we are going to have a battleground, which is rather what several noble Lords hoped we should not have. I find it very sad that some noble Lords opposite still hold the view that there is something morally reprehensible about private medicine and that, if it is allowed at all, the private sector and the NHS should be kept as far apart as possible. It is, we feel, both very sad and very silly.

In our March debate speaker after speaker emphasised the positive contribution that the private sector makes to the health care of the nation. Everything said demonstrated that the policies of the previous Administration—the attempt to sever the institutional link of pay beds between the private and the public sectors and the hostility to the private sector—flew in the face of both reality and the public good. The reality is that the NHS and the private sector have been working together over the past 30 years. As I pointed out in that debate, the NHS uses facilities in the private sector on a contractual basis as a way of providing services for NHS patients. Where the private sector has spare capacity, this is an entirely sensible arrangement of benefit to both sectors. We will do all we can to encourage health authorities to consider the option of using private facilities as a way of providing NHS services. Such co-operation has been the reality of the situation all the while the "private medicine" debate, instigated by the previous Administration, has raged. The public good is, of course, that the private sector adds to the health care resources of the nation.

My noble friend Lady Young asked noble Lords opposite how the NHS would cope if it had to bear the burden of all those currently treated in the 34,000-odd private hospital and nursing home beds. These homes and hospitals, many of which are run by voluntary or religious groups, are all part of the private sector, all lumped together under the Opposition's umbrella condemnation of private medicine. I have yet to hear a satisfactory answer to my noble friend's question. The truth is, of course, that there is no answer. The Opposition's principles on private medicine simply do not bear scrutiny when faced with reality. To force the two sectors apart (which was the Opposition's policy) or, what is even worse, to try to kill off the private sector (which is what seems to be the policy of at least some of the Opposition, from what we have heard recently in another place) is totally misconceived. It could do nothing but harm, and in the end the biggest loser would be the NHS. The Opposition claim that the NHS is harmed by the private sector, and imply that all the NHS problems would go away if private medicine were abolished. My Lords, I do not believe that this is true, and I do not believe that those who work in the NHS believe it is true.

The previous Administration brought private medicine into the political arena; our aim is to remove it. Far too much time has been spent on sterile arguments on this subject over the years. We wish to put an end to the debate, and the way we shall do this is by proving that the NHS and the private sector can, and should, co-exist and co-operate. If we can achieve that consensus view, then I believe that we shall have performed a valuable service which will allow the NHS and the private sector together to get on with their proper job, which is to provide the best health service possible. I hope your Lordships will now agree that this Bill should be read a second time.


My Lords, before the noble Lord sits down, there is something I must put to him by way of a question, as I cannot comment. I put it to him in the way of a question, but I do not require a reply. Is he aware that the Royal Commission advocated or recommended that the Health Services Board should continue? As the function of the Health Services Board was to phase out pay-beds as well as to control the number of new private hospitals, it could be argued—I say "it could be argued"—that the Royal Commission therefore favoured the phasing out of pay-beds.


My Lords, before the noble Lord sits down, may too, repeat a question I asked? I am not asking the noble Lord for a reply now, but perhaps he will be kind enough to write to me. It relates to Part I, Clause 6, subsection (7)(c) of the new Section 97A. It was when I was talking about the carry-over implication of that particular clause. I should be most interested in having a reply in writing from the noble Lord.


My Lords, I shall certainly have pleasure in writing to the noble Baroness. I am aware of the recommendation of the Royal Commission, but we do not happen to agree with the noble Lord, Lord Wells-Pestell.

On Question, Bill read 2ª, and committed to a Committee of the Whole House.