THE NHS AND PRIVATE MEDICINE

HL Deb 19 March 1980 vol 407 cc219-60

3.2 p.m.

Lord HUNT of FAWLEY rose to call attention to the extent of co-operation between the National Health Service and the independent medical services (private sector) during the past 30 years and to the potential for future co-operation; and to move for Papers. The noble Lord said: My Lords, in opening this short two and a half hour debate on co-operation between the National Health Service and our independent private medical services, I make no apology for dropping this political hot potato into your Lordships' laps this afternoon. It is an enormous and important subject which has been somewhat neglected. I hope that this debate will be a preliminary to the debates which we shall have on the Health Services Bill in the next few weeks and months.

The president of the Royal College of Obstetricians and Gynaecologists, Mr. Anthony Alment, in a letter to me recently said: I am quite sure the relationship between the National Health Service and the private sector is the most unconsidered aspect of medical practice, responsibility and ethics during the whole lifetime of the National Health Service, and any cool and reasonable debate which examines these issues must surely be helpful to both public and profession.".

When our National Health Service was introduced on 5th July, 1948, many people thought, in an idealistic, almost Utopian, kind of way that it would be so good that private practice would shortly die a quiet and peaceful death. This has not happened. After a trial of more than a quarter of a century, it is now in difficulties—financially, administratively and in some of its labour relationships. Meanwhile, the private sector is developing and expanding, filling some of the gaps efficiently. Although private medicine is still only a small part of our country's medical services, if all its different facets, which I shall mention shortly, are included, I believe that it is considerably larger than the very small percentage which the Royal Commission on the National Health Service suggested last year.

I wish to begin by reminding the House of what the leaders of the Labour Party and others have said about private medical practice in Britain during the past 30 years. Mr. Aneurin Bevan made the first gesture to encourage co-operation between the National Health Service and the private sector when he included pay beds in his plans for NHS hospitals: although I believe that he hoped they could be separated later.

Sir Harold Wilson, as Prime Minister, referred to: …the important and continuing contribution which we expect and want private practice to make … We expect to see it cortinue, and we want to see it continue, and we shall guarantee it in our legislation."—[Official Report, Commons, 20/10/75; cols. 37 and 39.]

The noble Lord, Lord Wells-Pestell, told your Lordships more than five years ago from the Labour Government Front Bench: We are not attacking private practice … There are a number of private hospitals. There may have to be many more… We are not objecting to that. "—[Official Report, 29/7/74, col. 2132.]

Mrs. Barbara Castle, when she was Secretary of State for Social Services, said: … we must do everything in our power to ensure that those who wish to practise privately can continue to do so.—"[Official Report, 21/11/75; col. 356. She added a little later: It would be intolerable in a democratic society to prevent people from buying private medical care."—[Official Report, Commons, Standing Committee D, 18/5/76; col. 38.]

The views of our present Government have been put to us recently equally vigorously. The Secretary of State for Social Services, Mr. Patrick Jenkin, said on 19th December last year: We believe that it is a part of a free society that patients who wish to seek private medical treatment should be free to do so. We believe that doctors who wish to practise privately should have the right to do so. These views are shared by the overwhelming majority of the people."—[Official Report, Commons, 19/12/79; col. 650.]

He mentioned the results of several recent opinion polls confirming this; he stressed that private practice must in no way harm the NHS; and he put forward six points, which he and the British Medical Association had agreed on, to ensure that.

The three senior Royal Medical Colleges are, in general, regarded as the academic leaders of my profession. I have already quoted the president of one of them. The president of another, the Royal College of Physicians, Sir Douglas Black, supports the continuance of a strong private sector which, in his own words: makes a most valuable contribution to medical care in this country …it is no kind of threat to NHS standards.". He is quite right about that. Our two medical services should work in reasonable collaboration, friendly co-existence and partnership. They should be potential allies with strong links between them. With its incentive, enterprise, flexibility and freedom of choice, the private sector should be able to initiate much pioneer work which could be of value to them both. It should be useful also as an indication of patients' needs, being able to respond more directly and more quickly to patients' demands for services than can the NHS.

The president of the Royal College of Surgeons, Sir Reginald Murley, wrote to me saying: The private sector is an encouragement to raise standards of personal service, as well as proper costing and economical use of resources. Those are three important points. In general, the independent medical services should be considered as a supplement to the NHS and not as a competitor. In the last sentence of my maiden speech in your Lordships' House, nearly seven years ago, I said that, if this friendly symbiosis and co-operation proved impossible, the two sectors would have to develop separately, which I felt sure would prove in the end to be to the detriment of both. I hope that the noble Lord, Lord Smith, immediate past-President of the Royal College of Surgeons, will agree with me on that.

All these senior politicians, doctors and many others in every party have accepted the existence of private practice in Britain, even though they know full well that it can often give a somewhat different personal service to some people, in certain respects, than it can to others who are in the National Health Service. Patients who have been provident enough to insure themselves against the cost of illness, often at considerable sacrifice, or those whose firms or trades unions have done this for them, expect and deserve something rather different—such as choice of surgeon and date and place of operation, especially for those who travel much, privacy, with a room to themselves, perhaps with a bathroom and lavatory, a telephone, and so on. Medical or surgical treatment may not necessarily be better than it is under the NHS. No private hospital, for instance, can really have all the equipment of a large teaching or other general hospital, and doctors vary in kindness and efficiency. Very often the clinical standards in both are much the same, but these other amenities mean a great deal to many people, and they are willing to pay for them, even though not at all well off.

What are the things that can interfere with and tend to spoil collaboration between the NHS and the private sector? Occasionally, a few years ago, so-called"queue jumping complicated this cooperation, when a patient who had been seen by a consultant privately—say, in Harley Street—was sometimes admitted at once to one of his NHS hospital ward beds ahead of other patients who had been waiting a long time for admission. That was recognised as quite wrong. It has been stopped now, by consultants and by the vigilance of hospital admission officers. These patients' names now go on to a common waiting list so that, for everybody, medical urgency is the only reason for early admission. But to use the term"queue jumping"still, like one sometimes hears, as a bitter, politically-motivated slogan against all private medicine, is unjustified. To apply that term in a derogatory way to someone who is admitted to a private hospital for treatment, for which he pays because he cannot get it when and where he wants on the NHS, is as unrealistic as it is to use it against someone who drives a private motor car or who takes a taxi, when in a hurry to keep an appointment, at a time when public transport is not running.

Another point which may affect cooperation is whether or not private medi- cine robs the NHS of doctors, nurses and ancillary staff and equipment, as is sometimes alleged. We must all share our country's resources and when there is real shortage the NHS should have first pick; but we must do our best to make sure that there is enough for everyone. A few private hospitals are training nurses now, and more will do so. Some doctors and nurses are unwilling to work in the NHS, for various reasons—they may prefer other jobs, such as in industry, or they may want to go abroad —just as some do not care to work for private patients. Neither can be compelled, and we want as few as possible to leave our country. Is there really a shortage of personnel and equipment in the NHS? The late Lord Murray of Gravesend told us on 14th November of last year that, with wards being closed all over the country, there were then 8,000 nurses unemployed.

Now let us look at the many ways in which our independent medical sector has helped the NHS during the last 30 years. The expenses incurred by outpatient attendance at different types of hospitals vary greatly, but it is always a considerable sum of money. The Department of Health and Social Security tells me that, on average, each out-patient attendance at hospital costs about £50. That is taking into account overhead expenses, the salaries of senior and junior doctors, nurses, porters and cleaners, the cost of heat and light, of X-rays, pathology and other investigations, and also of secretaries, administration and transport. For those patients who are admitted to hospital beds, with or without operation, the costs are even higher, but when patients are treated privately away from the NHS hospitals, the NHS is saved all this expense. Then the patient himself, or someone else on his behalf—his employer, or perhaps a trade union, or BUPA or other provident association —foots the bill.

The British Medical Association estimates that there are now only about 400 full-time private general practitioners in Britain who see patients in their consulting rooms, group practices or health centres, visiting others at home and perhaps admitting some of them into private hospitals, nursing homes or into NHS hospital pay-beds. There are many part-time general practitioners who do a fair amount of, or very little, private practice, and others who do none at all. Specialists and consultants see private patients in their consulting rooms, in patients' homes and in private hospital beds, too.

One further matter which affects cooperation is the feeling that doctors and nurses who have been trained in the NHS, at considerable expense to the State through university grants and subsidies. should spend their lives in it rather than in the private sector. But many doctors have given several good years of medical work and have made a considerable contribution to the NHS as students, house officers, registrars and later as specialists and consultants. Nurses do much the same in their jobs. Some other countries try to impose a period of compulsory medical national service, a kind of civilian conscription, on their young doctors after qualification. In Russia, when I was there 20 years ago, newly-qualified doctors were being asked to work for two to three years in the so-called"virgin lands ". But several, many of them women, found ways of avoiding this by getting married, becoming pregnant and so on. Even this short period of compulsory employment of professional people, in peacetime, is an infringement of personal freedom.

For other professions it is not necessary to work in the public sector after being trained largely at the State's expense. cannot help asking those who think otherwise about doctors and nurses how they feel about the many thousands who have been trained in medical schools abroad and who work now for our NHS and who do not for many years, if ever, return to their own developing countries which need their professional help so much.

The 30 private hospitals organised by the Nuffield Nursing Homes Trust throughout the country do a great deal for British medicine. The British United Provident Association helps, also, by encouraging health promotion and by arranging screening clinics. Three million people are covered by the umbrella of BUPA, the Private Patients Plan and the Western Provident Association. They are not all contributors themselves. The majority — about 80 per cent.—are covered by group schemes arranged through their employers or someone else. Increasingly, trades unions are negotiating private hospital care schemes for their employees.

We must not forget other important private hospitals, such as the King Edward VII Hospital for Officers (Sister Agnes) and the Royal Masonic Hospital; those of religious denominations, like the St. John and St. Elizabeth Hospital; and also those hospitals, rest homes and rehabilitation centres connected with trades unions like the Manor House Hospital, the NATSOPA Rehabilitation Centre at Rottingdean and the Benenden Chest Hospital. There are many thousands of beds in small private hospitals and nursing homes throughout the country for surgical, medical, maternity, psychiatric and convalescent patients with more in private old peoples' homes for geriatric and terminal care. About 4,000 of these private hospital beds in Britain are available to be let out to the NHS on a contractual basis, through local authorities, when required.

Charitable organisations do an enormous amount of good private work, too. Examples arc St. Dunstan's, which cares for about 3,700 war-blinded men and women (with its own private hospital of 60 beds for them), the Cheshire Homes and the Hospice Movement for the care of the dying, among a very great many others. One must add all the medical care outside the National Health Service that many industrial firms provide for their employees, and one should mention all the work done by the private paramedical and ancillary services and others—private nurses, dentists, physiotherapists, chiropidists, and so on. The work of sickness and life insurance companies is largely private, and so is some industrial medicine.

That is not all. The National Health Service is saved a great deal of money, time, work and responsibility by the advice, investigation and treatment which private doctors give, to so many of our overseas visitors, especially those from the USA and the Arab States, many of whom demand the very best, and at once. The standard of treatment we give them is important for the prestige of British medicine. With their families, they bring much money into our country.

My Lords, it is inconceivable that the National Health Service would want to take on as an extra much of this medical and paramedical work now being done by our private sector, with the responsibilities and the financial and administrative commitments involved. All this work of our independent medical services in Britain must have saved the National Health Service an enormous sum of money. The exact amount is impossible to assess. It may have been thousands of millions of pounds over the past 30 years. For that we should be grateful.

Knowing all this, and what leaders of the Labour Party have told us, it is very hard to understand those who want to abolish all private medicine (as resolutions at many recent Labour Party Conferences have suggested). One cannot agree with Mr. Stanley One, MP, the Opposition spokesman on Health and Social Services, who said recently: My objection to private practice is that it is immoral.—[Oficial Report, Commons, 23/1/80; col. 478.]

Nor can we agree with Mr. Andrew Bennett, MP, who spoke of: private medicine, which feeds like a parasite on the National Health Service ".—[Official Report, Commons, 19/12/79; col. 712.]

May we now look for a few minutes at the other side of the coin, at how much help the National Health Service has given to the private sector? First, there are the extremely valuable ambulance services and the hospital accident and emergency services, with intensive care and coronary care units, available to every patient and doctor, National Health Service and private. Usually their help is given so quickly, cheerfully and efficiently, at any time of the day or night, and with so much co-operation, that they are a great comfort and reassurance to doctors and to their patients and relatives. Another way in which the National Health Service co-operates with and helps private doctors is when our patients need diagnosis or treatment requiring highly complicated or sophisticated apparatus, such as X-ray or cobalt therapy, tissue transplants, and so on.

This co-operation can work both ways. During the year ended last August, the surgeons at a well-equipped private hospital in London, the Harley Street Clinic, reduced the waiting list of patients for open heart surgery at the Sefton Hospital in Liverpool by taking 24 of its NHS patients and operating on them in London, charging less, I am assured, than the operations would have cost the NHS in Liverpool.

Still another chance for helpful cooperation between general practitioners in the NHS and those in the private sector arises when a patient who is registered with an NHS general practitioner in the country near his home is taken ill or wants treatment or special advice from a private doctor when he is away, perhaps in London. Under these circumstances, friendly telephone calls or an exchange of letters between the GPs concerned can often do much to help the patient.

In my experience, all branches of the Social Services are willing to help private doctors and their patients, especially in emergencies, or when they are in difficulty or trouble over long-term treatment. We all belong to the National Health Service and help to pay for it, and the many benefits of the Social Services are willingly shared between the public and private sectors.

Hospital pay-beds, too, help the private sector and are a source of income to the NHS, bringing in, we are told, about £30 million a year. Pay-beds have been discussed endlessly, and I do not propose to describe their pros and cons now. Most of them have been successful but there has occasionally been trouble over labour relations when NHS and private patients have been nursed under the same roof. The last Labour Government phased out some of these pay-beds; our present Government plan to replace many of them soon; and the Labour Party says that it will repudiate that when it next returns to power. I must give a solemn word of warning here about such repeated changes of policy, because the pay-bed question could easily become a political bone of contention or a running sore, which would do nothing but harm over many years to co-operation between the National Health Service and the private sector. All concerned should do their very best to avoid that. The noble Lord, Lord Wallace of Coslany, said to us last year: No one in his right mind wants the National Health Service to become a political battleground". —[Official Report, 14/11/79; col. 1365.] How good it would be for patients, doctors and hospital administrators, if some permanent and stable agreement between the political parties could be reached soon on this matter.

In conclusion, my Lords, what of the future? There is no reason why all the points of contact and co-operation which I have mentioned should not be expanded. The Department of Health and Social Security naturally represents primarily the National Health Service, but it serves the whole of British medicine in general matters such as the control of infectious diseases, drug addiction, and so on.

Two important problems will have to be discussed and solved soon. The first is, does the internal structure of the DHSS now allow it to take an adequate, efficient and sympathetic interest in the needs of the private sector? What are now independent medical services could not and should not be controlled by the DHSS, but I believe that there is now a need for more co-ordination and perhaps some reorganisation at the top, with an influential committee, group, unit or sub-department within the DHSS, encouraging maximum co-operation of the type we have been discussing today, to help to sort out some of the problems I have mentioned.

The second problem is this: are all the different aspects of private medicine properly and fully represented outside the DHSS? Outside the department we have already several groups representing different aspects of our independent medical services, such as the Private Practice Committee of the BMA, the Independent Practice Sub-Committee of the Joint Consultants' Committee, the Association of Independent Hospitals, and the Independent Hospitals' Group, to mention a few. They are all doing good work but there is a need, I believe, for more cohesion between them, and for some of them, perhaps, to join together to improve liaison with each other, with other doctors working privately, and with the DHSS.

From what I have said, it will be appreciated that I am led to believe that there is not now nearly such a deep divide between the two sides of our House over private medicine as there was a few years ago. I feel sure that the prospects for efficient and friendly co- operation and collaboration between our National Health Service and our independent medical services are much brighter than they were then. I hope very much that we can ensure that this improvement continues, for the future wellbeing of the whole of British medicine. My Lords, I beg to move for Papers.

3.30 p.m.

Lord SEGAL

My Lords, I feel that the whole House is greatly indebted to the noble Lord, Lord Hunt of Fawley, for raising this very important question this afternoon. Indeed, it is a subject which is crucial to the whole future of medical practice in this country. But first may I be allowed to express the deep loss felt in the whole world of medicine by the death of Sir Ludwig Guttmann. The news only came to me a few moments ago. The whole world owes him a debt which is almost incalculable for the pioneer work which he did at Stoke Mandeville Hospital. He came to this country as a refugee from Nazi Germany; he has been instrumental in saving many thousands of lives, not least some of the lives of the most valued Members of your Lordships' House, who are better qualified than I am to speak of the great work which he accomplished. He was instrumental in organising the Olympic Games for paraplegics which caught the imagination of the whole world on behalf of those tragic sufferers, and his name will live not least among the many disciples whom he taught over a long period of years.

I should now like to start on perhaps a rather more optimistic note than did my noble friend Lord Hunt of Fawley. I have no hesitation whatever in calling him"my noble friend," whatever political differences may divide us on opposite sides of the House. It is my own personal conviction that the abolition of private medical practice in this country is as remote an eventuality as the abolition of your Lordships' House. I speak from these Benches perhaps as a somewhat wayward member of the party to which I belong—a party which is quite notoriously tolerant of the unorthodox views of some of its members; and yet may I say, with deep sincerity, that I feel more at home on these Benches than I am ever likely to feel in any other part of the House.

Having said that, may I say that whatever views I may express here are views expressed from the Back-Benches, individual personal views which may be corrected by my noble friend Lord WellsPestell, who, when he replies, has to recognise me here as a dedicated schizophrenic, torn between my loyalty to my profession and my loyalty to my party. Whereas I speak of the love for one's profession perhaps more from the heart, in cooler moments and on longer reflection perhaps with my head I sympathise with a great deal of what my noble friend Lord Wells-Pestell is likely to say.

This House has just completed in all its stages the Competition Bill and has passed it on to another place. After 32 years of State medicine we have now come to realise its limitations and its deficiencies, and today even its most ardent advocate is bound to admit that all is not well with the National Health Service. It would be a gross oversimplification to assert that this is due to any one particular cause. Many factors have been at work during this period; shortage of funds, shortage of beds, shortage of nurses, lengthening waiting lists, a widespread malaise which seems to have permeated many sectors of the National Health Service. Indeed, it is quite amazing what triumphs the NHS has been able to achieve, despite all these many handicaps which have dogged its progress ever since its inception in 1948.

In contrast to all that, medical insurance schemes seem to have flourished; in fact, many of us may take the view that because of all these difficulties these insurance schemes have flourished. The demand for private medicine in one form or another, whether to secure priority in queue-jumping whatever the morality or otherwise of that procedure may be; whether to secure special nursing care or private surgery performed by the surgeon of one's own choice, all these factors show no signs of abating. Private medicine has now even infiltrated into the ranks of trade unions, so that today's skilled workers are unabashed in demanding priority in medical treatment and specialised medical care.

This has exploded sky high the theory that it is immoral to condone priority in treatment. It has also made a nonsense of that term of reproach that is sometimes used of the creation of"second-class citizens"where medical treatment is concerned. No one today would expect a Minister of Health to take his place in the queue. No one denounces a Cabinet Minister for claiming some degree of priority in National Health Service treatment. In the last resort clinical urgency has to be decided on the basis of expert judgment, and cannot be left to rule-of-thumb decisions by non-medical personnel where human lives are often at stake. Some unfairness may result, errors of judgment may occur, patronage may exist but, like democracy itself, with all its defects, it remains a safer choice than any alternative.

What is sad about private and State medicine today is that they arc allowed to confront each other. So much is to be gained by retaining them both closely in active harness. The cost of a private bed has mounted to over £100 a day in our London hospitals. That, I understand, is to come into being on 1st April next, without, I hope, any significance attaching to that particular date. And with all the inflationary factors at work, the cost of a private bed in a National Health Service hospital is likely to rise even higher. It is small wonder that medical insurance schemes are bound to flourish. Nothing can be gained by suppressing them. Indeed so long as we continue to live in a mixed economy, medicine as a whole is likely to gain in many ways, not least by reducing the length of hospital waiting lists, by working in close harmony with the private sector.

Whatever inherent danger there is in creating a State monopoly, one of the risks that may develop in the course of time is that private benefactions are likely to get less and may even ultimately tend to dry up. The trade union hospital itself is outside the National Health Service, as the noble Lord, Lord Hunt of Fawley, has reminded us; it still remains a stronghold of private medicine. Trade unions do not cavil at that. The Royal Masonic Hospital, again as Lord Hunt reminded us, is a source of pride to the members of many powerful masonic lodges and a notable beneficiary of those who are generously inclined.

It is sad to have to preside at the burial at some of our sacred cows, but the sooner we recognise the potentialities of private medicine in effecting a symbiosis with the National Health Service, the sooner the National Health Service is likely to raise itself out of the slough of despond which now surrounds it. Let us face the facts. Private medicine has come to stay. It will continue to flourish so long as the demand for it exists. The greatest blow that could be struck against private medicine today would be the formation of a picket line outside a private hospital to prevent any patient from entering. So far as I am aware—and I speak subject to correction—this has not yet happened. Until then, it would appear that private insurance schemes will continue to grow and gain the support of those who cannot afford to wait indefinitely for treatment, or who wish to be operated on by the surgeon of their choice. So long as the private sector is able to maintain the highest possible standards of medical treatment, so long will it continue to survive, just as our private and public schools will continue to survive as long as some parents are prepared to pay, and even to sacrifice in order to pay, for their children's education.

In a mixed economy we have every reason to be grateful for the survival of private medicine, and ought to encourage both the private and public sectors, instead of leaving them to waste their energies at loggerheads with each other. It is of the utmost importance that they should work together in order to alleviate suffering wherever it exists, each supplementing the other and giving of their best to the whole community.

3.44 p.m.

Lord SMITH

My Lords, I had been a consultant for two years upon the inception of the National Health Service in 1948, and I can well remember that, although an enthusiastic supporter from the start, it worried me in those days that it might result in the evolution of two standards of medicine in this country. Such was the naivete of youth, however —not that youth has any monopoly in this respect—that my fear was that the private sector of medicine might not be able to keep up with State medicine, which presumably had access to an inexhaustible purse, a misconception that even now has not entirely disappeared. That there should continue to be an independent sector in medicine seemed to me to he quite essential, and it is, of course, apparent that the prime architect of the Health Service, Aneurin Bevan, saw this very clearly. I much enjoyed the account given by the noble Lord, Lord Hunt of Fawley, to whom we are much indebted for the opportunity of this debate, of the way in which various outstanding personalities have, over the years, acknowledged and emphasised that the National Health Service and independent medicine really must work together in harmony.

Since those very early days of worry about the survival of independent medicine, what has happened? First, there has been an enormous increase in the cost of medicine, particularly hospital medicine, and at the same time an enormous increase in demand for medical services of all kinds. It has, I think, become clear to all that the original objective of a comprehensive Health Service in the original sense of this word —that is, that all services that medical science has shown to be possible ought to be available to all patients—is a mirage. Within the National Health Service the gap grows bigger at an accelerating rate between what medical science could do for patients given unlimited resources and what any State can afford through the taxation of its citizens. Combined with this, there has grown up among many patients and potential patients the belief that payment of National Insurance contributions should entitle them by right to prompt medical care of the highest standard. No wonder a growing number of patients today react with disappointment when a place in hospital cannot immediately be found for them, and that some of these do turn to the independent sector of medicine.

I do not believe it is in any way wrong that a patient, if he wants to, should go directly to a doctor of his choice. Nor is it wrong that a potential patient should seek insurance in case the pressures on the National Health Service should prevent him obtaining prompt treatment when in need. In parenthesis, may I say that personally I except from this general approval of medical cover through private insurance schemes, schemes whereby the personal doctor-patient relationship, on which all good medicine is based, is undermined by an arrangement whereby a patient calling his doctor in an emergency can expect to be visited not by his own doctor, who knows all about him, but by some total stranger despatched by an agency, like a radio cab to a diner wishing to return home. This to me is not representative of good independent medicine. I doubt whether sometimes it is even entirely ethical. I hope that perhaps the General Medical Council will give such schemes a good hard look.

Today, through force of economic circumstance we are, I am afraid, back at the unattractive and to me quite unacceptable possibility of two standards of medicine in this country, with the State system unable to keep pace with the spiralling costs of ever more complex medicine, and frustrated patients increasingly seeking an escape from this situation, often through private insurance at a cost. Well, my Lords, what is the solution? Indeed is there a solution? Certainly no acceptable solution can be found by reversing the far-sighted provisions of Aneurin Bevan and others, by saying that in a situation in which standards relatively speaking are falling in the National Health Service, we can avoid two standards of medicine by ensuring that standards in the independent sector of medicine shall fall too. Still less is there a solution by aiming to obliterate private medicine altogether so that patients could be told,"Whatever the defects, State medicine is all you can get—it is that or nothing."

If we were to proscribe or unduly curtail independent medicine, if the idea of two standards is abhorrent, how much more so surely would be a black market in medicine or planeloads of patients taking off on package tours to the Mayo Clinic or medical centres on the Continent of Europe?

There is a solution and I believe that it lies in an acceptance, indeed an expansion, of the principle that State medicine and independent medicine must be interdependent. I am convinced that the existence of a healthy independent sector is much in the public interest, although I would say that it should not flourish in isolation. I believe that for a doctor to spend part of his time practising medicine independently of the National Health Service is less a right than a privilege to be exercised with due regard to the total medical needs of the community.

I believe that most people today are prepared to accept that the total separation of independent medicine from State medicine is wrong in theory and harmful in practice. However, that is a negative approach. I should like to hear the Government say that they would rather be positive about this and that, particularly at a time when national economic difficulties exacerbate problems which in any event create great stresses within the Health Service, there ought to be a specific and concentrated examination of all possible ways—some old and some new—in which independent medicine can support and sustain the National Health Service.

Private medicine has no wish to mount an assault upon the Health Service and would in no way regard such an examination as intrusive. The doctors who are mainly concerned with the organisation and control of private medicine regard this as completely logical and would join in such an examination with the Department of Health in an entirely co-operative spirit. I hope very much that we shall pursue that course, for through it we can arrive at a system which is best attuned to the needs of patients; that is, a real partnership between the State on the one hand and the whole of medicine (State medicine and independent medicine) on the other hand. We shall not arrive at that situation through some process of natural evolution: it requires not only goodwill, but imagination and hard work. It is surely worth the effort for the prize is great.

Baroness GAITSKELL

My Lords, before the noble Lord, Lord Smith, sits down, I should like to ask one small question. How can the situation be equitable as between the public and the private sectors of medicine when the private sector has equal use of all hospital facilities as the public sector? That is a problem which I had expected the noble Lord to tackle and which he has not tackled in his speech.

Lord SMITH

My Lords, I believe that, in a debate of this length, with individual speakers confined to approximately 10 minutes, it would be totally out of the question to tackle a subject of that kind.should dearly like to see such subjects discussed and that is why I firmly believe that it is no good making encouraging noises about the two sectors existing together; I believe that there ought to be a specific examination into how this relationship should work.

3.55 p.m.

Lord AUCKLAND

My Lords, I should like to add my own debt of gratitude to my noble friend Lord Hunt of Fawley for enabling us to debate this very important subject this afternoon as a prelude to what will be a much more comprehensive and no doubt highly controversial selection of discussions when the National Health Service Bill reaches your Lordships' House.

We have had from my noble friend a cogent and clear-cut speech, and we have heard from two eminent members of the medical profession. It is therefore with more than usual trepidation that I rise as one who is not in any way qualified in medicine. However, I have for some years, as your Lordships will know by now, served on a number of hospital committees. I must also declare that I, personally, have never—and nor have members of my immediate family—been a private patient. We are all, let me stress, consumers of the National Health Service and very satisfied consumers of it, although one is bound to say that at present there are features of the National Health Service which cause anxieties, and my noble friend mentioned some of them.

In an ideal world everybody who is ill or injured should have medical or surgical treatment without having to pay for it. None of us really wishes to be ill or injured—or very few at any rate. The real nub of the matter is the question of co-operation. Today throughout industry and throughout most organisations in our national life, we lack—or it is imputed that we lack—co-operation. There is far too much made of the differences between medical practices, between sides of industry and so on, and perhaps too little made of the spirit of co-operation which exists.

The report of the Royal Commission on the National Health Service, chaired by Sir Alec Merrison, is certainly a formidable document. I must confess to your Lordships that I have not read it all chapter and verse, and I presume that many of your Lordships, similarly, have not read every word of it. However, there is a most interesting section which deals with the question of private practice and the National Health Service. There is one paragraph which I should like to quote on page 290, column 1829, where it says: There is no doubt that the National Health Service has from time to time suffered from shortages of particular groups of staff both locally and nationally. However, bearing in mind the modest size of the private sector it is difficult to believe that such shortages were often due to National Health Service workers leaving for the private sector I shall content myself with that quote because of the exigencies of time; but I believe that this is a very important part of the Royal Commission's report. Like myself, many of your Lordships will have sons, daughters or other relations who are nurses or doctors in hospitals, both in this country and overseas. My own younger daughter is a second-year student nurse at one of the big London teaching hospitals and of course her experience so far has been entirely on the National Health Service side of medicine.

I have visited both National Health Service hospitals and also more recently two private hospitals in London, and I learned a great deal there of the cooperation between the two sides of the Health Service. For example, if at a weekend someone happens to be run over or otherwise injured outside or in the vicinity of one of those hospitals, that person would receive immediate treatment without charge. There is nothing in this about which one should make a meal; it is only right that this should take place. However, it is worth mentioning because much is made of the enormous apartheid—if one may use that expression—between the two sides of medicine, which does not really exist.

My late uncle was secretary of the Kingston Hospital at the time when the National Health Service came into being. He had many meetings with the late Mr. Aneurin Bevan. At a meeting of doctors and consultants he related one instance, where the late Minister had some very irascible words to say to the gathering. There was a stony silence, and a short time later he came back in a very much more genial mood, full of apologies that he had not quite understood the situation. I think that from then quite a fraternal relationship grew up, even though there were, naturally, deep divisions of opinion.

One of the most important aspects of this of course must be whether, with the growth of private medicine, there is a drain on staffs in the National Health Service. I have gone to some lengths to make inquiries as to this. The Royal Commission, as I have already quoted, largely discounts this. I am quite convinced that for the most part the fact that there is a shortage of nurses and, indeed, doctors in some areas of this country is not due to the growth of private practice. Indeed, an article published in the Lancet on 20th January, 1979, quoted Merseyside, where one of the leading private hospitals treated about 50 patients, who were National Health Service patients, for cardiac troubles. I am certain your Lordships will agree that this is one small example where cooperation takes place.

Obviously, there will be an interchange between the private and the National Health sectors of medicine, particularly among nurses. Is there anything wrong in that? I submit not, my Lords. They obtain more experience of meeting people from other countries; they obtain more experience of different types of technical equipment. Certainly my experience of touring hospitals is that the standard of technical equipment in the National Health Service is invariably of a higher quality than that in many—although not perhaps all—of the private hospitals. I certainly would not question that, but I believe that it needs stating for the record.

As was mentioned in Question Time today, there is much anxiety as to the number of nurses in our hospitals in this country. This can apply as much to private medicine as to State medicine. One of the problems—and I have mentioned this in your Lordships' House before, and it is relevant to this debate—is that of accommodation. There is little doubt that at least in some of the private hospitals better accommodation can be offered to nurses than is offered in a number of National Health hospitals, and even in the London teaching hospitals. Of course, that is perhaps an incentive for girls and, indeed, men to transfer from one to the other. I have heard of these proposed training schemes in the private sector for nurses who take up nursing in that sector from their student days. This, too, is I believe something to be encouraged.

I think that the value of this debate will be to highlight at least some of the areas of agreement which there can be between public and private medicine. There will obviously be a gap in some aspects; hut, in my submission, today there is far more in the way of co-operation between the two schemes than there is diversity, about which we hear far too frequently.

4.8 p.m.

Baroness MASHAM of ILTON

My Lords, as I was the person who brought the sad news to the noble Lord, Lord Segal, about the death of Sir Ludwig Guttman, I should just like to add my tribute to a very great doctor who saved the lives of thousands of paraplegics throughout the world, including my own. He worked for the National Health Service and for the private sector. We should rejoice in the expertise and knowledge which he has left behind. Tonight I go to a reception given by the Minister of Health, Dr. Vaughan, for the Stoke Mandeville Hospital rebuilding fund for the spinal injuries unit. This hospital became renowned because of the world famous treatment of spinal injuries pioneered by Sir Ludwig, who was known by thousands of paralysed people throughout the world as"Papa ".

I should like to add my thanks to the noble Lord, Lord Hunt of Fawley, for initiating this debate. I should also like to confine my remarks this afternoon to one independent hospital, which is a registered charity, and to tell your Lordships how successful the co-operation with the National Health Service has been during the past 30 years. For 100 years the Roman Catholic brothers of the order of St. John of God, which is a nursing order, have had a hospital at Scorton near Richmond in North Yorkshire. Their founder was St. John of God, who started the work of looking after the poor and sick in Granada in Spain. Over the years this hospital in Yorkshire has cared for anyone who was sick, and who could be looked after in their hospital, from all denominations. It served the local community which, in turn, supported the hospital. A French brother became a much loved figure as he visited farms and villages collecting for the hospital, and is still a legend talked about by the older people, who would always keep a glass of port for him.

With the inception of the National Health Service a friend of the order, and a local Member of Parliament, Richard Ewert, negotiated with Mr. Aneurin Bevan's Parliamentary Private Secretary, Arthur Blenkinsop, so that the hospital at Scorton would remain private and independent, having contractual arrangements with the National Health Service. This hospital was the first to have such an arrangement in the country. The private and National Health Service patients run side by side. To the order there is no difference, as both the National Health Service and the patients who come paying their own bills are buying the service. There are 125 beds: 100 are contracted out to the National Health Service and 25 are for private patients. There has been no history of industrial disputes. As this is a small institution everyone knows everyone and the management knows staff well and cares for them. There is a team approach.

By using independent hospitals the National Health Service must be at an advantage as it does not have to pay for capital development. This is found by the independent hospital. In a case like Scorton Hospital, which is not profit making, it has a further advantage. While retaining its independence the hospital has moved with the National Health Service for the last 30 years adapting to the changing needs. Much of the work undertaken on a contractual basis is the not so popular job of looking after the senile elderly and the disabled.

Having a hospital like this in the community gives patients a choice. Chemotherapy is not practised so the patients feel safe and have trust. Since 1970 women have been admitted. Before that time it was an all-male hospital. It even now has a mixed ward. Money was needed to build a private wing and a new rehabilitation unit. An appeal was launched. The Queen Mother laid the foundation stone, and within two years £700,000 was raised. The building was completed within a year. My Lords, the appeal was only launched three years ago. That is the difference between the National Health Service, which seems to take years in planning and putting off taking decisions and the independent sector, which goes ahead and gets things done.

Every year there is a dance, which is over-subscribed. The proceeds this year went towards a new operating theatre. The local community for miles around gets great pleasure in supporting this hospital and having the freedom to do so. Consultants enjoy working there because if they ask for a bit of new equipment they need, they know they will get it. In every method this hospital works in a most ecumenical way. When there is a Church festival an Anglican choir sings, and one of the senior consultants originates from Northern Ireland and is not a Catholic. For the past 30 years there has been the same harmony with the National Health Service. I hope it will be the Government's wish to continue these good working relationships with independent hospitals like this one.

May I ask the Government what will happen if the health authorities propose more cuts? Will they cut the contractual beds? If this happens, they will rob patients of their chance to choose, which may he the only thing that is left that matters in their lives.

4.16 p.m.

Baroness ROBSON of KIDDINGTON:

My Lords. may I first apologise most deeply to the noble Lord, Lord Hunt of Fawley, for not being present when he began to address the House. Unfortunately I was engaged in an appointments committee to appoint a senior member of my region, and inevitably I got stuck in the traffic and was therefore a few minutes late. I very much regret having been late, but I did arrive in time to hear at least half of his speech. From these Benches we should like to join in the feeling of regret at the announcement that the noble Baroness, Lady Masham of Ilton, has just made, and to say how much we appreciated the work that was done by this great man, and how much, as a nation, we owe to him and his memory.

I do not want on this occasion—and I notice that no other noble Lord has done it either—to take part in an argument about the size or the relevance of the private sector vis-à-vis the National Health Service sector. I think all of us realise and accept that the private sector is here to stay; that it has a lot to contribute to the National Health Service, and equally that without the National Health Service the private sector would, as I believe, have a difficult time today. The two sides complement each other, and to a certain extent they are dependent on each other for equipment, for staff, for training, and for all the things that go into creating the kind of Health Service that we would like to see.

I was sad to hear the noble Lord, Lord Smith, say that the standards in the National Health Service are falling. It is a statement that is made all the time, and I think quite unjustly. Of course one is prepared to admit that everything is not well within the service. But I believe that we in this country have a duty to try to support the people working in the NHS, and to try to boost the morale of people working in the service by acknowledging the good things they do, which are manifold, and without which we in this country should not be able to live. I was therefore delighted that the noble Lord, Lord Auckland, said that he had nothing but good to say about the NHS.

I wanted to say that before we proceeded any further because I am the first to admit that we have many things in the NHS in our collaboration with the private sector for which to be grateful. I had for instance in my own region in West Sussex—and I must inevitably relate most of what I say to what happens in my own region—an enormous problem about orthopaedic operations. The waiting list has been created largely by industrial troubles from all parts of the Health Service personnel, not just the ancillary workers. The waiting list had grown beyond what one could accept. We approached the King Edward VII Hospital and asked them whether we could use some of their facilities; whether they would take some of our patients in order to help reduce our lists. They were very willing to do so, and on every occasion when they had spare beds, or spare accommodation, they contacted us and offered us further facilities, and we were therefore able to reduce our waiting list enormously. Of course we paid, which was correct, but it was also the correct decision to make use of unused facilities in the private sector to lower the waiting lists, rather than to increase the facilities in our area, because in the long run we will not be needing them. That was a sign of great co-operation from the private sector.

I was pleased that the noble Lord, Lord Hunt of Fawley, referred to the great willingness with which NHS hospitals open their doors and equipment to private patients when that is necessary. A question was asked as to whether that was ethical— that a private patient should have the use of this equipment. So far as I am concerned anyone who needs lifesaving and the investigation equipment that exists in this country has the right to use it, and I would not stop anyone from doing so. I do not think we can argue about that, but I am glad the noble Lord appreciates that the NHS is trying to help and is being as helpful as it can.

We help the private sector in many ways. For instance, we in the Health Service supply all the blood from our blood transfusion centres to the private sector, and in my region we supplied enough blood last year for 370 patients in the private sector to have open-heart surgery. That is a lot of blood. I would ask the private sector to think not about the cost of that blood, because people give it free, but about the fact that it is difficult to keep the nation's hospitals supplied. I would therefore like the private sector to think about the demands they make on the blood transfusion service, and perhaps think of ways and means of helping us to get more people, including private patients, to give of themselves for this service.

I was pleased to hear of the possibility of a dialogue, under the wing of the DHSS, between the private sector and the NHS. That is highly necessary because people who work in the NHS are worried about the growth of private medicine and private practice. This was referred to by the noble Lord, Lord Auckland, and while I may not have agreed with his conclusions, it is a fact that whenever there is a planning request for a private hospital somewhere near a NHS hospital, the main objection by the NHS is that our staff will be attracted into the other sector.

It is difficult to be certain whether the NHS loses a large number of staff in that way, but it is certain that the NHS trains practically 100 per cent. of the nurses we have in this country. This is costly for the NHS and it is becoming increasingly costly with the change in the education pattern; no longer is the student nurse a pair of hands, and rightly so, and therefore the cost is greater. I believe that the private sector, if we are to co-operate fully, should consider how it can contribute to the cost of nurse training. It could either fund a certain number of places at a nurses' training school or it could by some means be done on a levy system, because it must be recognised that this is an additional cost which the NHS has to carry but which the private sector does not.

The same thing applies to medical education. With the many eminent doctors present, perhaps I am treading on the toes of medical schools in saying this. I find in my region that, as a result of the decision to increase the medical student intake, I have problems finding pre-registration places for young doctors, and even SHO placings for students. I have an arrangement again with the King Edward VII hospital; they take two of my pre-registration students. I am wondering whether that situation could not be widened very much more, of course with the agreement of the medical schools. By that means we would be able to give wider experience to some of our medical students. What concerns me about medical education is the fact that a particular type of clientele, with some rather rare diseases which are not common in this country, tend to go to private hospitals when, in the past, they used to come to NHS hospitals. This precludes our students in many cases from ever having experience of those conditions, and that is a matter which should be considered.

The one point about which I am most nervous of an excessive growth in private medicine is the fact that I would not want to see the National Health Service left with practically nobody but the long-stay and geriatrics, but that is a danger. Surgical cases, particularly minor surgery, and physical medicine, can all be and are provided for by many private hospitals. I have not seen the same desire to provide a private service for the geriatrics and mentally ill. There is a danger of an imbalance here if we are not careful. This is another subject which perhaps this committee under the wing of the DHSS could look at, to see where we could have more co-operation between private practice and the NHS.

4.27 p.m.

Lord WELLS-PESTELL

My Lords, this is really a rehearsal of one scene from a many-act play which will take place in the not too distant future when the National Health Service Bill comes before your Lordships' House, at which time we shall have to deal with the matters before us this afternoon and the many matters which will be covered in that Bill. I think the best thing I can do is to try to answer some of the points that have been raised today as they affect the Opposition. because the noble Lord, Lord Hunt of Fawley, drew attention to a divide between the party opposite and my noble friends. It would be idle for me to pretend that there is not a divide. In fact, there is a very great divide.

I was a little surprised that the noble Lord, who is the most generous of people —I know that personally—suggested, ifonly by implication, that the National Health Service was sort of dying on its feet; those are my words, not his. That is not a view which the Royal Commission shares with him, for the Royal Commission went so far as to say: The National Health Service has achieved a great deal and embodies aspirations and ideals of great value ". It will not die if that is in the forefront, as it is, of the minds of the people who are responsible for the NHS. I recall it could be 18 months or two years ago—the only statement by the Secretary of State for Health and Social Security, Mr. Patrick Jenkin, of which I have ever approved. That was his defence—a very forthright defence—of the National Health Service, which he made when he was in America.

What is there between we on this side of the House and, shall I say, the majority on the other side of the House? It is not that we are against the private sector. I have made it abundantly clear in your Lordships' House on many occasions that this is a matter of principle; that we Social Democrats believe in a mixed economy; that we believe that in a democracy people must have the right to choose; and if the chioce is to pay for something, they have the right to do that. What we object to is the opportunity and the position that privilege affords and that money can buy.

It is all very well for noble Lords to say,"Well, you know, the private sector does not really impinge upon the National Health Service so far as its personnel are concerned." There are about 1,220 private hospitals, clinics, and nursing homes in this country. Where would the doctors and the nurses for those establishments come from, if they were not already in existence? Is anyone suggesting that all those doctors, consultants, registrars, and nurses would otherwise be unemployed? Of course they come from the National Health Service. It may be that some of them have never in fact worked in the National Health Service, but if there had not been a private sector they would have been in National Health Service hospitals. I am not quarrelling about that; but do not let it be said that the private sector does not in point of fact take staff from the National Health Service.

The noble Lord, Lord Auckland, quoted from the Royal Commission, which stated: There is no doubt that the NHS has from time to time suffered from shortages of particular groups of staff both locally and nationally. However, bearing in mind the modest size of the private sector it is difficult to believe that such shortages were often due to NHS workers leaving for the private sector ". The Royal Commission went on to say: A number of the private hospitals we visited employed a high proportion of married women. They argued that the NHS was unable to provide sufficient opportunity for part-time employment ". But what did the Royal Commission say? It said: We did not find this argument wholly convincing …". It must be obvious to every sensible person that if there was not a private sector there would be a large number of doctors and nurses who wanted work, and they would work in the National Health Service. I do not wish to dwell on that point too much.

Let us consider the position if there is a private sector in this country. I am glad that the noble Baroness, Lady Robson of Kiddington, touched on this point, and I hope that she will forgive me if I appear to cross her"t's"and dot her"i's "; I am not trying to do that at all. The point that she made is one that I want to make—and want to make very strongly. I say to the noble Lord, Lord Hunt of Fawley, that if there is to be a private sector, let it provide everything that it needs to treat its patients. As we have been told, all the medical and nursing personnel in the private sector are trained at public expense and they receive their initial experience in the National Health Service.

That is not the only point. In addition, the private sector takes its administrators, works managers and other essential staff from among those who have trained in and worked in National Health Service hospitals. The private sector uses National Health Service facilities, but rarely pays the true cost of those facilities. The capital cost of equipment and building is rarely fully costed in the charges. Even when charges are levied on private patients who enter National Health Service hospitals, many of them leave without paying their bills; and not only do they owe the hospital, but very often they owe the fees of the consultant surgeon or consultant physician.

One of my complaints, which is shared by my friends, is that junior doctors are often expected to attend private patients when they are in National Health Service hospitals, but these doctors do not get paid for this work, nor is the time spent by them away from the National Health Service wards reimbursed to the National Health Service. The noble Baroness, Lady Robson of Kiddington, pointed out that there is no private sector source of blood for blood transfusions, and blood donors might be surprised to find that they supply blood for the private sector with no charge made by the National Health Service.

If the private sector wants to claim to provide a skilled, competent and comprehensive medical service for private patients, it really must face up to the cost of it. So far as I know, there is not a single private hospital in this country that provides an intensive care unit. Intensive care is provided, yes, but on an individual basis; there is not an intensive care unit, and often private patients who need this skilled 24-hours service in an intensive care unit have to be brought into National Health Service establishments. Of course the noble Baroness, Lady Robson of Kiddington, is right: no one would say"No"to this. But it ought to be paid for. It is paid for so far as the bed occupancy is concerned, but it is not possible to take account of all the other overhead expenses in their entirety.

I return to what I said originally: if there is to be a private sector, it really must face up to providing everything that it wants. If it cannot do that, there ought to be a definite arrangement with the National Health Service for a very substantial payment. I believe that the Royal Commission found that about £200 million is spent each year on private medical care. That is a very large figure. I should like to see part of it go as a lump sum to the National Health Service.

When speaking about private insurance schemes and private care, what are we really speaking about? That service will not help people who suffer from a chronic illness or a chronic mental or physical disability; and I think I am right in saying that if a patient requires treatment, it is available for not more than 180 days in any one year. The National Health Service does not stop at the end of 180 days. It does not stop because you have some chronic illness—and this is the difference. What I am saying is that if the private sector wants to provide medical care for people who can pay for it, then it ought to he prepared to cover the whole range and field of facilities that the National Health Service provides.

We are concerned about the whole question of pay-beds. Again, I say that if the private sector finds it necessary to use beds within the National Health Service, it ought to think about itself providing the beds. When we closed 1,000 pay-beds, we closed them because they were never used by the private sector. There was an arrangement whereby the private sector should have access to something like 4,000 beds, but in fact they were never used in their entirety. The Royal Commission calls attention to the number. I think in 1979 it was not much more than 2,000. So when we closed 1,000 beds we were not depriving anybody in the private sector of help of any kind. When the Bill to put an end to the Health Services Board goes through the other place and comes here, this Government will be doing, I believe, a great disservice to the private sector, because it was the responsibility of the Health Services Board to look at the situation in every region and to say to the Secretary of State,"Beds are needed here, and they are not needed there ".

It was a board under (if I may say so, because I believe this to be so) a very distinguished Member of your Lordships' House, Lord Wigoder, who, with two representatives of the trade union movement and two representatives of the medical profession, did a magnificent job and, I think—and I am sure your Lordships will allow him to invervene if he wants to—did it without any acrimony at all and with a good deal of goodwill. That is to go, and the discretion is to be given to the Secretary of State, who cannot possibly exercise it on his own. He has got to be advised by, not one person but a group of people; and I believe it is his intention to have a panel. Why not let the existing Health Services Board go on? What is going to be solved by sacking them (because that is what it amounts to) and putting other people in their place, when they have accumulated an enormous amount of knowledge in this field? The noble Lord, Lord Hunt, said that Nye Bevan agreed to the pay-bed principle. Nye Bevan would not have been able to get the National Health Service through the House of Commons and through Parliament generally unless he had given that undertaking. It was a question either of agreeing or of having no National Health Service; and, as a rather wise individual, he accepted that. But he did not accept it in the sense that he was happy about it.

My Lords, we are concerned about a common waiting list. I am informed that there is a kind of understanding between the private sector and the National Health Service that, in an emergency, then, of course, provision will be made for the use of the National Health Service to meet that emergency and that situation. But whichever way you look at it, it is very galling when the vast majority of people in this country know that, because the money is not available to equip the National Health Service as one would like to see it equipped, they have got to go on a long waiting list, while other people with the same complaint, with the same problem, can go into a private hospital within a few days and have it put right.

There was what I thought was a classic example reported in the newspaper quite recently. I do not know how true the report is, but it told of an elderly man who was having certain difficulties which necessitated his getting up about 12 times during the night, and who was told that only an operation could put it right but that such an operation could not be performed for at least a year. He could not wait, the report said, and so he went in as a private patient. It cost something like £700, and he sent the bill to the Secretary of State. I have not heard the result of that yet; but it is just as necessary to him, at his age, as it is to a man who can afford, as I say, to by-pass the large number of people who are waiting for similar treatment— and, you know, in a caring society that is not really the kind of situation which should exist.

But having said that, I am not against a private sector. In a democracy I think we have got to provide a choice; but I want to say to the noble Lord, Lord Hunt—and I have said it to him already—that if the private sector wants to provide a medical service it must face up to providing a comprehensive service which is entirely and completely independent of the National Health Service. If it cannot do that, I hope he will take the advice given to him by the noble Baroness, Lady Robson, and see whether there cannot be a very substantial sum—but it will have to be a very substantial sum—to compensate the National Health Service for the various services which it supplies.

4.48 p.m.

Lord CULLEN of ASHBOURNE

My Lords, it gives me a great deal of pleasure to respond to this short but stimulating debate. This is the first time in this Parliament that this House has had an opportunity for a full discussion of private medicine, and I am grateful to my noble friend Lord Hunt of Fawley for instigating this debate. I am particularly pleased with the precise form of his Motion—to call attention to the extent of co-operation between the NHS and the independent medical sector during the past 30 years, and to the potential for future co-operation. That is right: it looks both to past achievement and to the future. It also allows us to approach the subject of private medicine and its relationship with the NHS in its widest sense, not confined to the narrower issue of pay-beds. My noble friend followed his own lead with a very wide- ranging and positive speech, and other contributions have gone similarly wide.

Before I respond to some of the points made in debate and deal with some other specific issues, I should like to take my noble friend's lead and speak in very general terms about this Government's attitude to the private sector. Reference has already been made to the Health Services Bill, currently under discussion in another place, and this House will shortly have an opportunity to discuss its detailed provisions, as the noble Lord, Lord Wells-Pestell, has mentioned. I am sure this House will bear with me if I leave my response to some of the points noble Lords have made on the Bill until these forthcoming debates. What I should like to do now is to set out some of the general principles behind our approach; the context in which the detailed provisions of the Bill should be seen.

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 threatenes the concept of the NHS nor prejudices its ability to function. Indeed, for reasons I shall come to in a moment, 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. But, first, I should like to deal with that fundamental principle.

It is very simply stated. We believe that people have a right to decide to spend their own money on health care and that there is nothing morally wrong either with this or with the creation of private services to meet this demand. It seems to us fundamental that people should be free to do this. To deny anyone the freedom to seek aid outside the State-run system is to interfere in a basic liberty. I know that not everyone can afford private medicine; although I believe (and the evidence supports this) that private medical insurance, the means under which, increasingly, private medicine is obtained, is by no means limited to the so called"rich ". Indeed, it is a cause of some embarassment to certain people that that is the case. There are deep divisions in the ranks of those who formerly held that private medicine should be opposed. As I say, not everyone can afford it, but that is no reason to deny it to those who can. That brings me to my second point: that there is added reason not to deny private medicine to those who want it when it poses no threat to the State system.

In his speech, my noble friend Lord Hunt emphasised the positive contribution to health care made by the private sector. That is right. For far too long, discussion on private medicine has been bedevilled by the attitude of"them"and"us"—the private sector versus the NHS. This was an attitude which was fostered by the previous Administration; and their policy of no co-operation between the private sector and the NHS and their attempted severance of the institutional link of pay-beds between the public and private sectors attempted to put this into effect. As my noble friend has shown, this policy flew in the face of the first 30 years of the NHS.

Since its very beginning, the NHS has had power to use non-NHS facilities to provide NHS services. This includes arrangements with independent hospitals and nursing homes to provide accommodation and services for NHS patients. At present, there are about 4,000 such contractual beds in private establishments in Great Britain—mainly, but not exclusively, for the elderly and mentally-handicapped. Also over 20,000 outpatients were treated by the private sector on a contractual basis.

It is for health authorities to negotiate such contracts. We will give them every encouragement. Where the facilities are available at an economic cost and to equivalent standard, then it makes sense to use them. The Department of Health is currently discussing with representatives of the private sector how the general guidelines under which these contracts are arranged can be improved. The aim is to allow authorities and private institutions as much flexibility as possible in negotiating contracts. Private facilities are as much part of the health care resources of this country as NHS ones, and we will do all we can to encourage the NHS to use them where that makes good sense.

We hope that co-operation between the NHS and the private sector will extend beyond this: that as the private sector expands so co-operation will extend to other areas. Health authorities, through their responsibilities for the registration of private nursing homes and hospitals, are already closely involved in the early stages of private developments. We would hope that these discussions would be widened to deal with the overall planning of health facilities in a particular area. The private sector is as yet small compared with the NHS. There are only some 34,000 beds in private hospitals and nursing homes and only about 5,000 of these provide acute facilities, compared with 160,000 acute beds in the NHS. Even is the private sector were not growing, even if it always remains small relative to NHS, it is still important to ensure that the two sectors each know what the other is about. Our aim here, as throughout, is co-operation to ensure the best use of resources.

My Lords, I now turn specifically to answer the point that is sometimes raised that the existence of a private sector is harmful to the NHS. We simply do not believe that to be true. There may be areas where individual private hospitals can pose problems for local NHS hospitals —and I will deal with that in a moment—but generally we believe that the private sector adds to the total health care resources available in this country. It is a small but vital supplement to the NHS. Opponents of the private sector often speak as if the private sector was a single entity. That is not so. It is made up of a variety of bodies: hospitals and nursing homes, managed and financed in a variety of ways. Many are run on voluntary lines, others are non-profit making. They are used by a wide variety of people, from all walks of life. This is no monolithic service, used only by the rich, that is sapping the strength of the NHS. Nor is the contribution of the independent sector confined to the glamorous acute services. Some 30,000 of those private beds are for long-term care, particularly for the elderly. The private sector does not consist, as some would have us believe, of"healthcare Hiltons"catering for the rich. How would the NHS cope if all 34,000 private beds were closed down and the patients transferred to the NHS? The answer is that it could not. The NHS would be very foolish to believe that any of its problems are caused by the existence of a private sector; and I do not believe it is so foolish.

Private provision relieves the NHS. We are not forcing anyone to use it but we see no reason why we should not encourage those who wish to to make use of it. The problem for the NHS, as we all know, is one of infinite demand and all-toofinite resources. The private sector helps to close that gap. Thus, every time a person decides to opt for treatment in a private hospital, this frees the NHS facilities which they might otherwise have used. This point was made by my noble friend Lord Hunt.

Why then, if there is no threat, does the Bill propose retention of some of the powers in the 1976 Health Services Act, and, indeed, modify them in one important respect? The main changes proposed are an increase in the threshold for authorisations of developments to hospitals with 120 beds throughout as against the current position of 100 in London and 75 elsewhere. Also, the Bill proposes 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 that a number of small hospitals could jeopardise the NHS as much as a large hospital. Only if there is a proven danger of harm will the development not be authorised. We see this power only as a safeguard for the NHS—not as a control on the private sector. Thus our commitment to the NHS goes hand in hand with our support for the private sector.

One of the main points on which applications for private developments turn is the effect of a new private hospital or the NHS' ability to staff local hospitals. This takes us to the more general points already referred to in debate about staff training in the private sector. It is a common criticism of the independent hospitals that they drain staffing resources from the NHS, and put nothing back. First, on a point of principle, because a person has been trained in the public sector there is no reason why he or she should have to work there. There is no proof that those nurses and other staff who have left the NHS for the private sector would not have left the NHS anyway—for example, to go abroad, to go into industry, or to enter other jobs, and so on.

Also, many doctors work both in the NHS and privately. Allowing them to do private work may help to retain them in the NHS. If we deprive them of ability to combine private and NHS work or ban private practice, they may leave the NHS or the country. I would also refer to the nursing home side of the private sector: these homes are often run and staffed by nurses who have chosen this form of nursing and who would not want, for various reasons, to come back into the NHS. These nurses are providing a vital service which the country and the NHS would be hard put to do without.

My noble friend Lord Hunt referred to the statement made by Lord Murray that there were 8,000 nurses unemployed. In fact only about 3,500 of those are qualified nurses. The problem is that these nurses are not necessarily in the places where the many NHS vacancies exist. However, we do recognise that the Health Service does have a particular staffing problem, and I am pleased to be able to tell the House that that is accepted by the independent sector themselves. At local level, a private hospital development could cause difficulties for the staffing of adjacent NHS hospitals—especially so far as nursing staff are concerned. As I have already said, this is one of the main reasons why the Government are retaining the powers of control on the development of private hospitals. But a more positive response is that the private sector should itself try to train staff. It is right that the private sector should make a positive contribution to the training of staff, a view which is shared by many within the private sector, and by several speakers this evening.

There is already a fair amount of training and education, mainly for nurses, carried out in private hospitals. Basic nurse training courses approved by the General Nursing Council are provided at such hospitals as the Royal Masonic Hospital; St. Andrew's, Northampton; Cheadle Royal Hospital; and King Edward VII Hospital, Midhurst. In addition to those formal courses, the independent sector provides a range of in-service and developmental training for nurses. The independent sector are considering, in consultation with appropriate bodies, ways in which their contribution to staff training might be developed further.

I have concentrated mainly on the private sector and its relationship with the NHS. I should now like to turn to that narrower issue to which I referred earlier: the issue of pay-beds. We will of course be discussing this when we consider the Health Services Bill but I should like to say a few words now. The Government believe that the policy of phasing pay-beds out of the NHS was wholly misconceived. It was of no benefit to the NHS; and the Bill, if passed in its present form, will end compulsory phasing out and allow the Secretary of State to authorise new pay-beds.

What of the arguments—often heard—that the existence of pay-beds in NHS hospital prejudices the treatment of other NHS patients? In his speech, my noble friend Lord Hunt mentioned one of the main criticisms—that pay-beds enable those who can pay to"jump the queue ". I should like to add something on this. We are committed to allowing private patient use of NHS facilities and to protecting the interests of the NHS: the two are not incompatible. We are convinced that private practice can be encouraged within the NHS without interfering with the provision of services to NHS patients. Just as our proposals on the retention of powers of control of private sector developments are designed to safeguard the interests of the NHS while allowing the private sector freedom to develop, so the proposed arrangements for private practice in NHS balance the two interests.

There are two parts to this: one statutory, one non-statutory. The statutory safeguard is that the Bill retains the legislative provision that pay-beds will only be authorised where this does not prejudice NHS services. The non-statutory safeguard lies in the agreement which my right honourable friend has reached with the medical profession on six principles about the arrangements for private practice in the NHS.

I think this House will find it useful if I state these important principles in full. They are: first, that the provision of accommodation and services for private patients should not significantly prejudice non-paying patients. Secondly, subject to clinical considerations, earlier private consultation should not lead to earlier NHS admission or to earlier access to NHS diagnostic procedures. Thirdly, common waiting lists should be used for urgent and seriously ill patients, as at present, and for highly specialised diagnosis and treatment. The same criteria should be used for categorising paying and non-paying patients. This principle extends common waiting lists to patients needing special diagnosis and treatment.

Fourthly, after admission, access by all patients to diagnostic and treatment facilities should be governed by clinical considerations. This principle does not exclude earlier access by private patients to facilities especially arranged for them if these are provided without prejudice to NHS patients and without extra expense to the NHS. Fifthly, standards of clinical care and services provided by the hospital should be the same for all patients. This principle does not affect the provision on separate payment of extra amenities nor the practice of the day-to-day care of private patients usually being undertaken by the consultant engaged by them. Lastly, single rooms should not be held vacant for potential private use longer than the usual time between NHS patient admissions.

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 and is a product of co-operation and negotiation.

My noble friend, Lord Hunt referred in passing to the fact that no one is compelled to work on private patients if they do not want to. While this is certainly true, in the sense that no one is compelled to work in the private sector, I feel it is important to make sure that our view on this, as it affects NHS staff involved with private patients in pay beds, is quite clear. Our view is that, where pay-beds exist in the NHS, then all staff are expected to treat or look after those private patients in the same way as they treat any other patients. Once it is decided that there should be pay-beds in a particular hospital then that becomes a service provided by that hospital and its staff. This is something we can no doubt deal with in more detail when we discuss the Bill.

I should like to end by endorsing a small but important point which was raised by my noble friend Lord Hunt. I am glad to tell him that three of the main representative groups of the private sector—the Independent Hospital Group, the Association of Independent Hospitals and the Registered Nursing Homes Association—have formed a Joint Liaison Committee. This is of inestimable value to Government. It helps liaison with the DHSS. We are not looking for a single voice from the private sector—they have many and varied interests—but I fully support my noble friend, Lord Hunt, when he says that cohesion is needed in the private sector in representing itself to Government. This is vital if we are to be able fully to discuss the role of the private sector in health care. With such co-operation, I believe we can heal the rift caused by the policies of the previous Government.

I conclude by saying that we are corn-mined to the NHS but we are also committed to health care as a whole, and in that the private sector has a role which should be recognised and fostered. In conclusion, I wonder whether the philosophy of the Government could have been better put than it was by the noble Lord, Lord Smith. Such wise words from the Cross-Benches were, I believe, welcomed on all sides of your Lordships' House. It is perhaps not realised by many people that of the 1,150 or so Members of your Lordships' House, there are now 212 Cross-Bench Peers. What better forum than your Lordships' House could there be for debates on subjects which relate to the health of all our countrymen, and what better example of this than the words of the noble Lord, Lord Smith?

5.10 p.m.

Lord HUNT of FAWLEY

My Lords, I should like to thank the noble Lord, Lord Segal, for his kind words from the other side of the House. I agree with him about inflationary factors raising the cost of the private sector, but that also applies to the National Health Service in everything it does. There are still some generous private benefactions coming in. In, I think, today's paper, it is reported that £600,000 has been given by two donors to the Papworth Hospital to encourage their open heart surgery, and that is very generous indeed.

I thank the noble Lord, Lord Smith, for his support. He stressed the need for medical care of a very high standard in both sectors and I am sure that he is right. I am glad that the noble Lord, Lord Auckland, spoke largely in favour of co-operation, which is what the whole of my speech was about. I was also very glad to hear him say that the shortage of nurses in some parts of Britain is not, in his opinion, due to the work of the private sector. I must thank the noble Baroness, Lady Masham, for the very good example that she gave of most excellent cooperation.

I am sorry that the noble Baroness, Lady Robson, could not be here for the first part of my speech, but I hope that she will read the report of it. I was pleased to hear her encouraging words about the need for co-operation. I am sure she is right that everyone should help to boost the morale of all those working in the National Health Service. Her mention of the Blood Transfusion Service was very close to my heart. I had a patient the other day who was bleeding very badly. I rang up a private hospital, but they had no blood and could not get it. I sent the patient to a large National Health Service hospital which gave a transfusion right away and in a few days gave 20 pints. I quite agree with the noble Baroness that the private sector should pay something or should help towards collecting blood when this is in short supply.

I think that the noble Lord, Lord WellsPestell, misunderstood some of the points I made. I had no intention of saying that the NHS was"dying on its feet ". I never thought that, and I do not think I said it. But the NHS certainly needs some help, and the private sector can give some of that. In my maiden speech in 1974, I said that the National Health Service was one of the finest conceptions that has ever come out of this country and I wanted to help it in any way I could. The noble Lord said that the private sector should produce everything it needs, but it must be remembered that everyone in it also belongs to the National Health Service, and while they do that they are entitled to some of its benefits. What he said about intensive care units was, I think, wrong. The best intensive care unit in Britain is in a private hospital—the Wellington—and, very shortly, nurses are to be taught in that unit. The Harley Street Clinic also has a very good intensive care unit. Certainly, all that the noble Lord, Lord Wells-Pestell, said supports my contention that more co-operation is needed between the National Health Service and the private sector.

In winding up this debate, I shall say little more, except to thank all those who have taken part. As your Lordships have already heard, several of the points which have been raised will be discussed in detail when we debate the Health Service Bill in a few weeks' time. All I want to do now is to beg leave to withdraw my motion for Papers.

Motion for Papers, by leave, withdrawn.