Lords Sitting of 10 March 1982

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

Tributes to the late Lord Butler of Saffron Walden
The Chancellor of the Duchy of Lancaster (Baroness Young): My Lords, it is my sad duty as Leader of the House to pay tribute to the noble Lord, Lord Butler of Saffron Walden, who, as the House will know, died on Monday. It is fitting that a tribute will also be paid this afternoon in another place by my right honourable friend the Prime Minister, because the noble Lord's greatest public achievements took place between 1929 and 1965, during which time he was a most distinguished Member of another place.
It is no exaggeration to say that the noble Lord had one of the most outstanding records of service to his country and to his party this century. He was a Minister of the Crown for no less than 27 years—in itself a remarkable record. As so many have said in tributes over the last day or so, he was in every sense of the word a great and accomplished statesman. We recall his early achievements in the pre-war Government in the India Office and in the Foreign Office. From 1941 until the general election in 1945, Lord Butler was President of the Board of Education. Many of your Lordships will still link the 1944 Act directly with his name and I, and I know many others, regard that Education Act as one of the great and fundamental reform measures of recent times. Nearly 40 years later it still remains the basis of our system of education.
After the war the noble Lord, Lord Butler, built up the Conservative Research Department and in so doing he laid the foundations for the return of a Conservative Government in 1951: as a vice-chairman of the Conservative Party, I should particularly like to pay tribute to this aspect of his work. Between 1951 and 1964 he served as Chancellor of the Exchequer, as Home Secretary and as Foreign Secretary. He became one of the finest politicians of his generation.
The noble Lord came to your Lordships' House in 1965 and I know that there are many of your Lordships who will remember him in this House with great affection. He became a most distinguished Master of Trinity College Cambridge, but he still found time to come to the House to give us the benefit of many fine and memorable speeches on the great issues of the day. We all recognise the truth about politics revealed in the title of his autobiography, The Art of the Possible. I am sure that the whole House will wish to join me today in expressing our sense of loss and our sympathy to his wife and family.
Lord Peart: My Lords, I should like to add a tribute from these Benches. Lord Butler was one of the outstanding statesmen of his day. He was a consummate
196
politician but he was also highly regarded as an academic. He had a distinguished university career at Cambridge before entering politics, to which, indeed, he returned in 1964. He held every great political office except that of Prime Minister. But, most important, and what he will surely always be remembered for, particularly in the Labour movement, was the Education Act 1944—an Act that had the all-party support of the war-time coalition Government. It remains one of the most important and far-reaching reform measures of this century and one that has stood up to the test of very changing circumstances in the last 40 years.
The noble Lord was pleased to tell how he insisted on the word "comprehensive" being included in the Bill, and we in this House also well remember when he stood up for this Act during the passage of the Education Act 1980. When the clause dealing with transport was reached in Committee, he made a powerful speech and your Lordships rallied to him. He will always be remembered for his wit, his compassion and his contribution to art and learning.
Lord Byers: My Lords, we on these Benches would wish to be associated in full with the tributes just paid by the Leader of the House and by the noble Lord, Lord Peart. I count it as my good fortune that I served in the other place in the 1945 Parliament with politicians and statesmen of stature from all parties, of whom Rab Butler was an outstanding example. It was a fine Parliament and he shouldered a heavy workload in leading for the Opposition in many of the major debates of that exacting period of radical reforms. Before that, he had many achievements in his career—pre-war on the India Bill; as an influential proponent of speedier re-armament; as has been mentioned, the 1944 Education Bill; and for the next 20 years he was deeply immersed in practically all the major measures and important political issues as a leading member of the Government or the Opposition. Indeed, he did have a remarkable political record. At all times he was charming and courteous and he was often mischievous. Those who knew him will never forget that inimitable chortle and the glint of fun in his eyes. I wish that we could have seen and heard more of him in this House, but whenever he did come it was to very good purpose indeed.
My Lords, we send our sincere condolences to Lady Butler, with whom my colleagues and I on these Benches have for so long felt that we have shared a common political philosophy.
Lord Kennet: My Lords, in the absence of my noble friend, I wish to associate the Social Democrat Peers with what has been said. We salute in Lord Butler not only the founder of our education system, but also the master par excellence of the possible and a man who left half his name, along with half that of a most respected leader of the Labour Party, to an "ism" which is perhaps no more than a synonym for practical moderation. His characteristic and deceptively low-key sayings again and again threw light on reality, not only to those engaged in politics but also to the people at large, and there are few greater services that a politician can render than that.
Lord Caccia: My Lords, no one on these Benches can normally speak for others who sit there, but on this occasion I am confident that they would wish to be associated with what has already been said about Lord Butler of Saffron Walden. This perhaps especially as, of course, constitutionally in the other place they can have no voice. Even so, I speak with all due diffidence, for although I was one of a number of Permanent Secretaries who served him as their Minister, my direct experience was relatively short-lived, as his period of office as Secretary of State for Foreign Affairs was only to last barely a year between 1963 and 1964.
Characteristically, he made it plain when I first went to see him that he thought that it would be inappropriate for him to seek to adopt any new attitude or strike out on any new line of policy in the remaining months before a general election. He had, rather, decided to continue generally on course. As usual in foreign affairs, the going was sometimes bumpy. It was reassuring that he brought to his department a sense of calm in apparent crisis and a hunch, as Sir Edward Grey had remarked before him when Foreign Secretary, that things were rarely so good or so bad as when first reported.
Further, through his experience of administration and Government he did in his year of office put through the first reform of the terms of service of the Diplomatic Service since the Eden-Bevin reforms of the 1940s. In short, and to the great gain of that service, he was one of those Secretaries of State who showed in action that he cared for the good order and morale of those in his charge. It was yet another example of what has already been said of his eye for doing what was possible in the time available.
Within a year, in 1965, he had become the head of one of the greatest colleges in Cambridge, and I was then Provost of Eton. There, in education, I gained some means of knowing at first hand what the Butler Act of 1944 had achieved in the 20 odd years since its enactment. As has been said, this Act may well be judged as the single and most important contribution among many that he made to the history of our times. He it was who, by patience and persuasion, was able, with his Labour colleague, Chuter Ede, to get on to the statute book a measure agreed, as the noble Lord the Leader of the Opposition has just said, between parties and by religious denominations—an achievement that had eluded us between the wars.
With less diffidence yet with fitting deference, may I also speak on a personal note. I had got to know Rab, as he wished and expected his friends to call him, in his earlier pre-war days as Under-Secretary of State in the Foreign Office. That friendship continued unbroken in and out of office, as president of Trinity and thereafter. Here at home he was a lucky man, for no one should rightly regard him
"as an island entire of itself".
His first wife, Sydney, provided him, among much else, with the firm base, with the thrust and impetus which fortified him during the earlier part of his career and until her tragic, fatal illness, so courageously borne. Then he had the fortune to marry as his second wife someone who successfully surrounded him with charm and warmth, with unaffected devotion and admiration during his later years. I am sure that all who knew
198
him—and not only on these Benches—would want their sympathy and prayers to go to Lady Butler. May she, as Homer put it:
"be smiling through her tears",
when she brings back to memory the happy days she did so much to create.
Noble Lords: Hear, hear!
The Lord Bishop of Lincoln: My Lords, with all brevity, may I say with what respect and gratitude Lord Butler's work was always viewed by all the Churches in this land. Obviously, I think particularly of the Education Act. It was his gifts which turned what might have been a mere compromise into the very remarkable dual system which we still have today. Lord Butler's understanding of religion as well as of education was wide as well as deep. He was deeply concerned with the education of the disabled, the less able as well as the high fliers, and he extended education into adulthood. On the basis of those insights, I think that the Churches very much hope to play their due part in shaping the education service for the multi-faith and multi-racial community of the future, and in so doing we shall be following his spirit.
I remember asking him to come and preach at Coventry when I was there some years ago. I shall always remember his reply to my letter. He said:
"I should love to come, but I do not preach very well because I always wait for applause which I do not get".
He did come and he did preach, and his sermon was splendid.
Lord Boyd-Carpenter: My Lords, as one who had the privilege of serving under Lord Butler as Financial Secretary during the epic first three years of his term as Chancellor of the Exchequer, may I add just a few words about my old chief. Some of your Lordships will remember that Winston Churchill entrusted the whole management of the finance and economy of this country to Rab Butler, and, although Rab had not had any previous experience in an economic department, he took an immediate and effective grip on the Treasury. It was a wonderful experience to see his handling of that department, containing, as it did then and does now, the élite of the public service and the complete mastery of the intricacies of macroeconomics, which he so rapidly acquired and which enabled him to handle a very grave economic crisis with conspicuous success.
I have always thought that his public service during those years has never been fully understood or appreciated, and yet he effected a turn-round in our national economy which had beneficial effects for very many years to come. It was a wonderful experience to serve under him; to hear what the noble Lord, Lord Byers, so well called his mischievous humour, his always assumed cynicism, and his profound skill in the management of men. I join with others in expressing our deepest sympathy to Lady Butler of Saffron Walden, whose care of Rab during all these recent years has been so marvellous. Our hearts go out to her. All of us who have worked with him are left with a profound feeling of gratitude to him not only for what he did for his country but for what he did for us.
Lord Paget of Northampton: My Lords, may I add just one word from these Back-Benches from one who was not alone here in regarding Rab as a dear friend. Nobody did so much as he did to civilise the vast transition in our social order which took place between the beginning and the end of the war. It was his influence that made that transition civilised and affectionate. I can assure your Lordships that love for him was not confined to his own party.
Baroness Trumpington: My Lords, as another ordinary Back-Bencher, a friend, and one who had the privilege of having Lord Butler as one of my two supporters at my Introduction to your Lordships' House, I should like to express my deepest sympathy to Lord Butler's widow and children. I would add that for several centuries the Butler family have served the City and University of Cambridge with great distinction. Lord Butler in his capacity as Master of Trinity College, High Steward of Cambridge University from 1958 to 1966, and as High Steward of the City of Cambridge from 1963 until his death, added his own particular brand of lustre to that tradition. I feel sure I echo the feelings of Cambridge people when I say that we shall not see his like again.
The Lord Chancellor (Lord Hailsham of Saint Marylebone): My Lords, I hope I shall not be thought impertinent if I add a word of my own to the tributes which have been paid to the late Lord Butler. From the moment when I first entered another place in 1938 until his death two days ago, he and I were colleagues in one House of Parliament or the other, and members of the same party, and I like to think close friends. When I first arrived I can remember the Under-Secretary for Foreign Affairs fielding with almost incredible agility that terribly difficult series of Foreign Office questions which took place in the aftermath of the Spanish Civil War and in the run-up to the Second World War.
When I got back from the Middle East there was Rab entering into the negotiations for the Education Bill, which has been referred to so often and is perhaps his most enduring monument. I think it is now difficult to recall, and perhaps many people do not recall, the welter of apparently irreconcilable opinions with which the education world was then afflicted, and the incredible mastery and diplomacy with which Rab Butler was able to create not a compromise but a permanent structure.
When the party to which I belong suffered that landslide defeat in 1945, there was Rab in the Conservative research department laying the foundations of what subsequently turned out to be the post-war Conservative Party. I know that I speak not only for my own party when I say that the continuance of more than one powerful party in the state, the unofficial part of our constitution without which the more formal structures would not work at all, is one of the bastions, foundations, of our liberty; and Rab did that. Then followed the 13 years of distinguished service in the very highest offices of state one after another, all of which he brilliantly performed.
My Lords, that is only a part of the matter. There is something else that I would like to add. There was a school of thought—perhaps there still is—on both sides in politics that Rab was in some ways too irenic
200
towards his opponents. That was the foundation of the word which was referred to from the Social Democratic Benches. I never shared that view. I believe he was acting as a Christian statesman should act by treating, even under the conditions of democratic polemics, his opponents as he would wish to be treated himself. I should like to say, in that connection, that in Hugh Gaitskell, whose premature and tragic death was mourned outside the ranks of his own party, he found somebody who treated him in the same way. I have never thought that English life in politics can be long protected without mutual behaviour of that kind.
Several times when he was Master of Trinity I visited him there. His understanding of, and love for, the young was so noticeable. And so we remember him today and his widow with affection and with regret at his passing. We think of the man: his love of the countryside and of country people; his patriotism and, for me, always the extraordinary intellectual power and equipment which he brought to public affairs. Like others, I shall remember that roguish sense of humour which showed that in all the great affairs with which he was concerned he took neither himself nor his colleagues, nor the vanities of this wicked world, too seriously. God rest his soul, and light perpetual shine upon him!

Fires in Penal Institutions
2.58 p.m.
Baroness Masham of Ilton: My Lords, I beg leave to ask the Question which stands in my name on the Order Paper.
The Question was as follows:
To ask Her Majesty's Government how many prisoners and staff have been injured by fires in penal institutions during the last five years.
The Parliamentary Under-Secretary of State, Home Office (Lord Belstead): My Lords, our records for the years from 1977 to 1981 show that 66 prisoners and 10 staff suffered cuts, burns or other injuries as a result of cell fires. We do not have information collected centrally about injuries resulting from other fires.
Baroness Masham of Ilton: My Lords, while thanking the Minister for his reply, may I ask him whether he is aware that one of the main dangers is toxic fumes from the smoke from mattresses which are now used in our prisons and other penal establishments, and whether the Government are considering supplying other mattresses and giving breathing equipment to prison staff?
Lord Belstead: My Lords, we are now testing five different types of mattress to find one which is more resistant to fire than polyurethane foam mattresses and one which, if ignited, will give off less toxic fumes. So far as breathing equipment is concerned, we are also testing two types of smoke protection hoods in four different establishments. These hoods would not be used for fighting fires but for rescuing a prisoner from a smoke-filled cell.
Lord Boston of Faversham: My Lords, can the Minister say whether the number of fires has been increasing in recent years? Can he give any indication of the proportion of fires which appear to have been started deliberately? And is he satisfied that everything possible is being done by way both of the adequacy of supervision staff and of precautions?
Lord Belstead: My Lords, the number of fires has, broadly speaking, been increasing. I cannot, I am afraid, give the noble Lord figures of the numbers which have been started deliberately. As for precautions, I replied to the noble Baroness about the tests being carried out now on mattresses, because we believe that they are the main cause of fire in prisons, or, rather, the main hazard of fire in prisons arises from them.
Baroness Masham of Ilton: My Lords, would it be a good idea if the prisoners themselves made some of their new mattresses, so giving them employment and saving them being shut up in their cells for 23 hours a day?
Lord Belstead: My Lords, the mattresses which are now being tested are the products of firms which have developed them themselves. They would, I have no doubt, wish to secure the contract, if there is to be a contract, and we should have to look at the noble Baroness's suggestion in that light.

Local Authority Services and Private Contractors
3.2 p.m.
Lord Orr-Ewing: My Lords, I beg leave to ask the Question standing in the name of my noble friend Lady Gardner of Parkes on the Order Paper.
The Question was as follows:
To ask Her Majesty's Government how many local authorities in the United Kingdom have put any of their services out to private contractors.
The Parliamentary Under-Secretary of State, Department of the Environment (Lord Bellwin): My Lords, I regret that comprehensive information on the number of local authorities that have employed private contractors to provide their services is not collected centrally at the present time. Nevertheless, I can say that the extent to which authorities are considering and taking up this option has increased significantly and is continuing to do so.
Lord Orr-Ewing: My Lords, does this extension of the private sector, in order to save money and achieve higher efficiency, extend not only to refuse collection but, for example, to catering and cleaning services? Would my noble friend agree that we should have the opportunity of judging the effectiveness of this move by auditing in order to show that there are real financial savings and improved services as a result of this application?
Lord Bellwin: The options are open, my Lords. There should be no service which is not compared so as to see what the private sector can provide by way
202
of competitive value for money. Thus, the two suggestions which my noble friend makes are certainly valid, but there are very many more. As to the role of the district auditor, in future, under the 1980 Act, the auditor will be much more involved than in the past in looking at value-for-money possibilities within local authority accounts. It may well be that all authorities will want to know what are the possibilities of perhaps obtaining greater value for money than with their own in-house labour.
Baroness Birk: My Lords, would the Minister agree that putting services out to private contractors does not necessarily promote efficiency or result in direct savings? Is he aware that, by winding down the sub-units of road construction units and using independent consultants rather than direct labour, the extra cost is estimated at £13 million up to the end of 1983, though it may be much more, and that new construction and improvements to roads have had to be cut by at least £13 million?
Lord Bellwin: My Lords, I do not know the instance to which the noble Baroness refers. However, I cannot get away from the basic premise that it cannot be wrong to obtain competitive tenders for anything. I should have thought that any local authority which is really concerned about value for money would always want—and many of them are now doing it—to obtain tenders from whatever source, and, should it prove that they are not as competitive as their own workforce, then that is fine, but at least everybody should want to know.
Lord Harmar-Nicholls: My Lords, is my noble friend aware that many people will be surprised and disappointed to learn that central Government are not collecting evidence on this issue and are not sorting out whether it is good or bad? Is he further aware that the point made by the noble Baroness, Lady Birk, should be confirmed or denied by the facts, facts which would be available if central Government took the trouble to get all the evidence collated?
Lord Bellwin: My Lords, we are in many ways in relatively early days on this matter. There is now such a significant movement in this direction that to attempt to compile statistics at this time might be self-defeating. Nevertheless, the point made by my noble friend is absolutely correct basically, and I assure him that we shall continue to watch matters very carefully. I can tell him, for example, that in the case of one service alone, I know of more than 100 authorities which are at present looking into the possibility of provision by the private sector. That indicates the extent to which the trend is growing, but I certainly take the basic thrust of what my noble friend said.
Lord Shinwell: My Lords, if the Minister is satisfied that a great deal of money can be saved by transferring the collection of refuse from local authorities to private contractors, may I ask him why he is confining it to the removal of refuse? Why not ask private contractors to undertake all the functions of local authorities and then abolish the local authorities? Consider the amount of money we should then save.
Lord Bellwin: My Lords, I was not aware that I had suggested that the removal of refuse was the only service. On the contrary, I suggested that all services should be looked at. If, however, as the noble Lord, Lord Shinwell, suggests, it should prove to be the case that all services can more competitively be provided by the private sector, then what greater incentive could there be for an authority, which is responsible for giving to its electorate that for which it was elected in the first place—namely, a proper level of service provided at a proper and most advantageous level of cost?
Lord Boardman: My Lords, can my noble friend confirm that, in those cases where facts and figures have been published, such as in the case of Southend's refuse collection, it has been shown quite clearly that this has benefited the ratepayers both in the level of costs and the standards of service?
Lord Bellwin: My Lords, from all the information available to me, I gladly so confirm, and I am glad my noble friend referred not just to the level of savings, substantial though they are, but also to the standards of service, because that, too, is a very important factor.
Lord Davies of Leek: My Lords, is the Minister aware that we are all concerned with seeing that value for money is obtained? Is he further aware that over the years we have set up between local authorities, local hospitals and all kinds of organisations dealing in radioactive material a system for getting rid of effluent and burying radioactive material so that the public shall not be damaged thereby? Will he ensure that, in the aim to get value for money, that aim is not measured without taking into account the serious responsibility undertaken by any private contractor who gathers refuse from the public for local authorities?
Lord Bellwin: My Lords, the noble Lord is referring to the subject of waste disposal, and I know he is aware that the private sector has worked together with the public sector for many years in providing that service, and of course the basic point he makes is absolutely right.
Lord Kaldor: My Lords, would the Minister agree that it is difficult to conceive how, in respect of certain vital services—street lighting, for example—the private sector rather than the public sector could provide it?
Lord Bellwin: My Lords, not at any time, despite my answer to the noble Lord, Lord Shinwell, would I say that every aspect of every service necessarily lends itself to the involvement of the private sector. It is a matter, as always, of common sense in deciding what is the right thing to do. But, then, unfortunately we do not always get that prevailing, do we?
Lord Bruce of Donington: My Lords, further to the point raised by the noble Lord, Lord Harmar-Nicholls, concerning the necessity for the collection by the Government of statistics relating to the relative performances of private contractors in various fields, may I ask the Minister to take steps to ensure that the information is not only collected but is also made public?
Lord Bellwin: My Lords, as I am sure the noble Lord, Lord Bruce of Donington, well knows, such information as we have is always available to anyone who requests it. I consider that in this particular case the answer I gave was a fair one; namely, that it is a moving situation and that the statistics that are required I do not have. Nevertheless, I would gladly make available to the noble Lord or to anyone else at any time such information as we do have.
Lord Orr-Ewing: My Lords, will my noble friend bear in mind that from both sides of the House there has now been a request for a measure of the comparative cost effectiveness of the different services? After the new auditing arrangements have come into force will my noble friend consider collecting and collating comparative statistics, so that we can measure what is good, what is moderate, and what is bad in this area?
Lord Bellwin: My Lords, I would commend your Lordships to read the recent survey carried out by Coopers and Lybrand for our department on service provision and pricing in local government. It is an extremely informative, arguably the most informative, publication on this whole subject, and could well be read with advantage by all who are interested.
Lord Glenamara: My Lords, will the noble Lord bear in mind that many of us would have no ideological objection to such arrangements, but what we would object to would be the removal or weakening of democratic control of the provision, supervision and monitoring of local services? If this movement gains pace, will the noble Lord see to it that democratic control is not weakened in any way?
Lord Bellwin: My Lords, the noble Lord is absolutely right. In no way should that control be weakened. In any case statutory obligations rest with the local authorities to ensure that the services are carried out; the end responsibility is still theirs. However, there is no reason why carrying out a service through the channel that we have been discussing need in any way be to the detriment of local authorities.

Social Security Benefits Uprating
3.12 p.m.
Lord Denham: My Lords, my right honourable friend the Secretary of State for Social Services will be making a Statement in another place this afternoon on social security benefits. In view of the length of the list of speakers for the debate this afternoon, and the length and complexity of the Statement, it has been agreed through the usual channels that, with the leave of the House. I should on this occasion arrange for the Statement to be made to your Lordships' House by inclusion in the Official Report. I will also arrange for copies to be available in the Library.
Following is the Statement referred to above:
"I with permission, Mr. Speaker, make a Statement required by the Social Security Act 1975 about the annual up-rating of social security benefits which will come into operation in the week beginning 22nd November. For the convenience of the House a detailed schedule of the new rates of benefits, which forms part of this Statement, has been placed in the Vote Office

205
and will be included in the Official Report. The new rates reflect the estimate that the general level of prices will increase by 9 per cent. between November 1981 and November 1982. Benefits generally will be uprated in line with that forecast and in addition the 2 per cent. shortfall at the 1981 uprating will be made good—not only for pensions and other related long-term benefits, as we had already promised, but also for all other weekly benefits. This gives a total increase for most benefits of 11 per cent.
"Turning, first, to the uprating of national insurance benefits the standard rate of basic retirement pension for a single person will go up by £3·25 a week from £29·60 to £32·85. The rate for a married couple will go up by £5·20 from £47·35 to £52·55. The standard rate of sickness benefit and unemployment benefit will go up by £2·50 for a single person from £22·50 to £25·00, and by £4·5 from £36·40 to £40·45 for a married couple.
"The same percentage increase of 11 per cent. will apply to the earnings-related additional component to national insurance pensions; to pensions payable under the old graduated pension scheme; to those who receive guaranteed minimum pensions from contracted-out occupational pension schemes; and to public service pensions. It will also apply to all other weekly national insurance benefits, including industrial injuries benefits, and to war pensions.
"Child benefit will also be increased by over 11 per cent. from £5·25 to £5·85, an increase of 60p per qualifying child. One-parent benefit will go up by the same percentage from £3·30 a week to £3·65. So a one-parent family with two children not in receipt of any other social security benefits will find the amount paid for the children rising from £13·80 a week to 15·35.
"After taking the increases in child benefit into account, as has been the practice in previous years, the dependency additions for children paid with short-term national insurance benefits will he 30p a child, compared with 80p at present. The child dependency additions payable with retirement, widow's or invalidity pensions will increase from £7·70 a child to £7·95.
"Family income supplement is payable to people in work where tile family's gross income. apart from child benefit and one-parent benefit, falls short of a prescribed level. The prescribed level of income for family income supplement will go up by £8·50 to £82·50 weekly for one-child families and the additional amount for each further child will he raised from £8·00 to £9·00 a week. The maximum payment for a one-child family will rise from £18·50 to £21·00 a week, and the addition for each further child will go up by 50p to £2·00. This means that the increases will be particularly helpful to larger families with the lowest incomes.
"I turn now to supplementary benefit. As the House will be aware from the proceedings last week in the Committee stage of the Social Security and Housing Benefits Bill, we propose to increase the scale rates of supplementary benefit from next November in line with the forecast increases in the general level of prices, after excluding housing costs. This is because both under the present scheme, and when housing benefit is introduced, the housing costs of supplementary benefit claimants are met separately. Supplementary benefit is different in this respect from all other benefits. The treatment of housing costs distinguishes those costs from all other day-to-day living expenses that are covered by the supplementary benefit scale rate. The Government's approach recognises this, and—in effect—avoids double-counting while maintaining full price-protection for all claimants. In addition, as with other benefits, we will he making good the 2 per cent. shortfall. The effect of this will be that the increase in the scale rates will be 10·5 per cent., but housing costs will of course be paid on top of that.
"The ordinary supplementary benefit scale rate will therefore rise from £23·25 to £25·70 for a single householder and from £37·75 to £41·70 for a married couple. The long-term scale rate will rise from £29·60 to £32·70 for a single householder and from £47·35 to £52·30 for a couple. The scale rates for children will rise from £7·90 to £8·75 for children aged 10 and under, and from £11·90 to £13·15 for children aged 11 to 15.
"There has been a great deal of concern about the effects of the capital limit for supplementary benefit. This is the limit on the amount of capital a person can have and still get supplementary benefit. It has been argued that the current limit of £2,000 set in November 1980 is now too low. The Government recognise the force of the argument and proposes to raise the limit by 25 per cent. to £2,500. This will fully restore the value the limit held when it was introduced.
"We also propose a further small, but worthwhile, improvement in the supplementary benefit scheme. We are increasing
206
the amount of occasional payments by way of a gift, for example, at Christmas or for a birthday, which can be disregarded. At present any excess over £20 is deducted from benefit. We propose to increase the amount that can be totally disregarded to £100.
"Supplementary benefit heating additions are now paid to over 2 million families. In 1980 we boosted them with a record increase. The 1981 uprating turned out to be more than enough fully to protect this increase against rising fuel costs. For 1982 we propose to increase the heating additions from this higher base in line with the expected rise in fuel prices between November 1981 and November 1982. The standard amount will rise from £1·65 to £1·90 a week, and the higher rate from £4·05 to £4·65.
"As the Chancellor announced yesterday, mobility allowance will no longer be subject to tax. I am sure the whole House will welcome that change, which will benefit some 40,000 recipients who have other taxable income. In addition, the rate of mobility allowance will be increased in November from £16·50 to £18·30. This means that since coming to office we have increased the rate of mobility allowance by 83 per cent. These measures will help even more disabled people to take advantage of the Motability scheme for leasing or buying cars on advantageous terms.
"I have also decided to make an improvement in the rules affecting invalid care allowance. The weekly amount which can be earned by someone who is looking after a severely disabled person will be increased from £6·00 to £12·00. The disregard has been £6·00 since the benefit was introduced in 1976 and the increase will restore its original value.
"A further improvement affects the therapeutic earnings limit, which helps people recovering from illness who want to get back into full-time work. The present earnings limit is £16·50. I intend to raise this by 21 per cent. to £20. The Christmas bonus of £10 will be paid on the same basis as last year in the week commencing 29th November. I also propose to increase the earnings rule limit for retirement pensioners in November from £52·00 to £57·00, the first such increase in three years.
"The total cost of this uprating will he close to £3 billion in a full year, of which about £2 billion will fall on the National Insurance Fund, the balance coming out of the Consolidated Fund. The House has already approved the changes in contribution levels in 1982–83 set out in the Social Security (Contributions) Act 1982, and I shall as usual further review contribution rates in the autumn. Any necessary changes will take effect from April 1983.
"These proposals mean that annual expenditure on social security benefits will rise to over £30 billion in 1982–3, which represents about 26 per cent. of all public spending. The changes I have announced mean:

full price protection of all weekly benefits;

the 2 per cent. shortfall in 1981 made good for all benefits;

the supplementary benefit capital limit increased to £2,500;

supplementary benefit heating additions protected against rising fuel costs;

the retirement pension earnings rule increased for the first time in three years;

mobility allowance taken out of tax and fully price-protected;

a doubling of the earnings disregard for those receiving invalid care allowance;

an increase of more than 20 per cent. in the therapeutic earnings limit for those receiving incapacity benefits.

"The measures will particularly benefit the elderly and disabled people. They will also give valuable extra help to all families with children. They are designed to bring practical help to those who most need it."
INCREASED BENEFIT RATES
(The Social Security Act 1975, as amended, is referred to as "the Act"; the Social Security Pensions Act 1975, as amended, is referred to as "the Pensions Act").

PART 1 BENEFITS PAYABLE FROM NATIONAL INSURANCE FUND (See also Parts 3 and 4)

Existing weekly rate £

Proposed weekly weekly rate £

Basic component of Category A retirement pension* (section 6(1)(a) of the Pensions Act), Category B retirement pension* (section 7 of the Pensions Act), widowed mother's allowance and widow's pension

29·60

32·85

Existing weekly rate £

Proposed weekly rate £

Category B retirement pension* (section29(7)(a)(i) of the Act)

17·75

19·70

Basic component of invalidity pension

28·35

31·45

Standard rate of unemployment and sickness benefit

Beneficiary under pension age

22·50

25·00

Beneficiary over pension age

28·35

31·45

Invalidity allowance:

Higher rate

6·20

6·90

Middle rate

4·00

4·40

Lower rate

2·00

2·20

Maternity allowance

22·50

25·00

Widow's allowance

41·40

45·95

Child's special allowance

7·70

7·95

Guardian's allowance

7·70

7·95

The weekly rate of graduated retirement benefit payable for each unit of graduated contributions will be increased by 11 per cent. from 3·86 pence to 4·28 pence.
The following sums will be increased by 11 per cent.:—

(a) additional components in the rates of long-term benefits calculated by reference to any final relevant year earlier than the tax year 1982–83;

(b) increases of retirement pensions for deferred retirement under Schedule 1 to the Pensions Act;

(c) increases of graduated retirement benefit for deferred retirement under Schedule 2 to the Social Security (Graduated Retirement Benefit) (No. 2) Regulations 1978;

(d) increments in guaranteed minimum pensions under section 126A of the Act.

*An age addition of 25p is payable to retirement pensioners who are aged 80 or over.

PART 2 BENEFITS PAYABLE FROM CONSOLIDATED FUND (But see also Parts 3 and 5 to 8)

Existing weekly rate £

Proposed weekly rate £

Attendance allowance

Higher rate

23·65

26·25

Lower rate

15·75

17·50

Non-contributory invalidity pension

17·75

19·70

Invalid care allowance

17·75

19·70

Mobility allowance

16·50

18·30

Category C or D retirement pension*

Higher rate

17·75

19·70

Lower rate

10·65

11·80

*An age addition of 25p is payable to retirement pensioners who are aged 80 or over.

PART 3 INCREASES FOR DEPENDANTS

Existing weekly rate £

Proposed weekly rate £

Increase for a wife or other adult dependant of:—

Category A or B retirement pension

17·75

19·70

Invalidity pension

17·00

18·85

Unemployment benefit and sickness benefit (where beneficiary is over pensionable age)

17·00

18·85

Unemployment benefit and sickness benefit (where beneficiary is under pensionable age) and maternity allowance

13·90

15·45

Non-contributory invalidity pension, in valid care allowance and Category C re tirement pension

10·65

11·80

Increase for a qualifying child of:—

Widow's allowance, widowed mother's allowance, invalidity, non-contributory invalidity, and retirement pensions, in valid care allowance, unemployment and sickness benefit (where beneficiary is over pensionable age) and child's special allowance

7·70

7·95

208

Existing weekly rate £

Proposed weekly rate £

Unemployment benefit and sickness benefit (where beneficiary is under pensionable age) and maternity allowance

0·80

0·30

PART 4 INDUSTRIAL INJURIES BENEFT

Existing weekly rate £

Proposed weekly rate £

Injury benefit:

(a) beneficiary 18 or over or entitled to increase for child or adult dependant

25·25

27·75

(b) beneficiary under 18 and not entitled to such an increase

22·50

25·00

Disablement pension:

(a) beneficiary 18 or over or entitled to increase for child or adult dependant—

Degree of disablement per cent.

100

48·30

53·60

90

43·47

48·24

80

38·64

42·88

70

33·81

37·52

60

28·98

32·16

50

24·15

26·80

40

19·32

21·44

30

14·49

16·08

20

9·66

10·72

(b) beneficiary under 18 and not entitled to such an increase—

Degree of disablement per cent.

100

29·60

32·85

90

26·64

29·57

80

23·68

26·28

70

20·72

23·00

60

17·76

19·71

50

14·80

16·43

40

11·80

13·14

30

8·88

9·86

20

5·92

6·57

Maximum disablement gratuity will be increased from £3,210 to £3,560.

Existing weekly rate £

Proposed weekly rate £

Unemployability supplement

28·35

31·45

Increase of unemployability supplement for early onset of incapacity for work:

(a) if on the qualifying date the beneficiary was under the age of 35, or if that date fell before 5th July 1948

6·20

6·90

(aa) if (a) does not apply and on the qualifying date the beneficiary was under the age of 40 and he had not attained pensionable age before 6th April 1979

6·20

6·90

(b) if (a) and (aa) do not apply and on the qualifying date the beneficiary was under the age of 45

4·00

4·40

(bb) if (a), (aa) and (b) do not apply and on the qualifying date the beneficiary was under the age of 50 and had not attained pensionable age before 6th April 1979

4·00

4·40

(c) in any other case

2·00

2·20

Maximum increase of disablement pension in cases of special hardship

19·32

21·44*

Maximum increase of disablement pension where constant attendance needed:

(a) except in cases of exceptionally severe disablement

19·40

21·50

(b) in any case

38·80

43·00

Increase of weekly rate of disablement pension for exceptionally severe disablement

19·40

21·50

Increase of injury benefit for dependent children

0·80

0·30

Existing weekly rate £

Proposed weekly rate £

Increase of disablement pension with unemployability supplement for dependent children

7·70

7·95

*or the amount (if any) by which the weekly rate of the pension, apart from any increase under sections 61, 63, 64 or 66 of the Act falls short of £53·60, whichever is the less.

Existing weekly rate £

Proposed weekly rate £

Increase of injury benefit for adult dependant

13·90

15·45

Increase of disablement pension with unemployability supplement for adult de pendant

17·00

18·85

Widow's pension—

(a) initial rate

41·40

45·95

(b) higher permanent rate

30·15

33·40

(c) lower permanent rate

8·88

9·86

Widower's pension

30·15

33·40

Allowance under section 70 of the Act in respect of each qualifying child—

(a) higher rate

7·70

7·95

(b) lower rate

0·80

0·30

Maximum under section 91(1) of the Act of aggregate of weekly benefit payable for successive accidents—

(a) beneficiary 18 or over or entitled to an increase in respect of a child or adult dependant

48·30

53·60

(b) beneficiary under 18 and not entitled to such an increase

29·60

32·85

Maximum weekly rate of lesser incapacity allowance supplementing workmen's compensation (Section (6)(c) of the Industrial Injuries and Diseases (Old Cases) Act 1975)

17·75

19·70

Weekly rate of allowance payable where disablement is not total (Section 7(2)(b) of the Industrial Injuries and Diseases (Old Cases) Act 1975)

17·75

19·70

PART 5 MAIN INCREASED SUPPLEMENTARY BENEFIT RATES

Existing ordinary weekly rate £

Existing long-term weekly rate £

Proposed ordinary weekly rate £

Proposed long-term weekly rate £

Supplementary benefit:

Couple

37·75

47·35

41·70

52·30

Single householder

23·25

29·60

25·70

32·70

Non-householder—

age 18 and over

18·60

23·65

20·55

26·15

age 16–17

14·30

18·15

15·80

20·05

Existing weekly rate £

Proposed weekly rate £

Any other person aged:

11–15 years

11·90

13·15

under 11 years

7·90

8·75

Existing ordinary weekly rate £

Existing long-term weekly rate £

Proposed ordinary weekly rate £

Proposed long-term weekly rate £

Boarders' Personal Expenses

Couple

15·40

17·10

17·00

18·90

Single person

7·70

8·55

8·50

9·45

Existing weekly rate £

Proposed weekly rate £

Personal expenses for dependent children aged:

18–19 years

7·70

8·50

16–17 years

4·60

510

11–15 years

3·95

4·35

0–10 years

2·60

2·85

210

Existing weekly rate £

Proposed weekly rate £

Non-householder housing addition

2·55

*

Heating additions to supplementary benefit

1·65

1·90

4·05

4·65

Dietary additions to supplementary benefit

1·30

3·05

8·70

*

Blindness addition to supplementary benefit (unchanged)

1·25

1·25

Addition for claimant or dependant over age 80 (unchanged)

0·25

0·25

Existing level £

Proposed level £

occasional gifts—level of disregard

20·00

100·00

Supplementary benefit—capital cut-off

2,000·00

2,500·00

*To be announced after the February index of retail prices becomes available.

PART 6
MAIN INCREASED WAR PENSION RATES
All ranks receive the same increases, officers' rates being expressed in pounds per annum.

Existing weekly rate £

Proposed weekly rate £

Disablement benefits:

Disablement pension for private at 100 per cent. rate

48·30

53·60

Age allowance with assessments of:

40 to 50 per cent

3·35

3·70

Over 50 and not exceeding 70 per cent.

5·25

5·85

Over 70 and not exceeding 90 per cent.

7·50

8·35

Over 90 per cent.

10·50

11·70

Unemployment allowances

Personal allowance

31·40

34·85

Increase for wife or other adult dependant

17·75

19·70

Increase for child

7·70

7·95

Invalidity allowances

Higher rate

6·20

6·90

Middle rate

4·00

4·40

Lower rate

2·00

2·20

Constant attendance allowance

Special maximum

38·80

43·00

Special intermediate

29·10

32·25

Normal maximum

19·40

21·50

Half and quarter day

9·70

10·75

Comforts allowance

Higher rate

8·40

9·30

Lower rate

4·20

4·65

Allowance for lowered standard of occupation (maximum)

19·32

21·44

Exceptionally severe disablement allowance

19·40

21·50

Severe disablement occupational allowance

9·70

10·75

Existing annual rate £

Proposed annual rate £

Clothing allowance

Higher rate

65·00

72·00

Lower rate

41·00

46·00

Existing weekly rate £

Propose weekly rate £

Death benefits:

Widow's pension—private's widow:

Standard rate

38·45

42·70

Childless widow under 40

8·88

9·86

Widow's children

10·85

11·25

Rent allowance (maximum)

14·65

16·25

Motherless and fatherless children

11·65

12·15

Age allowance for elderly widows

Ages 65–69

3·75

4·15

Age 70 and over

7·50

8·30

Adult orphans

29·60

32·85

Widowers'pension (maximum)

38·45

42·70

PART 7
FAMILY INCOME SUPPLEMENT

Existing weekly level £

Proposed weekly level £

Family Income Supplement

Prescribed amount for family with one child (gross income below which FIS is payable)

74·00

82·50

Increase in prescribed amount for each additional child

8·00

9·00

Maximum weekly amount for a one-child family

18·50

21·00

Increase in maximum amount for each additional child

1·50

2·00

PART 8
CHILD BENEFIT

Existing weekly rate £

Proposed weekly rate £

Child benefit—

each child

5·25

5·85

One-parent benefit—

first or only child of certain lone persons

3·30

3·65

PART 9
EARNINGS RULES
The amount specified in Section 30(1) of the Act (amount of weekly earnings which must be exceeded before a Category A or Category B retirement pension is reduced by reference to earnings) will be increased to £57·00.
The amount specified in regulation 8(1) of the Social Security (Invalid Care Allowance) Regulations 1976 (amount of personal weekly earnings above which invalid care allowance is not payable) will be increased to £12·00.
PART 10
THE THERAPEUTIC EARNINGS LIMIT
The amount of net earnings from permitted work (the "therapeutic earnings limit") which can be received without loss of benefit by claimants to sickness, injury and invalidity benefits and non-contributory invalidity pension will be increased from £16·50 to £20·00 per week.
The corresponding level of earnings which a beneficiary can be capable of earning without losing entitlement to an Unemployability Supplement to the industrial injuries disablement pension will be increased from £858 to £1,040 per annum.

Medical Care in the National Health Service
3.13 p.m.
Lord Hunter of Newington Lord Hunter of Newington rose to call attention to the need for improved medical care in the National Health Service in the 1980s and to the effect of the reorganisation of the administration of the health service on this objective; and to move for Papers.
The noble Lord said: My Lords, I owe a debt to the noble Lord, Lord Campbell of Croy, who has drawn my attention to a possible uncertainty in the Motion standing in my name. He has reminded me that the Scottish Health Service has separate legislation, and is in a different form, and I would confirm that what I have to say this afternoon concerns the Bill for England and Wales, and not the Scottish Bill.
In 1938, after 40 years in public life, Lord Horder claimed that it was "not very difficult" to define the needs of an ideal health service. These were:
"Firstly, we must help the fit to remain fit. Secondly, we must raise the general standard of fitness (health) by correcting certain tendencies towards lowering it inherent in modern life. Thirdly, we must do our utmost to control diseases due to preventable
212
agents. Fourthly, we must cure or alleviate disease when it occurs. These are our needs",
said Lord Horder,
"and they should be considered in that order, more and more in that order as civilisation progresses and as the grosser infections come under control".
So Lord Horder put health first, together with the health-creating services, which were seen to be those that provided better food, housing and recreation.
The year 1938 also brought the planning for the war and the organisation of the emergency hospital service, provision and co-ordination of local hospitals and the medical services through the EMS. The wartime service proved to be an effective instrument for the utilisation of all types of hospitals, and medical officers of health played an important part in it. Consultants from the voluntary hospitals visited local authority hospitals, or the new EMS hospitals, and there was a massive step forward in communication between the different parts of the hospital service, which had lived in isolation with different responsibilities for so many years.
During that time of course the general practitioner service and the medical officer of health services continued along established lines, but even during the war, with all the extra work (ARP, evacuees, and many others) the medical officers of health made substantial developments in the field of nutrition, prevention of infectious diseases and others—something we should not forget.
If one remembers that wartime experience, one appreciates that the plan for the National Health Service as it emerged on 1947 was not surprising. The main feature was to extend the hospital changes to which I have referred and bring all hospitals under state ownership, though that was not the issue that was publicly debated. There was to be a continuation of local government health services and general practitioner services—a tripartite division, therefore, with different and disconnected responsibilities within one National Health Service, but not unified. The Ministry of Health found its territory much widened to include all hospital services. The medical officers of health lost the responsibility for local government hospitals, but gained new responsibilities in the preventive and allied social fields.
We next enter the period from 1948 to 1968, the time when attempts at rationalising the hospital services were extended and when the voluntary and ex-local authority hospitals were run by regional hospital boards and boards of governors. That had to happen because the voluntary hospitals were bankrupt. A complicated relationship grew up, particularly in medical teaching centres, between boards of governors and regional hospital boards. That was the period of major capital investment in hospital medicine, which inevitably set the stage for developments in the 1970s and 1980s.
Expenditure by regional hospital boards and boards of governors on capital works was very modest in the first seven or eight years of the new service and did not in fact exceed £10 million in 1955. But in the late 'fifties and early 'sixties there was a rapid acceleration, according to a hospital plan for each region published in 1962. By 1968–69 capital expenditure had increased to £94 million a year.
The interesting, and I think important, thing is the delay for a decade after 1948 before capital building got under way, and, having been concerned with some of these things, one realises how difficult it was to get started. Planning took five to eight years. This poses very serious problems, my Lords, if you want to change course, particularly if the foundation of change is tied up with capital building. It is impossible to do it quickly.
By 1974 £124 million had been spent in the West Midlands alone. In other words, the hospital building programme was accelerating rapidly. It seemed as though the stage was set to create a massive range of new hospitals across the length and breadth of the land, and they would be the linch-pin of the new service.
However, by the late 1960s other factors were beginning to impinge on the concept of a hospital-based service. The reorganisation of local government was planned and, inevitably, changes in the social services. Secondly, the Department of Health and Social Security was established in 1968, thus replacing the old Ministry of Health. Medical care was now to be part of the social network.
The merger of health and social services was in practice only a gradual process of cross-departmental discussion and policy-making, and for a number of years co-operation was not very close. The effect on the health service of having a Secretary of State who also had to argue in the Cabinet for the needs of the social services is a very important matter. It would not be unfair to say that the interests of Dick Cross-man and his successor, and also David Ennals, were probably more in the social services than in health. One naturally became anxious as to whether the wide-ranging responsibilities of the Secretary of State would have an adverse influence on the expenditure on health. Although in volume terms the share of health in the social budget seems to have fallen, I am assured that the health share of the total public expenditure remains unchanged. The Minister, I would hope, will give us up-to-date figures on this matter.
The position is a complicated one affected substantially by the increase in the numbers of unemployed, but the evidence would seem to be that the Secretary of State's social services role has not had an adverse effect on health expenditure. Perhaps it could be argued that health may have done better than it might otherwise have done by having a Cabinet Minister in charge, even with a wider span of responsibilities.
But what is perhaps most relevant is the conflicting philosophies which formed the background to reorganisation in 1974. The hospital service, as we have seen, received a massive capital injection, and this in fact decided the future. The general practitioner services were substantially run in isolation, though the regional boards had developed important contact with them. But the key, as I have said, is the massive investment in the hospital part of the sickness services. Major expenditure was controlled by the department through the capital development programme and its recurrent costs. The magnitude of the change and the focus of major change is also illustrated by the staff changes which occurred in England. Between 1949 and 1969 the population increased from 43·8 million to 48·8 million, but the number of general practitioners
214
fell somewhat. The number of hospital consultants practically doubled. The number of registrars and senior house officers increased four-fold, a reflection of the major investment in the hospital services.
In the period between 1948 and 1974 the tripartite structure maintained the gulf between the parts of the health service, and those who thought about the whole complicated business of the delivery of medical care to the people of this country were very few, apart from the Chief Medical Officer and his staff. The new Department of Health and Social Security led the developments which culminated in the 1974 Health Services Act, which proposed the amalgamation of medical practice, health education, preventive medicine, hospitals and general practitioner services in one organisation. I am sure other speakers will deal with the success or failure of these efforts.
During the period 1948 to 1974, as some noble Lords will remember vividly, there were changes taking place in Government and also in the attitude of people to sickness and health. But to doctors the most exciting changes were taking place in the hospitals. Thus was because of rapid scientific discovery—the development of a new and effective range of treatments from penicillin to cardiac by-pass. It is well understood that in 1948 Britain had fallen behind in medical discovery because of the war, but in the next 20 years we developed a whole host of new specialties based on scientific discoveries. The places where this happened—in fact, the only places which were geared to receive these ideas and exploit them—were the London and civic university hospitals, which were equipped for research as well as for medical care. No one really appreciated the magnitude and cost of this scientific development, going on at the same time as socio-political change. Its cost has to be recognised as one of the factors in causing inequality of medical care in this country, but it must also be recognised that if it had not happened then British medicine as a whole would have suffered.
The medical student of the 1950s was brought in contact with this exciting world. He did not see very much—a little, perhaps—of preventive medicine; a little of general practice; perhaps a little about mental illness. He was more likely to hear of social revolution in the students' union than in the medical schools. Modest attempts were made to correct those deficiencies by the revision of the medical curricula in the early 1960s, particularly following Lord Todd's Royal Commission in 1968; but in spite of the scientific revolution and the medical advances to which I have referred, the intriguing position in which we now find ourselves seems to be that the pacemaker of change is no longer the hospital combined with scientific: advances and therapeutic medicine, but rather medicine has become part of an expensive social structure within which the health service will have to fight for the resources that it needs.
I have mentioned some of these wider political and medical changes and changes in attitudes. What about resource allocation and management in the health service? As might well be imagined, the development of the voluntary hospitals often reflected the wealth of a city as well as the public interest, and these and local authority hospitals all varied in quality for a number of reasons. The consequence was that the

215
hospital resources were unevenly distributed in Great Britain in 1948, when the service was initiated. Inevitably, as a consequence of the on-going commitment, the resources which the Government first provided were designed to meet the existing needs and took into account existing development plans together with an element of "development money". Between 1948 and 1970 there was a series of forward looks in resource allocation: but towards the end of that period it was becoming perfectly obvious to the new Department of Health and Social Security that "development money" was always outweighed by the vast bulk of resources attracted by existing programmes and commitments, and the growing capital programme to which I have referred.
The result was that after 20 years, with the possible exception of Wales, there were only a few substantial developments outside the well-off areas. The poor were getting poorer. At the same time there were, as I have indicated, good practical reasons for the increased costs: the massive and costly advances in diagnosis and treatment. It was hoped, I think, that as the capital programme grew and became more substantial, then the deprived parts of England would be rescued in the same way as Wales had been rescued by a capital investment with additional recurrent costs. Incidentally, I think it is true to say that Scotland was never deprived.
In 1970 the Crossman redistribution formula was introduced as an attempt to move away from what appeared to be an increasingly unsatisfactory state of affairs and the increasing awareness of the new department about the competing claims of the social services and other health measures, as well as hospitals for the sick. It was proposed to phase out the system of recurrent costs of capital schemes over a number of years; the additional monies would just have to be found by the boards. By 1975 it was quite obvious that this was not working. The recurrent costs of new hospitals varied from two to five times the recurrent costs of the old hospitals which they replaced. In consequence, the Resource Allocation Working Party (RAWP) was set up by Dr. David Owen, the then Minister of Health. Its interim report was somewhat similar to the Crossman formula, but it rejected the bed element in that formula and introduced the standard mortality rate as a measure of morbidity, which it is not.
It is not my intention to discuss the details of the RAWP formula, but it is a fascinating study illustrating the interface between political decision—fair shares for all—and practical reality. RAWP specifies equality as a principle, and it is clear in the concept that results are related to calculated need, if that can be determined, and not to rights or economic value. It was concerned with the needs of administering bodies, not of the patients. The needs of patients were not dealt with.
There are, of course, several alternatives within the notion of "equality", and the examination of an apparently simple formula leads one into some fairly difficult problems. The rates of approach towards the targets that were proposed were unrealistic, and have been modified again by ministerial statement. The whole process of resource distribution must be greatly revised if a proper distribution of resources between the
216
new district authorities is to be achieved, though the RAWP formula may well be reasonable in relation to regions.
The new look in recent years has been the provision of guide lines by the DHSS to regional and area authorities. An example of this is Care in Action—a recent DHSS publication—and it refers to nearly 100 reports, many made by professionally interested people about their own interests. These reports are recommended for study by Ministers. The weakness of this approach, as Sir Douglas Black has indicated, is the determination of each branch of the profession to do its "own thing". Some really hard professional synthesis and analysis is required—and it does not seem to be happening.
May I quote from Sir Douglas's report Inequalities in Health. He says:
"All professions tend to become over-committed to existing practice and their receptivity to the need for change is liable to become weak. The medical and nursing professions are like other professions in this respect. We are pointing out the uncomfortable fact that society cannot look to the professions working within the health services for an account of illness and health which is always as detached or as full as it might be".
Political and social decisions with medical consequences—often unsuspected—are inevitably made by Ministers. The reallocation of resources for the care of the elderly is one. Five out of six of all patients over the age of 65 admitted to British hospitals require short-term care and curative or palliative procedures, and they would be the first o lose if funds now applied to acute hospital care were withdrawn to pay for amenities during long-term care or for social services in the community for the elderly. The patient with blindness due to cateract requires an operation, not social support as a blind person. A wheelchair and a sympathetic social worker are poor substitutes for surgery when an individual requires arthorplasty of the hip.
There is an urgent need for proper consultation and debate on these and other issues and, paradoxically it seems to me, the least intensely involved in this are the medical profession. Many of their leaders do not seem to concern themselves with the complicated problems that we are discussing and yet it is the informed, critical, professional input into the system which is so vitally needed and which is, in my view, deficient.
Doctors must be prepared to compete and argue for the resources available and be prepared to strike a realistic balance with the demands of the social services and welfare, the needs of which are so much more easily understood by laymen, and also one can produce a politically satisfying result in months in many of the social services. The planning of complex modern hospitals takes many years. We do not hear cogent and convincing medical arguments. What we hear are constant complaints against the Government. It is simply self-defeating to spend our efforts on demanding more—particularly when effective co-operation does not seem to have been tried.
Now a further reorganisation of the administration of the health service is taking place. The area health authorities are to disappear and be replaced by district authorities with different responsibilities, as yet not finally defined, and by regional authorities with functions also undefined at the moment but undoubtedly

217
different from the present regional arrangements and, we are told, likely to be the subject of future review.
While these changes in administration are going on, is it not appropriate to look at the demands for medical care and the organisation of its delivery? Would it be too hold to suggest that the real need is the organisation of patient services and that the administrative changes proposed should meet that need effectively as well as political and democratic aspirations? Patients first! Let us look at it broadly and consider where the need is greatest and how most effectively we can use the resources.
The priorities are: health education and preventive medicine; the care of children; occupational health; the care of the mentally ill and mentally handicapped; the care of the elderly; and, of course, there must be some investment of resources to maintain and improve the quality of medical care. There is undoubtedly much to be learned about health education—who should do it and how to influence people to avoid or prevent diseases—but the main focus must be in the education of children. They are most at risk from malnutrition, from alcohol, tobacco, and easily-formed habits that go with them into adult life.
Many modern philosophies militate against success in health education. It is generally accepted that individuals have responsibilities in relation to personal health and their habits; but in some curious way any attempt to coerce them into meeting their responsibilities is an intolerable intrusion into personal freedom. Yet it is expected that the resources to meet the consequences are met without question by the state. What are the barriers to the assumption of responsibility for one's own health? Lack of interest; poor education programmes; perhaps until recently the general indifference of the health professions. So the reorganised health service must provide for health education, preventive medicine, and the care and health education of children, but it must also provide a safe environment for the work they do and that means occupational health—until now the Cinderella of the service.
The mentally ill and mentally handicapped are subjects of much concern which finds expression in the Mental Health (Amendment) Bill lately debated in your Lordships' House.
The final priority group was the elderly, which often means active people who, like old cars, need a little bit of care and attention and sometimes a spare part. Only a small number of them are infirm or confused and incontinent. At present, the majority of the elderly sick are treated in general medical and surgical wards. Should they not continue to be so treated?
It is easy now to see that in 1974 we should have built on what was good. The regional hospital boards had a quarter of a century of experience behind them. Their officers had developed channels of communication with the medical officer of health and his growing social services and also with the general practitioners.
The question that has to be answered now is: Can we get the National Health Service on an evolutionary path with sufficient flexibilities to make changes when patient needs demand? I think it is possible and that the regional health authorities can do this. But they must have the correct status and authority and not face the threats of further review. It cannot be done at district level. The boards at district level do not have a wide
218
enough vision to achieve the kind of balance in the situation that I have been describing. To attempt to achieve it by national direction, apart from general guidelines, I believe is courting disaster.
Can we get responsible medical planning and a proper balance between the needs of patients and new developments? Have we in fact too many clinical research centres? They have only developed in relation to medical schools and teaching hospitals. Should we not be doing something more in the way of the equivalent of product development in the engineering field? Should quality control systems of some kind be introduced to monitor the clinical work and its cost? I believe they should at least be seriously examined by the professions concerned, all of which believe in good practice. They should be "seeking quality"; but the place to begin might be to examine and debate Sir Douglas Black's report Inequalities in Health. My Lords, I beg to move for Papers.
3.39 p.m.
The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Elton): My Lords, I should like to thank the noble Lord, Lord Hunter of Newington, both for introducing an important subject for your Lordships' consideration this afternoon, and for giving us an overview of the National Health Service and part of its history from a position of very considerable authority. His name at the foot of the Report of the Working Party on Medical Administrators—and, moved from the foot to the top of it, adopted as the short title of that report—is already in the reference books and will pass inevitably into the history books of medical administration in due progression of time.
He posed a number of questions, some of which I hope to answer in the course of what I shall say now and the answers to the rest may not emerge until I reply to the debate. I am aware that the proportion of the national expenditure represented by the National Health Service at present is 12 per cent., but I could not tell him what it is I am comparing it with and what it is that he wishes me to compare it with from the time before the amalgamation of the department; so I will try to put the whole thing into perspective for him later. I shall not follow him back to the roots of the developing welfare state but shall content myself with looking first at the immediate past and present and then at the future.
I must, at the outset, establish the credentials of the present Government in the field of health. It has, after all, been the subject of a concerted campaign of denigration and slander the like of which is rarely seen in the politics of this country. The aim of this campaign would seem to be to try to establish in the subconscious minds of everyone in this country the totally erroneous idea that we have in some way diminished the National Health Service rather than increased it—and I hasten to add that I am not addressing myself to the noble Lord who moved this Motion. This Government have never decreased expenditure on the health service: indeed, they have consistently increased it, not just in cash terms but in real terms. Yet the ritual chant persists. People are seriously asked to look at our cuts. People who should know better follow party propagandist lines as

219
slavishly as the courtiers who followed the line of that vain and mythical emperor when they said: "Just look at the emperor's clothes".
Our cuts in the health service have no more reality than had the emperor's clothes. Noble Lords who doubt me—and the emperor has some courtiers even in this House—should look at the Public Expenditure White Paper published yesterday. They will see it quite clearly stated there that for hospital and community health services—that is the services for which health authorities are responsible and whose future we are now discussing—the Government have provided additional cash planned to provide growth of about 4 per cent. between 1978–79 and 1981–82. In practice, the path of growth is never entirely smooth. For example, the last Government had left plans for growth of 2.1 per cent. in 1979–80, but had not provided enough money for the price and pay increases they had left in the pipeline. So we were in the position of getting into the driving seat of their motor-car and discovering there was not enough petrol in the tank. Up to the present year, the actual growth of health authority services has been a little less than 4 per cent. We estimate, in fact, that the level of services is now about 3½ per cent. above the 1978–79 level.
It is right that I should establish the basis from which we move into the future. We are discussing the future of the health service and we cannot do that unless we know where it now is; and I wish to establish firmly in your Lordships' minds what the position is, what the policy is, and what its credentials are for saying that it will do what it proposes to do. I see nothing to apologise for in that. The growth to which I have referred means more and better services. As the White Paper says, the growth has been used to meet the needs of increased numbers of very elderly people, to whom the noble Lord referred, to provide for advances in medical treatment, and to continue the process of remedying imbalances in service provision between health regions—and the noble Lord addressed himself to that as well. Therefore, we are looking at a position where there is more money, there are more nurses, there are more doctors and there are more patients being treated. These facts are facts of record.
We have done this because we recognise the pressures for more and better care. I have already mentioned the needs of the increasing number of very old people, and also the need to make some allowance for medical advances. Very old people need care that costs on average eight times as much as the care needed by people of working age. In fact, the overall extra cost of changes in the population structure to health authority services is now running at a shade over ½ per cent. of their total spending annually. One cannot ignore the costs of the care of the elderly in present demographic positions. The medical world is in a state of almost permanent revolution—I do not refer to the student revolution to which the noble Lord, Lord Hunter, referred but to the ferment of discovery and development in the technical medical fields.
I do not need to go into a great amount of detail to convince your Lordships that medicine has become more scientific, more effective—and more expensive. For example, haemodialysis costs on average between £6,700 and £11,850 per case per year, according to
220
the type of dialysis given. In 1980 the NHS was spending about £32 million on dialysis, treating nearly 4,000 patients. Another enormously beneficial advance has been the development of joint replacement techniques, and the noble Lord made a pertinent reference to that and to the care which should follow it. It costs about £2,000 to fit a patient with an artificial hip-joint. At the moment, there are about 21,000 cases per year, costing in all about £42 million.
Both these examples are well-known, and they benefit a large number of patients. There are of course many other examples of new techniques that have evolved more recently; for instance, in the treatment of people with diabetes whose sight is at risk from their illness, in the treatment of heart disease and of cancer. The NHS must of course keep pace with these advances, which will continue in the decade to which the noble Lord directed attention. To do so it must scrutinise constantly and carefully its priorities and the use it makes of the resources it has, to make sure that it concentrates resources where needs are greatest when account is taken of the new benefits that can come from advances in medical skill. It is therefore very reasonable that we should have emphasised the need for health authorities to maximise their efficiency, by asking them to find a small part of the growth in services for the present year, and a small part of the further 1·7 per cent. growth planned for next year in this way. For the years beyond 1982–83 covered by yesterday's White Paper, we look to health authorities to find further efficiency savings to use for the development of their services though, as the White Paper explains, the provisions for these years are subject to review in the light of the availability of resources and the scope for further increases in efficiency in the NHS.
Future years will bring still further developments and your Lordships will see the obvious problem that this will pose. It is a difficult one and it will always, I fear, be with us because, quite simply, every developed country now has available to it more treatments and cures than it can ever afford to apply to the whole of its patient population. Within the professions there will continue to be, as I believe there always has been, the stark need to establish priorities—priorities not only for research but also for the application of the results of the research. It follows—does it not?—that there will be a continuing need, in particular, for research into preventive practices that will reduce demands on other resources. In the meantime, under any Government and under any economic circumstances, constraints upon resources continue to be an unavoidable factor both in strategic planning and in local decision making, even if they were almost infinite. Improvements in medical care which do not carry a cost penalty will therefore continue to be of very great importance. Sometimes what is needed is a simple change in the way that care is delivered. As an example, I would quote the longer-stay mentally ill and mentally handicapped patients. Many thousands of these are at present lodged, quite inappropriately, in very large institutions a long way from the communities from which they come. The buildings are so solid and have been there for so long that they look, as it were, invincible; as if there were no other answer to the problems which generations have asked them to resolve. Indeed, for many of their inmates they are the only home that they have known

221
since childhood, perhaps 50 years or more ago; and we have to remember those people when we start talking about a more acceptable form of provision. To some people, what we have is the only home they have known.
Nevertheless, it is very refreshing indeed to see the successes that are now being achieved by a totally different approach, in which quite high-dependency patients are being cared for in small, homelike houses close to, or even within, the community. I should particularly like to commend the example being set in this way by the Wessex Regional Health Authority, which I recently visited. Accurate costings are difficult, but it seems to be the case there that this sort of provision for the mentally handicapped is no dearer, and may actually prove to be cheaper, than care delivered in traditional large-scale hospitals and homes. If it does prove cheaper, then that is the answer to the anxiety of the noble Lord, Lord Hunter of Newington, that a move to this kind of provision might be in some sort of competition with the kind of provision which is necessary in conventional establishments with expensive equipment. I have no doubt at all that the much more personal atmosphere that one finds in such a place, and the much more socially integrated lives which the people who live there can lead within the community, have their own important therapeutic value. I recall in that context a home which was recently opened in Andover for only eight patients and which may prove to be typical of a great many more in the years to which the noble Lord is addressing our attention.
Therefore, while I cannot speak too highly—and I strongly emphasise that—of the dedication of those who work in our very large traditional institutions (I believe that those qualities are as invincible as the very bricks and mortar in which they work), I think, nevertheless, that it is likely that one change we shall see over the next decade is a reduction in the size of a great many of our institutions. The scale needs to be humanised, and we are already seeing the process getting under way.
This will often mean a radical reappraisal of the route by which resources should be delivered from central Government to the eventual consumer—the patient. It may often be much more practical and much more appropriate for delivery of the service to be not by the health authority, as is now the case in Wessex, but by the local authority. But, doubtless, the best solution will vary from case to case. Noble Lords will be aware that we published last year a consultative document suggesting ways in which such patients could be cared for by local authorities. This would involve a transfer of resources—not, please note, necessarily increased resources—but it should help to ensure that a truly appropriate form of care is provided.
We have had many helpful comments on our proposals. These are being studied at the moment and we hope to be able to make a statement about them before long. What I can say now is that, whatever proposals are favoured, the specialist in community medicine will have a major role in implementing the new policy. This will necessitate liaison with the local authority—and here the specialist in community
222
medicine has a unique position—and a significant planning and co-ordination task, for which the wide knowledge and experience of the community physician will be required. I shall return to him shortly, but I should like to stay for a moment longer with the idea that the cost of delivering a service is not immutably fixed.
It is not only in long-stay provision that a service can be delivered at the same, or even at a reduced, cost. Even at the other end of the scale, in the shortest stay units of all, there is something to offer. Studies at the day surgery units at North Tees General Hospital, for instance, and at Western General Hospital in Edinburgh have shown that the same quality of care—or, indeed, an improved quality of care—can be provided at significantly reduced cost in units which concentrate on minor surgery in specialised day surgery units. These are being developed increasingly throughout the National Health Service.
Incidentally, it is not always the case either that developments in treatment cause an automatic increase in the cost of a cure. If the examples I chose earlier gave your Lordships that impression, then I think I should refer, for instance, to the introduction of Tagamet, which often makes it possible to treat peptic ulcers without the use of surgery, and, indeed, without the need for a hospital admission at all.
More use of day surgery, more use of non-surgical treatment, more use of small-scale, cost-effective treatment units—these are more and more in the minds of clinicians. An increasing awareness of the comparative costs of different treatments and different drugs will be strengthened by the realisation that savings made in one area—and made without loss of the quality of the service given—can be used to improve the quality given in another. Here again, the specialist in community medicine has an important role, and this brings me back to him. He can provide information and advice on available resources and costs to the clinician. He also has an important role in the collection, organisation, interpretation and dissemination of information about National Health Service activities, especially in the clinical sphere. This is essential to the proper planning of services and in the stimulation of improving change. It is no good parts of the service developing in ignorance of what other parts of the service propose.
Community physicians also have important specific responsibilities in relation to environmental health, control of infectious disease and children's health services, and these I acknowledge. Today, however, I want to emphasise the contribution that they make to the management and planning of services generally. This aspect of their work is of paramount importance in making resources available for improvements in medical care. Their role is difficult to summarise briefly, but I need not attempt to do so. I need only refer your Lordships to Chapters 3 to 5 inclusive of the Hunter Report. If the noble Lord gets an increased distribution of his work by reason of that "puff", I am sure he will forgive me.
Co-ordination is very important. It is clear that clinicians themselves do not always have the time and resources to step back from the work that they are doing to identify ways in which their services could be provided more efficiently and effectively. There may be shortcomings in the way that non-clinical

223
staff are organised, which reduce the effectiveness of the support that they provide to the clinician. Changes in admissions and discharge procedures may be needed to increase the efficiency with which beds are used. For instance, additional physiotherapy staff may be needed to help patients recover more quickly, so that existing beds can be used more effectively and better use can be made of existing theatre facilities. The specialist in community medicine can help clinicians to identify these possible improvements. He can also help to implement them. He, or indeed she, can examine particular clinical activities within the context of the framework of direct and support services which contribute to their outcome, and can then stimulate and co-ordinate action in different departments to bring about changes which will release resources to improve other aspects of medical care. Intelligent planning can vastly increase the efficiency with which resources are deployed and the actual level of service delivered for a given sum of money.
I spoke earlier of what this Government have so far achieved in improving the National Health Service. I did so because the proper jumping-off ground for a review of the future is a review of the present. Another important consideration is, of course, the organisational framework through which the service will operate. The intention of the last reorganisation in 1974 was that better management would lead directly to more effective use and more equitable distribution of resources in the National Health Service. Planning was seen as the key, and the hope in 1974 was that area health authorities would take on this planning role and thereby provide a base for improved medical care for all. This hope has not entirely been realised. One important—perhaps the most important—reason for this is that area health authorities were too isolated from those actually providing and receiving medical care: the local community and the doctors, nurses and other professional staff who provide services to patients.
The new management arrangements for the health service which are to come into effect next month will change all that. The 90 area health authorities and their 199 constituent districts—251 bodies in all—are to be replaced by 192 district health authorities. We have also abolished the sector or co-ordinating management tier within the district so that senior administrators and nurses at unit level will be directly responsible to district officers. That will mean that decisions will be taken much closer to the local community. Local decisions will reflect local priorities. It will also mean that decisions on planning, management and the deployment of resources will reflect much more closely the views of the clinical staff responsible for providing services to patients. Here again, I believe that what we have in mind will answer some of the anxieties expressed by the noble Lord, Lord Hunter of Newington, about the apparent divorce between clinical opinion and planning decision.
By abolishing two out of the former six tiers of management between Ministers and the staff actually providing services to patients, we also look for a significant increase in the speed with which major decisions can be taken and with which policy decisions can take effect within the National Health Service.
224
Equally, if clinicians wanted to introduce a day surgery unit in the local district general hospital, there would, in the past, have followed consideration by unit management, by sector management, by the district management team and by the area team of officers before the issue reached the area health authority. In the future, such a decision will be taken by the district health authority after consideration by unit management and the district management team alone—once clinicians have identified the need. That is potentially a much more rapid process.
And, of course, the new arrangements will also provide better opportunities for the two clinical members of district management teams—the consultant and the general practitioner representing their respective colleagues in the district—to influence events. This is another response to the noble Lord's anxieties. They will be able to contribute much more directly than hitherto to the planning and management decisions of the authority and will thus be in a position to promote improvements in medical care.
The noble Lord referred to RAWP—the acronym developed from the name of the Resource Allocation Working Party—and I ought to respond briefly. The allocation of resources in the National Health Service is based on a formula embodying the recommendations of the Resource Allocation Working Party's report, Sharing Resources for Health in England. The working party's objective was to bring about a fairer distribution of resources in the National Health Service so as to ensure equal opportunity of access to health care for people at equal risk. The allocation process involves weighting regional populations to reflect their relative need for health care resources and then, after comparing the cash equivalent of this with their existing level of resources, distributing the available growth differentially in favour of those regions shown to be most in need.
The application of RAWP principles in determining regional allocations over the past four years has already brought about a significant redistribution of resources between the under-provided and the better provided regions. The revenue allocation of the worst-off region in 1977–78 was 10·9 per cent. below average and it is now 5·6 per cent. below average. The best-off region in 1977–78 was 14·9 per cent. above average and in 1982–83 it is 12·3 per cent. above average. We have to recognise that this process takes time, but it is taking place.
My last reflection on reorganisation is that the post-1974 structure has attracted criticism both from clinicians and from others examining the structure of the National Health Service—notably, the Royal Commission which reported in 1979. This is the complex and often bureaucratic system of professional advisory machinery. Its weaknesses included too many formal committees expected to consider a wide range of often routine matters in order to satisfy the belief that all decisions, of whatever importance, should have been considered and agreed by everybody—even those whose views were irrelevant. One of the changes we have made as part of the reorganisation is to introduce a much more flexible approach to consultation with professional staff. This will of itself release resources for clinical work and patient care.
In closing, I should like to turn to our view of the

225
relationship between the National Health Service and the private sector of health care. Encouragement of the private sector has been an important part of our policy since we returned to office. We have explained many times why we wish to encourage private care and why this poses no threat to the National Health Service—indeed, the reverse. Even those who cannot afford it benefit from the fact that others use it. The development of private facilities increases the total provision of health care in the country. Moreover, it can relieve pressure on the health services, either directly or by allowing the National Health Service to direct resources to other areas. We see the public sector and the private sector as essentially complementary. They are partners, not rivals.
There are many ways in which the National Health Service can benefit through a more flexible relationship with the private sector. There are signs of a growing co-operation, and I hope that this will extend even to the planning stages. This Government have made already a significant increase in the volume of resources directed to health care in this country. They have brought about a significant increase in the number of people working within the National Health Service. They have devised an administrative framework which will, when it has settled down, bring about a significant improvement in the cost-effectiveness of management. I cannot see further than can the noble Lord into my crystal ball. However, I can say that we have here the basis for a sound progression into a future in which the money of the taxpayer is more and more effectively turned into the security and the health of the whole population.
4.7 p.m.
Lord Wallace of Coslany: My Lords, I am sure that the House is extremely grateful to the noble Lord, Lord Hunter of Newington, for raising his important and timely Motion on the National Health Service. When I first entered your Lordships' House I was told that whenever I rose to speak in the Chamber there would almost certainly be an expert on the subject listening to me. Following, as I do, the noble Lord, Lord Hunter of Newington, and having listened to the noble Lord the Minister, I am very much convinced, so far as the noble Lord, Lord Hunter of Newington, is concerned that we are listening to one of our acknowledged experts.
I cannot say that I enjoyed the opening part of the speech of the noble Lord the Minister. I wondered where he was. I thought he was up at Hillhead addressing a by-election, for he came out with quite a number of political brickbats. I do not intend to reply in kind. All I would do is to remind him that the Conservative Party voted against the bringing in of the National Health Service. The noble Lord the Minister cannot object to that because I was there at the time. I could of course fling brickbats across the Chamber but, quite frankly, this debate is not a subject for political brickbats. If I make anything in the nature of critical comment it will be only because of my own experience, though in a somewhat minor way, of the National Health Service. And it will be on a constructive basis.
In a very wide subject like medical care one has to consider related issues like good housing, unemployment
226
and deprivation, particularly in the inner city areas. Today, however, we are primarily concerned with the National Health Service, mutilated—let us face it—as it has been by the bureaucratic, remote reorganisation of 1974, and now again going through further agonies of reorganisation. I am not making a party political point, just a statement of fact, when I say that both of these reorganisations were carried out by a Conservative Administration.
It is estimated that this reorganisation will result in financial savings of some 10 per cent. of management costs. I believe that a cash figure of £30 million has been mentioned. The calculations are somewhat obscure and should be treated with reserve. In view of the importance of this debate—at least, that is how I view it—I have taken the opportunity of consulting nursing and medical staff at my local general hospital, which I feel gives a typical overall picture of present day problems. The noble Lord the Minister has boasted that the Government have ploughed a great deal more money into the National Health Service, but from the comments I have received—particularly from medical staff—it seems that financial cuts are hitting hard at patient care.
Consultants comment that acceptance and implementation of the Short Report indicates a doubling of the consultant establishment, but at the hospital in question there are two consultant general surgeons, and although the South East Metropolitan Region has agreed to a third post, the money is not available. This is leading to a deterioration in the waiting lists. I am advised that financial shortages in the district concerned have led to attempts to close wards at both general and mental hospitals, which again affected patient care. This situation arises again in the accident and emergency department, where the threat of closure hangs over the Brook and Orpington hospitals. And there is the failure to expand the accident and emergency department at Queen Mary's Hospital, despite general acceptance of general need. Again, this is a threat to patient care.
A further example is understaffing at nursing level and among district nurses, in order to balance the books. This is yet another example of the threat to patient care. These were not political comments but comments made to me by consultants—with many of whose political allegiances I would probably not agree. The doctors consulted approved the general principle of spending more on what they term the "Cinderella services" for the geriatric, mentally handicapped and disabled—but not at the expense of the acute services. Reorganisation is welcomed by the doctors, as they hope that it will be more efficient, but add that that will only be so if the resultant savings are ploughed back into the services and do not make excuses for further cutbacks. Savings must be used to improve, or at least maintain, present levels of service to the public. The views I have just given are those of the doctors. Now I come to the reactions of the nurses and midwives. I am afraid that I must make a very serious statement; it is so serious that I have taken great care to check every word that I am about to say with the nursing service, with which I have been in touch.
As with the doctors, the nurses and midwives are delighted to see the end of the area tier on 1st April as, in their words, it was management from afar and with

227
out any understanding of the local situation. Those are words which I believe the noble Lord, Lord Elton, uttered a short while ago. They say that the new form of administration may ultimately be all right as in many cases it should draw closer to patient level. But they add that there are still too many district health authorities dealing with too great a population. Management, they say, should remain functional—"general or midwifery", "psychiatric", "community", et cetera.
There undoubtedly exists a considerable amount of unrest, especially among senior nursing staff, at the widespread advertising of senior posts and the prospect of continuing to advertise people's posts a good way down the line, in the next 18 months, to nursing sister level. There is obviously a great deal of distress and despondency among senior staff, all of whom have to apply for their jobs—jobs they have done in a first class fashion for many years in some cases. I am informed that in some areas that widespread advertising had resulted in applications for senior posts reaching three figures. This is a serious situation, and it is a ridiculous situation bordering on chaos. Somebody in authority, in the famous words of the noble and learned Lord the Lord Chancellor, has gone "stark raving bonkers". This is a situation which demands a Government investigation. I say again that the alarm and despondency which already existed will gradually go down the line to nursing sisters and will affect staff morale—and that must affect patient care.
This upheaval and disruption to the divisions of nursing and midwifery will inevitably filter down to the patients where the existing functional divisions are being split, as is the case in many midwifery divisions, and their fragments attached to general nursing areas to form new units of management. Units of management they say, and I agree, should be kept small, and preferably functional, and decisions should be made as near to patient level as possible. Staff have more or less settled down after the 1974 reorganisation and it appears that some changes are being made now merely for the sake of changing once again. This is stupid and non-productive.
I have just given the views of people v ho are professionally and personally concerned with patient care at ground level. I am extremely grateful to them for the trouble they have taken to tell me of their grave concern at the possible threat to patient care. I have done my best to check that every word I have said so far has their approval. If we are not careful, career prospects will be blighted for those who are giving selfless and devoted professional care to their patients.
I should now like to refer to the question of management. My experience of management in the National Health Service has been, first, as a member of the old-type management committee and, secondly, as vice-chairman of an area health authority. The contrast between the two was remarkable. In the old HMC we were close to patient level with special committees, including finance—and I stress "finance". We even had a visiting committee on a rota basis. All that went with the new area health authority. We had no committees at all and no committee for finance. There was no visiting, at least in the early days. In fact the chairman even imposed a ban on myself and a few colleagues visiting our local hospitals. In the end, we had a very hard battle to get joint
228
consultative committees set up for hospital staff. All we had was a monthly meeting where the law was laid down by the area management team and the chairman, who steam-rollered the decisions through. Decisions were taken without consultation with members. I sincerely trust that district management teams will operate differently. Members appointed to the new authorities must be consulted on decision-making and not be treated as mere pawns.
I come to the subject of committees. The view of the area team at that time was that they were a darned nuisance; they did not want them and they did not get them. But, on one angle of health administration, it is absolutely essential that a finance committee should operate in order to channel finance to the essential services with the overriding theme of patient care. Not only that, expenditure can be more closely controlled—as indeed we did in the old days, particularly in the dispensing of drugs. It is absolutely essential that there is a finance committee.
I quote an instance that occurred in the Bexley health district. The area health authority and the chairman in particular, the management team, had a great idea. The Bexley health district was accommodated in a large suite of offices, one of these tower blocks near Sidcup station. They entered into a contract of tenancy. Then the chairman thought it would be cheaper to go somewhere else. So they closed down an old maternity hospital and turned this into district authority headquarters, at Erith Road, Bexley-heath. But do you know what happened? They were supposed to be saving money. They overlooked the fact that they were on a contract of tenancy and had to find tenants for the offices they had vacated. True, a little bit of their office accommodation has now been let, but talk about economy and control of expenditure!—they are still spending thousands of pounds of public money in maintaining empty offices because they had not the wit to understand that it would not be an economy measure to close down the offices and shut a maternity hospital. That is fact and the department obviously knows a great deal about it—at least the regional health authority does.
What is not wanted in the new set-up is a continuation of dictatorship by management teams. That is not democratic control and must be avoided at all costs. The setting up of joint consultative committees for hospital staffs is, in my view, essential. Hospitals are remarkable venues for rumours and such committees can nip these in the bud, and much industrial strife can be avoided. In my experience, they are also excellent mediums for consultative suggestions for improving patient care, as well as keeping staff informed. I know for a fact that consultative contact with medical, nursing and ancillary staff can yield very positive results in improving patient care. It may be that each suggestion is small, perhaps the repair and maintenance of wheelchairs, but they are constructive suggestions, and teams of management and members must go out and consult with their staffs and invite their co-operation.
What I have said about joint consultative committees applies equally to community health councils, whose primary duty is to represent the consumer. I have a feeling, I am sorry to say, that the Government do not like community health councils, and are cer

229
tainly placing financial difficulties in their way. My impression is that management teams regard them as an absolute nuisance—I nearly used other words which have been expressed—but to me this indicates their value. In discussing the National Health Service, the general practitioners tend to be overlooked. They are an essential and vital part of the service, often over-worked and too frequently operating from poor and inadequate premises. There is a need for more health centres, combining group practices, together with all the other services, such as chiropody, ante and post natal service et cetera. Such centres are, in my view, an important section of primary health care. Furthermore, family practitioner committees should be integrated with the district health authorities and not act as health authorities in their own right. It is essential that primary care services be planned across the board and in relation to hospital services.
Now I come to the subject of postgraduate medical centres; and that, of course, in relation to general practitioners. Postgraduate medical centres should, and do in some cases, provide the means to refresh general practitioners on new developments in medicine, by seminars, courses et cetera. Although there are 418 such centres existing, more are needed, particularly in the new hospitals. The Government in a recent Answer to me could not say how many more are projected.
Now I come to a little publicity if I may. I can mention one, Queen Mary's Hospital, Sidcup. Through lack of finance, a makeshift centre has been established; friends have helped with the carpets and so on. The most active and popular vocational training courses for general practitioners in the South of England are being carried out, as well as training of medical staff, in very inadequate surroundings. Public money is not available for a purpose-built centre. I must now reveal the fact that I have an interest, as I am chairman of an appeals committee to raise £280,000. In case your Lordships think consultants are well paid and do not bother about the financial aspect of the service, they do. I can say that up to this minute consultants have already covenanted a total of over £32,000, and the fund has reached £40,000. Now we are going to go public. So what the regional health authority failed to provide these doctors in the NHS are making their own personal sacrifice to achieve, a worthwhile objective. This is a spirit to be admired. I would add, somewhat hurriedly, that if there is any noble Lord in the Chamber at the present time, or any noble Lord who reads Hansard, who has access to large sums of money, he can contact me at a later date, and he will find my name in this brochure with the necessary forms. I think I heard somebody say, "That will be the day!"—you never know your luck; I have tried.
Just a few brief words, not very pleasant ones, on private medicine. I take the view that if a person wishes to spend money on private treatment, that is his or her affair. They want to buy priority. But my firm view is that the overwhelming priority in medical treatment is the medical need of the patient and the patient alone. On that basis, money should not buy priority. Private hospitals are developing at a rapid rate, with obvious Government encouragement. American interests are coming in. Their objective is not basically patient care; obviously, it is a business
230
with the profit motive. What, however, concerns me, and a lot of other people, including many in the health service, is the fact that many doctors and nurses trained with public money are being taken on by private schemes. We cannot stop this, but at the very least private hospitals should make a token contribution either by a levy or a form of taxation. That, I feel, is only reasonable and fair to the taxpaying public of Britain, whether they use the National Health Service or not.
Social services operated by local authorities also play an important part in health care and there should be close links between local authorities and the new district health authorities. Unfortunately, under the new structure the loss of coterminosity between health authorities and local health authorities with social services responsibilities, may jeopardise joint planning between the two. Joint planning and financing should be strengthened to the advantage of the service.
There are many other points that I would like to make, but there is an excellent and lengthy list of speakers to follow, so I shall conclude. Some of us were in those early days fighting for a National Health Service. It was established in the 1945–50 Parliament and became the envy of the world—make no mistake about that. All I hope is that we shall resume that exalted status once again.
4.31 p.m.
Baroness Robson of Kiddington: My Lords, I, too, am extremely grateful to the noble Lord, Lord Hunter of Newington, for giving us the opportunity to debate this very important issue at this time. Obviously I am considering this Motion as a recently retired regional chairman. I agree whole-heartedly with what the noble Lord, Lord Hunter, and the noble Lord, Lord Elton, have said about our desire for an improved National Health Service in this country in the 1980s. However, I think that we must look at the economic possibilities and chances of improving the services within the constraints of the economic climate.
There was a debate in the other place on 18th February. On that occasion the honourable gentleman, now the Minister for Consumer Affairs, quoted some figures which were as follows: In 1978–79 the gross capital and revenue expenditure of the health service were £6,500 million. In 1982–83 the gross capital and revenue expenditure will be £12,100 million. In cash terms that is an increase of 87 per cent. After that he announced that the increase in real terms during that period was 5 per cent. As I understand it, the noble Lord, Lord Elton, has reduced that to 4 per cent. today—at least that was what I thought I heard the noble Lord say.
Lord Elton: My Lords, I took it to 1981–82. We come to the 5 per cent. in 1982–83, which we have not yet reached.
Baroness Robson of Kiddington: My Lords, it is 5 per cent., so I am quoting correctly. If one wanted to make a political point one could say that it is a terrible indictment of the economic policy pursued by this country in that period. However, that would not get us very far. What I think we should consider is what a 5 per cent. increase in real terms means for the National Health Service over such a long period of

231
time. It is assumed that 1 per cent. to 1½ per cent. per annum is necessary for demographic growth. The noble Lord, Lord Elton, admitted in his address to us that ½ per cent. was necessary for the increasing elderly population that we are having in this country. If we need that amount of money for normal demographic growth, how are we to improve the service on the amount of money available to us?—particularly when we keep in mind something that the noble Lord, Lord Hunter, mentioned; namely, the massive investment in hospital building that went on in the 1960s and early 1970s, the revenue consequences of which, in inflated terms, have had to be taken on by the regional and area health authorities. That makes their economic or financial problems even greater.
On top of that, as has already been referred to, the Resource Allocation Working Party's re-distribution of resources between the regions has been superimposed. I happen to have been representing one of the so-called rich regions in the country. All of us, as regional chairmen, when we met the Secretary of State and discussed the RAWP formula, agreed that it was only fair. The problem that has been created is that RAWP was introduced at a time of economic decline and as a result the so-called rich regions, which have been given hardly any development monies, have suffered in comparison very greatly.
What are called so-called rich regions are not necessarily rich over the whole of their territory. There are deprived areas within regions and obviously the intention is that the regions should redistribute the regional resources to help the deprived areas. But, with hardly any growth money, the impact of change has been very small. If we consider a region like mine—which has a particular problem down on what is commonly called the "Costa Geriatrica"—the problems and our increase in expenditure have been enormously great. So when we are looking at what we want to achieve I think that we must look at it in cold economic terms because we will not achieve an enormous change in the service without extra input of finance.
The noble Lord, Lord Wallace of Coslany, also referred to the growth of private practice and private hospitals. Having been involved in the health service under various Administrations, it is my view that the greatest impetus given to the development of private practice and private hospitals was the action taken by the previous Labour Administration in attempting to close down private beds in the National Health Service hospitals. That is what gave the original impetus. Since then there has been great encouragement, I believe, by the present Administration to private hospitals. I have no objection in principle at all to private hospitals—
Lord Molloy: My Lords, I hope that the noble Baroness will allow me to intervene for a moment before she completes that phrase. I hope she will say that she has no objection to those who use the private wings of National Health Service hospitals and pay their bills. I understand that in the area in which the noble Baroness was involved there is close on now £1 million owed by people who were admitted and had private medical treatment but did not pay their bills.
Baroness Robson of Kiddington: My Lords, I do not approve of people using National Health Service hospitals as private patients and not paying their bills—nobody approves of that. Having been regional chairman, I am afraid that I am not aware of the £1 million to which reference has been made. I have had the odd case brought to my attention where we have tried to take action. However, I shall take advice from my former region on this matter.
As I was saying, I have no objection in principle, but we must be very careful about how we allow this development to take place because it would be tragic if, in certain parts of the country, the growth of private hospitals was such that the National Health Service was left with perhaps very little of the acute services, but all the mentally ill, mentally handicapped and geriatric services. That I would deplore.
I also think that there is a great danger in the present reorganisation. Under RAWP we were trying to equalise services all over the country. But it is doubtful whether a lot of, or any, private hospitals will be built in certain parts of the country. Therefore, in that way we would be creating a different service in one part of the country from that in another. I hope that the Government will keep this in mind when further applications for the building of private hospitals come up for review.
Also on private hospitals, I am interested in them being sited quite close to a National Health Service hospital. One of the benefits of having private beds in National Health Service hospitals was that the consultants were available on a full-time basis—they were within reach. I believe that this situation could also be beneficial if the private hospital was within reach of the National Health Service hospital.
I should now like to turn to the reorganisation itself and to the aims set out in Patients First. I do not think anyone disagrees that there is a general acceptance that smaller, locally-orientated health authorities are more likely to be sensitive to the needs of the community. But, as a former regional chairman, before proceeding I should like to pay tribute to the marvellous job that the areas did under very difficult circumstances, particularly the members of area health authorities, who were working under great difficulties. I should like to pay tribute to the service that they gave us while they were in existence.
As has been mentioned in Patients First, there is a cloud over the future of the regions and their role. With over 200 district health authorities, if there is to be uniformity—I do not mean uniformity in a boring sense, but real equality of service in the NHS—it seems to me that it is obvious that the region's role as a co-ordinating factor is vital.
However, before discussing the region's role in some detail, I have some comments to make on recent decisions which relate to the reorganisation and to the general policy of the present Administration. First, may I say how very much I welcome the Secretary of State's recent circular on accountability, which seems to recognise the need for a regional tier but as the accounting body; and the proposal of a yearly review by Ministers themselves coming to the regions and meeting regional chairmen and officers and reviewing their progress towards the stated priorities within the nation.

233
Previously, up to a point this has been done at officer level and it had also been done, up to a point, at meetings between regional chairmen and Ministers. But yearly meetings, designed to be followed up, to look backwards and forwards at the same time to see where we are going as a health service, I believe will help to create greater understanding between Ministers and the service itself about the difficulties that we encounter. I hope that direct exposure to the service's difficulties will help to avoid too sudden changes in policy, because in the NHS quite often in the past we have suffered from pronouncements about priorities by various successive Ministers of Health who have had the best of intentions, and the general public take it for granted that it will happen tomorrow. It does not happen. Therefore, I think that the greater communication that exists on that level, and particularly the accountability of the region for what goes on in that region, is highly welcome.
What I regret very much is the decision that consultants' contracts and those of senior registrars should be held at the region. I am a great believer that a managing authority—and that is the district health authority—should hold the contracts of all the staff that it employs. I believe that this is essential if we are to achieve the economic use of the resources at our disposal. I am also sad that it appears that the Family Practitioner Committee is to be given even more complete independence from the main run of the NHS. I find this regrettable.
The expressed desire that we all have to move away from a hospital-based NHS to one of total health care, needs the establishment of improved primary health care services. I believe that the further divorce of the FPC from the general run of the NHS makes this difficult, particularly in London where 50 per cent. of the GPs are single-handed practitioners, often with lock-up surgeries and telephone answering machines. How can we create a good primary care service unless the health authorities have some control over that situation?
As a result, in those parts of London we have a much greater demand for hospital beds and high-cost services. Those districts are accused of having too many beds; they are accused of having too high costs and of taking too large a slice of the limited resources; whereas, in actual fact it can often be proved that they need those resources to give any kind of care at all in that particular community because of the lack of general practitioner services. I believe that that is a sad omission. A chance to remedy this should have been taken in this reorganisation, because I sincerely hope that we shall not have another reorganisation for along time to come.
I am also very disturbed about the continued emphasis on reduction in management's costs at a supposed saving of £30 million. As the noble Lord the Minister knows, the exercise started some three or four years ago, and at that time the NHS had an average management cost of about 6 per cent., 7 per cent. or 7½ per cent.—it varied between various regions. Over a period of three years it has been brought down to 5.14 per cent. The aim now is to bring it down to 4.62 per cent. I took what the noble Lord, Lord Elton, said about the removal of tiers and the savings in this way. If you compare the management costs of the service in this country with the management
234
costs of services in the European Community, you will find them immeasurably higher in Europe; if you compare this with industry, you will find that it is very much higher in industry, although I admit that they have to sell their products; we do not have to sell—we are over-sold before we start. Therefore, that is not a fair comparison.
However, I think that we are running the danger of defeating the purpose of reducing management costs. I was 100 per cent. behind looking at management costs when we started the exercise, but management costs have become a popular sort of whipping boy, and I believe that too low management costs can mean high costs of waste and high costs of inefficiency. I believe that we can save more money in the general running of the service by having slightly higher and, if I may say so, in many cases more qualified managers within the service. I think that we should be very careful about reducing those costs too much because we may be defeating our own purpose.
I am particularly concerned about this, because during the restructuring—which will go on for a couple of years before it settles down—we shall need adequate financial control. I would not want to see any reduction in the cost of financial control of the service at the moment. Additionally, if we are to achieve the aim of Patients First—the exact aim about which the noble Lord, Lord Elton, spoke; decision-making down to the smallest unit—we need to strengthen the unit management; we need to up-grade that person. That will take some of the savings—indeed, it will take quite a lot of the savings—that we shall hopefully achieve in the management cost exercise. I would rather that we created in this reorganisation a local decision-making, efficient organisation without necessarily saving the £30 million than saving the £30 million and not improving on the management at the unit as we have it at the moment.
I should just like to return for a few minutes to the role of the region itself. There are two schools of thought about the region. There is a body of opinion which believes that to have a region above the DHA diminishes the resolve of other tiers to act on their own initiative. There is too much looking up: "I have always got a safeguard. I have a backdrop. I don't really have to take the decision myself". On the other hand, the absence of such a body would cause enormous diversity of policies. You could get parochialism, which would be both expensive and undesirable. You could get arbitrary and ill-advised decisions and general communication problems from district to district. The NHS is a highly complex organisation. There are inputs from industrial interests, local interests, clinical professionalism, and from the general public, all of which have to be co-ordinated. Although I am not a believer in an administrative pyramid, I believe that the role of the region is going to be more important after reorganisation than it was before.
No district under reorganisation can expect to be totally self-sufficient for all its services, and the quantity of inter-district service provision is going to be enormous, added to which the formerly area based services will have to be reallocated to one district or another to run on behalf of more than one, because there are many services—like the ambulance service, like works, for instance—that it would be completely and wholly uneconomic to run from each district.

235
Not only would it be uneconomic but we would not have the expertise at so many different points. All this problem of changing over from what was a three-tier system to a two-tier system will necessarily make the region's role more important.
The other problem is that we had a system between the areas of cross-flow of patients for the purposes of allocating resources to areas. The cross-flow of patients between districts is going to be enormous compared with the cross-flow between areas. On the whole, between areas it was purely on acute services, but between districts it is going to deal with geriatric patients and take in the whole concept, and setting the standards for reimbursement is going to be very difficult. The financial problems of the regions are going to be enormously increased in the allocation process.
Apart from that, there are certain other services that in most regions were allocated to areas that will have to come back to the regions. In my region we followed a principle that for all highly expensive medical equipment we allocated the money to areas and they had to control that money. Frequently I received unhappy letters from the medical profession who claimed that the areas were not always sensitive to the needs of the service. But I resisted taking it back to the region because I believed that the area was the managing authority. You could not possibly distribute that money on a district basis, because if you split it up between 13 districts none of them would ever be able to afford some of the expensive equipment. Therefore, that is another link that would have to come back to the regions.
I am a great optimist. Having been in the service both before reorganisation as a governor of University College Hospital and after that as a regional chairman, I was never happy with the organisation as it was during my term of office, but I look forward with great optimism to an improvement in the service from a management point of view. But I also hope that the present Government will be sensitive whenever the economy picks up to the financial needs of the service.
4.56 p.m.
Lord Todd: My Lords, the matters to which my noble friend Lord Hunter of Newington has drawn our attention this afternoon are most important to all of us. All of us at one time or another are users of the National Health Service, and therefore our well-being and the well-being of the service are intimately linked. It is for that reason that I venture this afternoon to make a few brief and rather general comments.
Speaking, as I do, from these Benches, noble Lords will not be surprised to hear that I do not wish to speak on political matters, nor am I able to present such a massive array of statistics as we heard from the noble Lord, Lord Elton. I am also, medically speaking, a layman. I am not in any way connected with the medical profession, or with the National Health Service—at least, not nowadays. It is true that I had the honour to be chairman of the Royal Commission on Medical Education in the latter part of the 1960s, and I also served as chairman of the governors of the United Cambridge Hospitals for five or six years until the reorganisation of the service in 1974. When that reorganisation took place I am afraid that I declined to
236
serve further, and that for the simple reason that I did not believe that the new organisation would work satisfactorily. I regret to say that my misgivings seem to have been largely borne out by subsequent events.
The three-tier system introduced at that time was bound to increase the bureaucracy which was already all too evident in the service. Growth in the size of any organisation—be it the National Health Service, industry, or anything else—is all too often accompanied by an even faster growth of bureaucracy. Communication between the component parts gets more and more difficult, and decisions get delayed and in the end a lot of them are avoided.
May I comment on something which the noble Lord, Lord Hunter, said when he pointed out that the Scottish health service differed from the English, and that what we were talking about was the health service in this country. I should like to make the comment to him that on all the information that I have the situation as regards bureaucracy is quite as bad in Scotland, at least in the Strathclyde Region, as it is anywhere else in the country. Therefore, I think that my strictures would apply to Scotland as well as to England.
In my opinion, the National Health Service has been no exception to this rule of increasing bureaucracy with increasing size. The process has been accelerated and emphasised by the way in which its staffing—the nursing, the medical, and the non-medical auxiliary staffs—has in recent years organised itself on a kind of industrial or unionised model, so that not infrequently the pursuit of industrial objectives redounds to the detriment of the primary object of the service, which is to cure the patient. There is an extremely interesting article bearing on that subject by Sir Douglas Black in the February issue of Health Trends, in which he emphasises:
"The welfare of Health Service staff, important though it is, is secondary in importance to the welfare of patients and the health of the community".
That statement should be pondered by the medical as well as the other staff in the NHS; the patients must always come first.
Under the reorganisation of the service, now to be introduced, we are to move to a two-tier structure in which the often cumbrous area authority layer is to be removed. That, I should have thought, can do nothing but good and should bring the service in the various regions into closer touch with local needs and speed up decision-making. I therefore wholeheartedly welcome the reorganisation.
The demand for medical care is, as a former Minister of Health, Mr. Enoch Powell, put it, infinite. Each new discovery in medicine provides the appearance of needs which up to that point did not exist. That is one of the reasons why the cost of the NHS keeps rising. But at a time of deep economic recession, such as the present, unlimited growth is not possible and for the foreseeable future we must cut our coat according to our cloth and select with care those areas on which we should concentrate our efforts for further development in the 1980s.
I shall not seek to identify and enumerate all the areas of urgent need in the 1980s and beyond. Some of those have already been mentioned by earlier speakers in addition to the noble Lord, Lord Hunter. I shall refer to only one, the care of the old, which has been

237
increasing in urgency as the proportion of the elderly in the population has been growing. Now, and certainly in the past, much of the burden of this problem has been borne domestically. No doubt that will have to continue, but with changing living patterns—for example, the increase in full-time employment by women—the maintenance of domestic care will he difficult unless we get a further marked development of district services in which we can produce a real working relationship between primary health and social care in the community and the supporting services of hospitals, residential homes and special housing.
In my view, that is likely to be achieved only by a further massive development of the health centre concept as proposed in the report of the Royal Commission on Medical Education. It is true that since that proposal was made there has been a gratifying increase in the number of such centres, but many more are needed, and in particular there should be much more involvement in the centres of senior hospital staff, for there is too much separation between the health centres and the main hospitals in the health service. In considering the needs of the very old, one must not forget that a substantial proportion of them will need hospitalisation, not long stay but short stay hospitalisation in many cases. The need for short stay accommodation arises in part because some of the old people may have to be looked after in hospital for a short time, if only to relieve temporarily the strain on domestic arrangements: a spouse or daughter who must have some help occasionally if she is to avoid total breakdown.
From cases I know in my region of East Anglia, it appears that such facilities are at times quite lamentable. I know it is difficult to get nurses for geriatric hospitals. I also know that it is difficult to get medical recruits for that speciality. But the problem, already acute, is becoming more so each year and it is distressing to see the deficiencies when one knows that there are specialties in medicine and surgery the consultants in which are increasing in number far more rapidly than the number of patients requiring them. I wonder whether, if need be, the health service should consider making it perhaps even financially more attractive for nurses and medical staff to take up the geriatric specialty.
The matters about which I have spoken would of course cost money, but perhaps it would be possible to help find some of the funding by looking rather more carefully at some other areas. In recent years we have seen some astonishing developments in many aspects of medicine involving the introduction of what we may call high technology. I do not mean just heart transplants and whole body scanners but all such developments; the cost of such things was mentioned by the noble Baroness, Lady Robson. As Sir George Godber, for long a Medical Officer at the Ministry of Health, and later at the Department of Health and Social Security, pointed out some time ago:
"The illusion that high technology in medical care is the summit of National Health Service achievement has flourished in the medical profession and the public media. It is not; the common things occur most commonly and the quality of the NHS depends on the relief it gives for them. We do need the high technology, but we need it for the support it gives for simpler work, not for its own sake".
238
I agree with that view and I suggest that, in accordance with it, costly high technologies in present circumstances should be confined to a few centres and not be allowed to proliferate virtually uncontrolled, thereby effecting a distortion of NHS funding to the detriment of the essential day-to-day work of that service.
5.8 p.m.
Lord Perry of Walton: My Lords, the noble Lord, Lord Hunter, painted on a very broad canvas a comprehensive picture of the development of the NHS. As one who has never worked in that service, I shall try to paint only a very small miniature. But since I shall be rather critical of some aspects of it, I feel it only right that I should make it plain at the outset that I consider the NHS to be one of the really glorious achievements of post-war Britain. If it did not eliminate the fear of being ill, it at least eliminated the fear of the economic consequences of being ill. It has throughout its life offered a consistently high standard of care.
I qualified in medicine during the war, before the NHS, and my contemporaries were almost all fired with enthusiasm for this new and bold concept which was clearly right in principle and, we hoped, about to he found right in practice, and I am therefore the very last person to denigrate the NHS on its achievements. But admiration for the service should not blind us to its shortcomings, and it is clear that all is not well. When I worked as a house surgeon in a voluntary hospital before the NHS was born, I earned the princely salary of 19s. 2d. a week and was on duty or on call for 110 hours out of the 168. Nurses, too, were appallingly badly paid, but were never in short supply. There was among the entire staff—doctors, nurses, administrators, porters, ancillary staff of every kind—a palpable sense of purpose. Morale was high; everyone shared in the team spirit.
I think the tragedy is that, despite all the achievements of the NHS, these things are gradually being lost. Looking at it from the outside, but with many friends in it, it seems to me that there has been a continued fall in morale, there is often a sad lack of team spirit, and indeed there is sometimes a sense almost of despair among the staff. Why should that have happened? Doubtless there are many factors. Indeed, in the 1979 report of the Royal Commission on the National Health Service there were 500 closely-packed pages of examination, diagnosis and suggested treatment. The diagnosis was penetrating, but I think that the commission was rather indecisive in suggesting treatment. I shall try to suggest one more radical cure, but I point out that even the very conservative treatment recommended by the Royal Commission has been withheld by Governments and the patient is no better. That may partly account for the growing popularity among patients and staff alike, and even among some trade unions, of private medicine.
By analogy, many of us have often said that state education ought to be so good that nobody would want to pay for private education. We have not yet reached that situation in education, but we reached it in medicine. There is no doubt that the National Health Service offers a range of facilities often unavailable in any private nursing home, and it is very

239
sad that things are swinging the other way—and I think for relatively trivial reasons.
I believe that one of the main reasons for the current malaise is, very simply, lack of leadership—lack of leadership at the top and in the units on the periphery. It is not, I think, primarily a question of money; it is primarily a question of organisation. We have already been told that the new reorganisation will improve things, and I very much hope and think that it will, but even that reorganisation will not provide leadership; it is not about that. At the centre the National Health Service is the responsibility of the Secretary of State for Health and Social Security. As a politician and a Minister, he must do all the things that politicians and Ministers have to do. He must fight for funds for his department. Whether or not his fight is successful, he must maintain that the NHS continues to offer a fully comprehensive service, which it could do only if its finances were unlimited. He must answer to Parliament for all the criticisms and complaints that arise anywhere in the service. He has to do that as well as looking after his own constituency and being a member of the Cabinet.
Then he has to run his department. In 1979 the department had a staff of 93,000. It is built on a grand scale, but only about 5,000 of the staff are concerned with the National Health Service; all the rest—over 90 per cent—deal with social security. That is perhaps one measure of how much time any Secretary of State can possibly devote to the health service. As one former Minister not unassociated with my own party said:
"The department has become bogged down in detailed administration covering day-to-day management, but has been sucked in by the parliamentary process. The answerability of Ministers to Parliament may have given some semblance of control, but on some major aspects of health there has been very little central direction of control".
Thus there is very little chance for any Secretary of State to give the kind of leadership that will fire the enthusiasm of the staff of the NHS. Would it not be better for the Minister to appoint a full-time leader of the service, to give him an NHS budget, and to charge him with doing the job? The person appointed could state quite openly what could be achieved within the budget and what was beyond his means. He could be held responsible publicly for the standards of the service and could give leadership and a sense of purpose to the staff.
The report of the 1979 Royal Commission, having diagnosed this particular problem, concluded:
"This is an important matter about which it is not possible to be categorical at this time and it is one that Ministers should keep under review".
My Lords, that is what I meant by indecisive treatment. The report went on to state that the commission was not persuaded that the change would benefit the service. I am so persuaded, and I hope that Ministers will review the matter again and that they, too, will be persuaded.
Let me turn from the organisation at the centre to the organisation on the periphery. In the individual hospital one finds that the problems of leadership are even more acute. I should like to quote another extract from the report of the Royal Commission:
240
"There were many complaints in the evidence about the quality of hospital administration in the form of allegations that the local administration could not or would not take decisions and that as a result of the development of different functional hierarchies getting quite minor problems dealt with was unnecessarily difficult and delayed".
A little later on the report stated:
"It is clear to us that the three main professions involved in the efficient management of a hospital—administrators, nurses and doctors—need to devise mechanisms to ensure that decisions can be made quickly and implemented effectively. This will best be achieved by the creation of an executive team representing these three disciplines, advised as appropriate by the other professions involved. It would have responsibility for the day-to-day management of the hospital".
I find that solution quite extraordinary. Rule by a committee, for that is what an executive team is, just cannot work unless one member of the team is in charge, is the boss. The chairman of the commission himself, Sir Alec Merrison, is, as I was, a vice-chancellor, and no doubt he has in his university, as I did in mine, an executive team. But there is never any doubt that the vice-chancellor is the chief executive and that he is ultimately responsible for everything. I just do not understand why it should be expected that a hospital, unlike a university, is supposed to be able to run efficiently without a chief executive, a boss—and I do not mean a dictator. This is a very serious matter indeed for both staff and patients.
I am aware that the system of having medical superintendents of hospitals did not always work very well, but ofttimes it did. The Royal Commission felt that a return to that system would be retrogressive, I doubt that. I am quite sure some single individual is needed to give local leadership. Perhaps any one member of the executive team could do so, but the leader should be appointed, not elected. He should do the job full-time, and he should be publicly responsible for every activity in the hospital.
Consensus management is a democratic concept, and is quite essential, but it ought not to mean rule by a committee. It should mean that the chief executive takes decisions in the knowledge that they will be acceptable. He must consult widely. There must be all kinds of committees, but to expect every decision to be arrived at by a committee is really to court disaster. I plead for a change in hospital organisation to put this right and to restore personal leadership and, through that, team spirit and morale to a service, of which we all wish to be justly proud.
5.19 p.m.
Baroness Lane-Fox: My Lords, to declare my very humble interest in the debate, I would say that for some years I was secretary of a children's orthopaedic hospital and then a member of two hospital management committees. I am now chairman of a large patients' association. In the presence of so many distinguished specialists on the National Health Service I hope to make just two or three points from the worm's eye view of the consumer. Progress of medical science has enabled very many of us to withstand the onslaught of killer virus, disease and accident. Thus longevity offers a new dimension to earthly existence. So the Government's recent consultative document, Care in the Community seems to be right on target. Its scope is almost as wide as life itself.
To take up the point made by the noble Lord, Lord

241
Todd, I would say that the network of hospital aftercare and family can work properly only if there is no weak link. But it has a very much better chance of doing so where there is support from something like a Cross-roads scheme, or schemes of this kind, devised to give back-up support to the hard-pressed families and carers who dearly need a break and can be helped to recharge their batteries, feeling that there is somebody who is responsible and reliable taking their place for a time.
I am sure I need not remind your Lordships that within community care the district nurses play an all-important and irreplaceable part. To take just one section of the community alone, it is invaluable to severely disabled people to have daily visits from these nurses—nurses of many nationalities—whether it is for dressings or other advanced medical care, or just to bath and dress their charges. They call regularly, day after day, in all weathers, and in the teeth of transport difficulties.
What is very disturbing is that they have often to wage a running battle with the traffic authorities about parking. Those who manage to scrape together the money to buy a car find that this greatly helps them in their work. But when they have a patient requiring more care than can be given before the warden or the meter catches up, they are caught in a very difficult dilemma. If the immediate needs of the patient make it worth running the gauntlet, the nurse may very well then collect a fine. During the last year I have met many nurses who have paid up and sent off their fines with long and careful descriptions of what they were doing and where they were at the time.
I cannot believe that it is the wish of society to add to the burden of these excellent people performing such a very important piece of work. It is not only the clerical work that is involved but the fact that it can take many months to receive the repayment of fines, and what a dozen or so fines are involved this presents a considerable financial outlay. There seems to be a great need for district nurses to have a nationally-recognised sign for their car to denote their calling, always with stringent safeguards to avoid abuse, obviously. But the work the nurses perform relieves in-patient hospital costs and the ambulance service, so it surely deserves all practical help, by passport, from the wardens.
On another theme, I was very pleased to hear the comment of my noble friend the Minister on the private scheme. If we are realistic, everyone who wishes to see an improved hospital service must appreciate that even when economies are made more cash than is convenient is required. It is very hard to see that much more finance can be made available quickly, and it is on these grounds that I am won round to the advantages of the private health scheme. The assistance it can be to the National Health Service is well reflected in the last two years, when there was a reduction of National Health Service hospital waiting lists, which coincided with an increase in the number of members of the private schemes.
It happens to suit me, I may say, very much better to be treated on a general ward in hospital. It so happens that I am interested in the scene. But I know that for all sorts of good reasons this is not the case with very many people, and if they are prepared to pay handsomely for private treatment, of course they should be enabled
242
to do so. I gather these people are present in all sectors of society, that it is purely a matter of personal taste, nothing whatever to do with one's walk of life. The private scheme can cater for these people who really want "to go private". In their private hospital scheme, the needs of the Cinderellas of the health scene are very much to be catered for. Beds for the elderly, the long-stay and the epileptics are very much included, and their acute beds form only a small proportion of the total. I hope that this might reassure the noble Baroness, Lady Robson.
What seems encouraging news is that the private schemes appear to be thinking of devising and developing a nurses' training scheme. This combined with their present facility to employ nurses through flexible rotas (dare I say it?) should take up a considerable amount of unused nursing potential and greatly reduce any suggestion of poaching from National Health Service sources. It is obviously the wish of your Lordships that overall medical care for the community should be constantly helped and improved. To keep pace with national and international proved lines of development, health care needs all the cash it can possibly get, all the cash the public is prepared to spend. My guess is that without the private sector health care resources could become impoverished despite the best intentions of the Government.
5.26 p.m.
Baroness Fisher of Rednal: My Lords, I, too, should like to thank Lord Hunter of Newington for giving us the opportunity to debate the National Health Service this afternoon. I stand here, I suppose, as a consumer, though I do not think that puts me in a category different from anybody else. If we had not got consumers and patients, we would not need health services, quite obviously. But from the course of the debate so far it would appear that the pattern of illness concerning the care of the elderly—that is, the heart disease, the strokes, the blood pressure, the arthritis and the chronic depressions of old age—will by definition require that much more care for most of the time is provided in or near the patient's home; and after hospital treatment one would expect treatment to be continued by the general practitioner and the community health service. Therefore, there is this great need in reorganisation for the effective and comprehensive primary and continuing health service to be firmly based, and if community care is to become a realistic possibility and not just an empty phrase then in my view definite guidelines will need to be established as the new organisation takes place.
I think it was Lord Hunter himself who stressed the need for greater co-operation between the local authority community medicine services that have to be provided and those provided through the area health authorities. Therefore, it is urgent, I think, and I would urge the Government to look very carefully at the most important aspect of local government social services, on the one hand, and health services, on the other, at their close collaboration and at their financing.
There are several district activities which are closely allied to the social services. The care of the elderly, the child health services and the special needs of the mentally handicapped are all arranged round services which are very often provided by the social services

243
authority. But I think it is important in this reorganisation that the specialist in community medicine, which I was pleased Lord Elton described to us this afternoon, should have under his wing specialists in, perhaps, child health, the care of the elderly and the care of the handicapped, so that the local officers who operate in the social services will have a direct link and a named officer to whom they can make direct approaches to benefit particular patients. This is important to encourage that good working partnership at local level for the benefit of recipients between those who will be working from a practical point of view in the field and those whose task it will be to be responsible for strategic and operational planning.
Like other noble Lords and the noble Lord, Lord Elton, I think that what we have to aim for is the development of the much more comprehensive health centre as a priority, especially in the inner city areas. I was privileged quite recently to visit what I thought was a complete, comprehensive health centre. There were two group practices of doctors operating. There was a district nursing team, a health visitor and qualified midwife. There were sessional visits from the probation service, from the Marriage Guidance Council, from psychiatrists and physiotherapists. There were also nursery facilities available and video health films were shown in various parts of the building. This centre has become a place which encourages people to seek not only curative help for their problems but advice on illness prevention, and a place where social medicine is practised properly.
If we are to achieve greater equality in health care in our inner cities, and in certain other areas where there may be major cultural and other social factors which contribute to a higher than normal morbidity, special resources are necessary to set up this kind of centre. I should like to feel that the Government are considering this as one of their prime objects in the reorganisation of community medicine.
The noble Baroness, Lady Robson, drew attention to the unfortunate disadvantages operating chiefly in the London area regarding the standard of GP practice. In some areas in the city of London there are higher mortality rates. As the noble Baroness pointed out, there are often single-handed practices with elderly doctors who rely upon deputising services.
As a member of the General Medical Council for five years—and the noble Lord, Lord Richardson, is speaking later in the debate—I know this was a special concern of his when I served under his chairmanship on the GMC. There is the problem of the single-handed doctor and the sick doctor, who becomes a harassed person in the community and undesirable elements will be trying to use the doctor for practices in which he does not want to indulge. I should like to say in passing that we must also remember the very, very dedicated service and the excellent service which is given by members of the medical profession who practise in declining urban areas. As a former Member in another place, I know from my own personal knowledge. having represented an inner city area in Birmingham, the dedication which so many of those doctors gave to the patients in that particular area. They not only gave medical advice but also involved themselves in community activities.
244
Like the noble Baroness, Lady Lane-Fox, and the noble Lord, Lord Todd, when we are talking about patients first—and I would be the first to say that the patient is paramount—I should like to draw attention to the need for relief for the person who is taking care in the community. As the noble Lord, Lord Todd, said, that is very often the daughter, the wife or the mother. One hopes that the good work which many voluntary societies do to be helpful in this respect, very often providing holiday homes to which patients may go for four or five or seven or eight days, will be encouraged by the Government, and that resources will be made available so that a rest can be given to those who are doing the caring. Caring in the community more often than not devolves very heavily on the loved ones who are taking care of their own. If that breaks down, there is a grave expense which has to be charged to health services—more often than not through the hospital service.
May I go on quickly to refer to improvements in medical care? I should like to make one or two comments regarding the expectant mother. There have been at least two reports from the other place on perinatal care which have drawn attention to some of the misgivings which expectant mothers have. If surveillance of all pregnant women from an early stage of their pregnancy is crucial—and this seems generally agreed—then the question arises regarding achieving the ways and means by which local take-up can be improved. The higher mortality figures appear greater in areas where medical advice and examination are not sought early enough.
There are a variety of reasons which are given and which are known as to why women do not attend hospitals. In some instances there is a very long journey to maternity hospitals. In others, it means that small children have to be taken with the expectant mother and there are no crèche facilities for looking after small children while a mother waits from one to two hours to see the consultant at the hospital.
There are a variety of reasons—and I give only one or two—why expectant mothers do not take advantage of check-ups in the early stages of pregnancy. If mothers will not do this and visit the hospitals, it is incumbent upon us to take the services to them. In many parts of the country there are library buses, and play buses visit inner city areas so that children can play outside their own homes. The mobile blood transfusion service goes round collecting blood. Is it impossible for us to have a mobile maternity bus that will be actually going along inner city streets and roads to encourage the people to walk from the front door? If it does anything at all to help to save the lives of babies it should be considered.
May I speak quickly upon a further extension of maternity care?—on the idea that patients come first. We have the technology and the skill to detect all serious abnormalities in the early stages of pregnancy. Any of these abnormalities can be detected through ultra-sound and other kinds of test. I know that these tests cost money. I also know that they need highly trained specialists to operate the scanners and the other kinds of medical apparatus that are available. But the cost of giving every women the opportunity for as thorough a scan as possible is small in terms of finance compared to the amount that will be required to care for a severely handicapped child.

245
I should like to feel that the Minister could give us some satisfaction that hospitals offering ante-natal and maternity care are able to offer to all expectant mothers the opportunity for them, if they wish it, to be screened in order that serious abnormalities can be detected in the early stages of pregnancy.
I will not go into the area mentioned by my noble friend Lord Wallace—that is, that health is not only seeing the doctor but covers all kinds of things (and he mentioned housing). I should like to draw attention to just one thing. If we are thinking about accidents to children, the third highest category of accidents to children is death from drowning, and I would say to noble Ministers: "When you remember education cuts, very often they mean that the children are not allowed to go to swimming baths to learn to swim unless the parents can provide the fares."
It has long been known that differences are to be found in the health service available in the well-to-do areas and in the poorer areas of the country. I think the noble Lord, Lord Hunter, should be congratulated on the timing of this debate because it is timely that we again consider one of the fundamental principles of the National Health Service—and that was to divorce the care of health from the question of personal means. Inequalities in health care create two societies in British society. The concern of my noble friends on this side of the Chamber is that the belief that the National Health Service was one of the measures on the statute book that created equal opportunities in health care, regardless of the ability to pay, is being seriously challenged at the present moment. There is evidence that the gaps in health care are widening and operating against the more unfortunate in the community.
In conclusion, I should like to say that I believe that the National Health Service, despite its obvious shortcomings, which are related in the main to the non-availability of cash and resources, still provides a remarkably effective service for the population at large, and I would support with enthusiasm those noble Lords who have spoken perviously and who have emphasised the theme of improvement and evolutionary change rather than a change to a completely different system of health care.
5.43 p.m.
Lord Colwyn: My Lords, I am most grateful for and very interested in the remarks of the noble Lord, Lord Hunter of Newington, this afternoon. I found myself also in agreement with most of the comments of my noble friend Lord Elton, with the exception of the implication that more funds are being allocated to all parts of the National Health Service. I do not think that is so for the general dental services; but I will return to that in a moment or two.
I am firmly of the opinion that we are on the verge of massive changes in the technology of the prevention of disease, in the diagnosis and treatment of disease and also in the administration of health care. I believe that we shall see far-reaching changes in the 1980s and the 1990s which are perhaps now beyond the comprehension and the imagination of most of us here today. It is with sadness that one views the poor track record of preventive medicine. To say that is not to decry the brilliant epidemiological work of men such as
246
Sir Richard Doll in linking cigarette smoking with cancer. As the noble Lord, Lord Hunter, stressed, the sadness lies in the public's lack of response to such information. This, as perhaps I need not remind your Lordships, is at best apathetic. It is almost as if the man or the woman in the street, when confronted with these facts, prefers to look the other way; and this, I believe, is the weakness of preventive medicine.
However, the practice of medicine has steadily improved over the years and life expectancy is slowly increasing as a result. This, too, brings its problems because we shall need to care for an ever-increasing number of aging and aged people and we must think carefully as to how this might best be achieved. We must ensure that these people have the facilities appropriate to their restricted activities and surroundings that allow them to spend the last years of their lives in dignity and comfort.
When looking forward to the 1980s, we can be sure of certain things but less sure of others. For instance, it is difficult to speculate on the enormous impact of modern electronics, principally in the form of the micro-processor, on health. Genetic engineering, the manipulation of genetic material within the cell, is in its infancy and already human insulin can be synthesised by bacteria. No one could have envisaged that a decade ago.
This afternoon we are trying to speculate on how medical care may be improved. I am certain that we shall rely more and more on allied medical skills. My noble friend Lord Ferrier is not able to be here this afternoon, but I am sure that if he had been with us he would have continued his powerful arguments on behalf of chiropractic treatments. I hope the Government will take note of the increasing importance of these skills, and those of osteopathy, to treat and cure the vast number of patients with orthopaedic and spinal problems, which should be cared for within the National Health Service.
I need not remind the noble Lord the Minister of the reported number of days lost from work because of these symptoms and of how their early treatment by specialised personnel would result in vast savings for our economy. I firmly believe that the sciences of homoeopathy, acupuncture, kinesiology and the study of stress-related illness will play increasingly major roles in health care in the 1980s. Their practice must be encouraged and aided.
I must declare an interest in that I am a dental surgeon and I must apologise to the House for aiming some of my remarks today to the increase in dental charges within the National Health Service that were recently announced. It is of great concern to my profession, and I feel that the Government's attitude to these charges will have a major influence on dental care in the 1980s. These regulations to massively increase the cost of dental treatment within the National Health Service come into force of 1st April. I must speak against them in the strongest possible terms and alert your Lordships to what is happening in our dental services and to the way in which regular dental treatment will soon be beyond the reach of a large section of our working population as we go into the 1980s.
Where extensive treatment is required, the maximum charge will go to £90—50 per cent. more than at present, and representing about one week's take-home pay for

247
an average man. Where high-cost treatments are not included, the maximum charge will go to £13—a 44 per cent. increase and a very large sum for, say, a young mother to find out of her housekeeping money perhaps twice a year.
As your Lordships will know, and as I know very well indeed, only about half the population of this country see a dentist regularly. We still have a very long way to go if we are to achieve what the Department of Health's own review team suggested last year as an appropriate aim for the dental services—and here I quote—
"providing the opportunity for everyone to retain a healthy functional dentitian for life, by preventing what is preventable and by containing the remaining disease by the efficient use and distribution of treatment resources".
Your Lordships will notice that stress is laid on opportunity for everyone and not just those who can afford it. The report to which I referred came from the Dental Strategy Review Group, chaired by the Chief Dental Officer at the Department of Health and Social Services, the department's own dental adviser. He made many imaginative and far-sighted recommendations, including one very clear proposal that the level of charges to patients should be set as low as possible because of the obvious deterrent effect of charges on patients. This deterrent is not simply financial. So long as most other health services are free at the time of use, the very existence of dental charges amounts, in the public's mind, to a statement by the Government that dental health and regular dental care are not really important—not really worth bothering about.
With these latest increases, it seems that the Government are saying that the dental services are not worth protecting at a time of cuts in public spending. For the NHS generally, of course, spending levels are being maintained and there is still provision for some real growth. The Government have claimed, and deserve, credit for having seen the NHS as an important national priority. But, for the dental services, we are now seeing a withdrawal, despite the clear recommendation of the Dental Rates Study Group report.
According to information given to me by my noble friend Lord Elton, the amount spent on the general dental services in England will be virtually the same in 1982–83 as in 1981–82—that is, £378 million as opposed to £374 million. With inflation still running at 10 per cent., this is far from maintaining spending levels. It seems to me, and to the great majority of my colleagues in the dental profession, that these charges have been levied with total disregard for their dental health consequences.
As a poster which is circulated by the British Dental Association says, they are a tax on dental health which the dentist has to collect. And at these new levels they move us a long way towards a two-tier dental service, where decent modern treatment is reserved for those who can afford to pay for it. Your Lordships should take no comfort from the fact that the charges for plastic dentures show only a small increase. This is not encouraging prevention. We can do better for our patients today, and the National Health Service should be prepared to pay for better dentistry, instead of imposing these punitive charges on crowns and metal dentures.
248
I should like to make one more comment on the subject. Your Lordships may be aware that the Parliamentary Under-Secretary of State has accused the British Dental Association of misquoting the former Minister and drawing an incorrect inference about dental charges from a statement which Dr. Vaughan made a year ago on prescription charges. I think that the matter may be clarified by a more recent statement by Dr. Vaughan, also about prescription charges, but with a clearer reference to the source document.
On 26th October, 1981, in a Commons Written Answer, Dr. Vaughan said:
"As announced in the White Paper 'The Government's Expenditure Plans 1981–82 to 1983–84'—command 8175—prescription charges will increase annually in line with costs ".—[Official Report.]
Cmnd. 8175 did not refer only to prescription charges. On page 117, paragraph 15, it says:
"Charges in all services (in all family practitioner services, that is) will increase annually in line with costs"
The Government's previous policy could not have been stated more clearly. And these latest increases breach that policy to the tune of £27 million in England in the coming year. It is unreasonable for the department to suggest that the British Dental Association are wrong in their claim that the Government have overturned their own policy. They clearly have.
Of course, prescription charges are in more common focus of political attention than dental charges. That is one of our problems in the dental profession, and it is why I am seeking to draw attention to these charge regulations today. Our dental services are under severe threat. I hope that your Lordships will recognise what is happening and will use all your influence from now on to protect those services.
I should now like to make a few comments on the current reorganisation, as it affects the general dental services. In 1974, dentistry finally achieved independence from medicine, in that the local authority dental service was no longer under the control of the medical officer. The profession can claim enormous success over the past few years, with a higher proportion of the population attending for treatment, more adults with their own teeth and a greatly improved standard of dental health of children. This is due partly to the change in the nature of treatment from extractions and fillings to the widespread use of preventive measures. I am sure than many of these changes might not have occurred had the dentists not been able to plan their own dental services.
The key issue in the maintenance of this drive towards better dental health in the '80s is for the profession to be properly represented in the decision-making process within the new dental health authorities. For this, it is essential to have a dental officer who is accountable directly to the district health authority. The purpose of the current reorganisation is to reduce expenditure on administration. Dentistry has never suffered from an excessive number of administrators and, indeed, the numbers were considerably reduced in the 1974 reorganisation. I am sure that that is the way it should stay, although it would be a great pity if the current policy of reducing the number of administrators were to apply even in an area in which a minimal level had already been achieved. Only one

249
tier of dental administrators remained, certainly in England, and that was the area dental officers.
I am very pleased to see that the British Dental Association have followed up the chief dental officers' working party report on dental services and advisory machinery, and that the Government have confirmed that the changes in titles and definitions are intended to provide sufficient flexibility to meet the varying needs of the authorities, whether based on single districts or joint arrangements over a number of districts. Further, the Minister has confirmed that, where new-style district dental officers are appointed, they will be subject to arrangements for accountability, rights of access and attendance at meetings similar to those applying to the present area dental officers.
This new explanation of the plans for reorganisation in relation to dentistry has given my profession some encouragement and, I hope, dispelled our fears that provisions granted to our Welsh and Irish colleagues, and to district pharmaceutical officers, were to be denied to the dental profession within the English regions. Dentistry seemed yet again to be under attack, despite the contribution it has made to primary care services over the last 30 years. We were all very concerned at the way the situation was developing. I hope that the Minister can confirm the status of the new district dental officers, and that the existing guidance on the relationship between officers of different disciplines will continue to apply.
However, this still leaves one problem unresolved. It is the Government's fundamental philosophy that the new district authorities should have wide discretion over the appointments that they make. I would urge the department and the Government carefully to consider the phrase "where appointed" and to provide every encouragement for each of the districts or groups of smaller districts to appoint a district dental officer.
I must stress the importance that my profession put on this dental representation at district level. The dental profession is a separate and autonomous one, with an independent governing body. The autonomous nature of the profession must be preserved if patients' interests are to be adequately served. Medicine and dentistry are the only prescribing professions, and dental surgeons contribute considerably to the initiation of primary health care. The dental representation is, therefore, vital at all relevant levels where decisions are made. It is of concern that some of the new districts may be too small to require the whole-time service of an administrative dental officer. In these cases, I feel it is important that such factors as the local population, the social geography, the relationship with family practitioner committees and local authorities and, where applicable, the additional responsibility associated with a dental teaching hospital, are carefully considered.
The preservation at district level of dental officers will continue to make possible the process of integration of local authority executive council and hospital services. Already we are seeing signs of the elimination of the overlap between the community service and the general dental service, which will leave the district dental officers able to redeploy their resources to the areas of greatest need.
There is an increasing need for guidance on the areas suitable for the establishment of new general practices
250
as the number of dentists in the general dental service rises. This should be done not by bureaucratic regulation but by advice from administrative dental officers on how to reduce geographical inequalities with provision of dental care. In most areas, the dental officers have been monitoring the rapidly changing pattern of dental disease in the child population for which they are responsible and, on the basis of the data collected, have been able to organise and reorganise their resources to meet the changing needs. It is vital that their function is able to be continued.
The remit of the community dental service has recently been extended to include the care of the handicapped, who, by the nature of their handicap, are ill equipped to compete in the scramble for a share of scarce National Health Service resources. I should be grateful if the Minister could confirm that the proposed district divisions will have no detrimental effect on the service; I feel that in some cases the best organisation can be achieved only through a unit larger than the proposed district. Can the Minister also confirm that the district medical officers, or administrators, will recognise that care of the handicapped has a dental dimension?
The Government have frequently stated that the emphasis in health care should be shifted from treatment to prevention. It is in this field especially that administrative dental officers, responsible for a population comparable with those of existing areas, have the opportunity to make a substantial contribution to dental health. It has recently been possible to establish schemes for the provision of emergency dental treatment. If these plans are to continue into the 1980s, they must be efficiently organised and serve a relatively large population if they are to be viable. I hope that the Minister can confirm that these schemes will be workable in the new small district units.
In his reply my noble friend the Minister will no doubt assure me that the increase in dental charges will not have any effect on the number of patients attending our surgeries. Although I must disagree with this in advance, may I suggest that another major factor is that of fear. It was a dental surgeon who first discovered and effectively used anaesthesia to perform the more unpleasant tasks of my profession, and dentists have always had the right to administer anaesthetics in their surgeries—for I believe that, in the skilled hands of those who are prepared to admit that fear is a major problem, we shall be able to approach and treat many of the patients who have not yet come into our surgeries. This form of treatment needs special skills and special training.
Developments in the field of dental anaesthesia and sedation over the past years have been such that the complexities and hazards related to this form of treatment have been under-recognised. The General Medical Services Committee have recognised that it is unacceptable that there should be restrictive and exclusive lists of practitioners recognised for specific activities, and as there is a fairly limited number of practitioners providing dental anaesthetics, the turnover and number of new entrants is relatively small. Because of the complexities associated with dental anaesthesia, few young general practitioners are seeking to enter the field without specific training, while entry into other training posts continues to increase.

251
In formulating a policy for the 1980s, I would urge the Government to note that there is a need for dental anaesthetics to be given by those who are trained and experienced in their administration and the management of complications; that the most effective inducement to training is best based on the moral pressure arising from the individual practitioner's sense of professional obligation to provide proper services to patients rather than on an alteration of the fee structure related to an approved list of practitioners.
I should be most grateful if the Minister could agree to take note of the Seward inter-faculty working party report and agree in principle to make provision for the training courses which are required and for the administrative expenses associated with their regulations. The appropriate bodies have indicated that facilities should be available for the provision of this training, which may involve only about 20 at a time, in England and Wales. The Scottish scheme is already in operation and concerns only some two to four practitioners at a time.
I should now briefly like to mention a further aspect of medical care that has been described by many academics and clinicians as probably the single most important factor in the improvement of the quality of patient care. I refer to the use of computers within the hospital service and National Health Service generally. 1982 has been designated International Technology Year and I would ask the Government seriously to consider our position in this country in the field of information technology within the National Health Service.
In 1966, the Department of Health and Social Security started an experimental computer programme, with objectives broadly to investigate how computers could be used in the National Health Service to achieve better patient care; increased administrative efficiency; better use of resources; and better management and research facilities. At that time, relatively little was known about computers but, despite early problems, four major projects were started, three of which achieved limited success.
The DHSS then followed the recommendation of the 1971 Rothschild Report on Government Research and Development, which effectively cancelled the work until the 1979 reorganisation which included, for the first time, a formal arrangement for the introduction of computer services at regional level. Some contribution was, however, required from each region, although each was existing very much on a day-to-day basis.
By 1976, there was a considerable range of projects in the DHSS experimental programme, but there was a growing feeling that there was no immediate prospect of these projects being delivered to the National Health Service at large. The project on clinical records had collapsed and a hearing by the parliamentary Public Accounts Committee in 1976 had marked inhibitory effects on the department's attitude to risk taking in computer research and development, although attitudes were generally supportive in that they perceived the long-term benefits for the National Health Service.
Since 1976 there has been a failure to capitalise on available resources, a situation which was quite favourable in terms of knowledge and expertise already
252
established. A natural home for the funding for further research and development would be the Medical Research Council which has declared an intention to concern itself to a greater extent with health services research, as well as with its traditional sphere of biomedical research, with the DHSS co-ordinating the subsequent dissemination within the National Health Service.
As the noble Lord, Lord Todd, stressed, it is of vital importance that the development of systems across the National Health Service is co-ordinated by some such authority. Unco-ordinated buying-in of packaged systems must be controlled so that the danger of incompatibility and the resultant difficulty of integration is minimised. This problem of transferability has been solved in the United States by private companies which supply groups of hospitals with products which are modular, transferable and integrable. The stimulus to the success of such ventures has been the need for American hospitals to charge patients, or their healthcare funding agencies, on an item-by-item basis. Such imperatives do not exist within the National Health Service, but only a moment's reflection is needed to comprehend that any system which can effectively be used for billing purposes is also an excellent collector of resource utilisation information. With such information, doctors, nurses, administrators and other health service managers would be in a much better position to plan the more advantageous use of resources than they are now.
Junior hospital doctors are overburdened by the vast amount of paper and record work that is essential for each patient. It is impossible for our doctors to be aware of up-to-date information about clinical data, the new methods of treatment, the new drugs—their side effects. Every day hundreds of hours are spent, particularly within the National Health Service, on duplication of work, on manual searching of records and in pathology. At present, doctors rely very much on memory. This cannot continue. The new information technology is of vital importance to medical care in the 1980s. May I ask the Minister and the Government to give a new lead?
There was a scheme at the Royal Free Hospital and application for funds for the installation of a computerised Problem Orientated Medical Information System—PROMIS. In September 1980 this was turned down, despite a recommendation to go ahead by the research and development and computer policy committees—and an offer of 7 million dollars-worth of help on development and software from America. The department turned down this application for funds to initiate the programme, even though development funds were provisionally allocated and only about 50 per cent. of their budget had been used for that period. The cost has now risen by three times; and the American group which offered this help has gone commercial and their offer is now no longer available to the DHSS. The group at the Royal Free are so convinced of its benefits to the National Health Service in the 1980s that they have had to form a company to deal with the commercial side of this operation to develop PROMIS.
Could the noble Lord the Minister confirm that this group will be given help and encouragement with their work on information technology and be seriously considered again for financial aid when available?

253
Eventually the savings to the DHSS will be enormous compared with the small investment now required. The DHSS must develop and maintain its interest in systems of evaluation, and it is of great importance that the funds held by the department for computer research do not, by disuse, vanish back into the general pool. They should be in some way transferred to whatever organisation takes over the job of research management in this field, which has a vast potential for improving health care in the 1980s. I urge the Government to make the radical changes which are urgently needed to encourage this essential development in information technology.
6.10 p.m.
Lord Richardson: My Lords, I will endeavour to be brief. I was particularly grateful to my noble friend Lord Hunter of Newington for finding time in his far-reaching survey of the health services to mention medical officers of health and the great importance of their work in the past, which has been taken over by the community physicians. I was extremely pleased to hear what the noble Lord the Minister had to say about community physicians and their great importance, because I must tell you that community physicians feel that their position is threatened. There is a faculty of community medicine which was set up by the three Royal Colleges in Great Britain, and the president of that faculty has informed me that they are suffering considerable anxiety. One reason is historical. In 1974 they lost their security of tenure, which had been given to them by an Act of Parliament for a long period, for the very good reason that they could be in contention with their employers. They could still be in contention with their colleagues. That is the historical side.
The present side is that they are deeply concerned about the establishment which may be or may not be implemented for their specialty. They are aware, of course, that a district medical officer must be appointed to each district. The noble Lord the Minister gave your Lordships an idea of the importance of their work; prevention, communication and education being but a few aspects. I want to ask the noble Lord the Minister whether he would consider giving a very clear directive, or if not a directive an indication, to districts that they should employ an adequate number of people to carry out the very important jobs that these medical officers will be required to do. This is not only because their work is so important but also because, if an adequate establishment is not attained, the establishment will not attract into this branch of the profession the men and women who will be so badly needed—or if the numbers are achieved, perhaps the quality will not match up to the importance of the assignments.
I now wish to turn to the work done by doctors in hospitals and how in the 1980s it can be strengthened. In 1966 a working party was set up jointly between the Ministry of Health, as it then was, and the Joint Consultants Committee. The Joint Consultants Committee was an elected body and this was the first working party with the National Health Service which was so constituted. The importance of their work was to try to find out the most efficient way in which doctors could work in hospitals. This was so clear
254
to the joint body that it ceased to have two sides and became a round table discussion. The burden of their recommendations was to show doctors how much of value could result for the care of their patients from their co-operation in the administration of clinical services within hospitals. This was a new concept. Doctors had regarded themselves as being there to "doctor" and administrators to administer. The first report from this joint working party was nicknamed "The Cogwheel Report" because its recommendations were interlocking and interdependent. The report discussed the nature of most medical work in relation to its management. This introduced into the mid-1960s the idea that doctors had a duty to their patients for the best use of resources and that those resources could never be truly plentiful. We all appreciate that now the need is very much greater and has become urgent.
Many communities in hospitals cannot possibly develop their medical services on the basis of money growth. Development now means the redeployment of services and both managerial and medical staff must know what they are about. It is unfortunate that there is no easy way of linking clinical activities to the costing returns. Statistical manoeuvres have been applied to try to find a link between information about hospitals and that about clinical practice, but there is a credibility gap which it is difficult to bridge. Nevertheless, I see it as being essential that the medical profession should become further involved in facing such problems, even if it means the use of some scarce resources in training, perhaps, a small number of doctors in techniques which are new to them. Indeed, I do not see how progress can be made without the active co-operation of doctors in this particular field.
This process involves the profession both nationally and individually. Nationally, the Royal Colleges already form views on clinical practices and the associated resources necessary for the training of future consultants. I would look to them to extend their descriptions of the range of resources required for consultant practice, and also to consider the level of provision of resources that will not put at risk their clinical services to their patients. These suggestions would need to be interpreted to meet local needs and regional circumstances. Here I come back to the "cogwheel" philosophy and the opportunity that must he provided for the review of current practice within clinical divisions and within the hospitals. This is where inaccuracies in the information—the credibility gap I mentioned—regarding the nature of clinical practice will be recognised, and where the lack of information with regard to cost will be felt most acutely.
If this work is to prosper, a lot must depend on the central department and the authorities within the service. I trust they will realize that the service to patients is speciality-based and will develop the information service with this in mind. I understand there is reason for encouragement in the discussions of the so-called Korner working parties on information, which have taken as their starting point the collection and analysis of facts which enable clinicians to review their clinical practice and take action. It is necessary now for the costing information to be brought similarly on to a speciality basis. I regret that time prevents

255
me mentioning what I mean by speciality basis. It has not only a clinical but a statistical meaning.
My Lords, I want to draw to your attention that further efficiency can be and is being achieved by inspection of quality care by doctors themselves inspecting their own work. There have been long-esatblished methods such as the grand rounds in hospitals, clinico-pathological conferences, complication and cause of death conferences, outcome, literature review, and radiological diagnostic discussions. These over the years have been supplemented by more formal investigations, the confidential inquiry into maternal deaths by the Royal College of Obstetricians and Gynaecologists, the development of quality control schemes for laboratories, investigation of anaesthetic deaths, and the considerable efforts of the Royal College of General Practice, and more recently inquiries by the Royal College of Physicians of London into audit procedures.
The advancement of means of assessment of medical performance are very far from easy and have progressed only slowly. Nevertheless, recent debates at the British Medical Association conferences have shown clearly the recognition of the need for more formal review of quality control to help meet the paramount concern for excellence in the service of patients. This is a job for doctors. All the evidence from different parts of the world appears to show that they must do it themselves. Nevertheless, I would point out to the department and to the National Health authorities in general that this work, which is most important for patients, should receive such administrative support as it requires for its prompt and accurate furtherance. I see the use of resources and the quality of care as separate problems, but with a common purpose, and I believe that as they come more and more closely together so will patient care improve.
My Lords, I wish to end with a very brief reference to the importance of experimentation within the districts, experimentation in the delivery of primary health care, general practice care. In 1978 the department sought the views of various bodies about the problems of inner cities in relation to primary care. The Council for Postgraduate Medical Education for England and Wales was one of those bodies consulted. After their Deans' Committee, the postgraduate deans for medical teaching, and their general practice committee had fully considered the matter, they recommended to the Government the appointment to the staff of hospitals, including teaching hospitals, of general practitioners, the siting of some practices in general hospital grounds and in teaching hospital grounds, and involvement of teaching hospitals in vocational training for general practitioners, quite a lot through the postgraduate medical centres that should be in all teaching hospitals and in all sizeable hospitals. In this regard I was most interested to hear what the noble Lord, Lord Wallace of Coslany, had to say to us.
I happened to be chairman of the Council for Postgraduate Medical Education at the time, so I was much interested in a paper by Professor John Dickinson of St. Bartholomew's Hospital, in which he made proposals for a trial marriage between primary and secondary health care in one or two districts in inner London. The object was to allow the districts to
256
manage a unified budget experimentally, without impinging on the independent contractor status and the entitlements of general practitioners. The Acheson Report on inner London primary care also made alternative suggestions to the present pattern of delivery. My plea is that the spirit of experimentation shall not be submerged under the difficulties of detailed administration, and that new ideas will contain within them a unifying concept based upon the obtaining of the maximum degree of co-ordination and the avoidance of fragmentation within the administration.
6.26 p.m.
Lord Wells-Pestell: My Lords, this century has seen the introduction of many developments of great social significance, but none so significant nor more important to the individual than the introduction of the National Health Service, which took place almost 34 years ago. In saying this I am not unmindful of the vision and action of the Liberal Government and its introduction of the national insurance legislation many years ago. I think those two things together are matters of very great significance which so far in the twentieth century have not been improved upon.
I have been reading the Second Reading debate of the National Health Service Bill, which commenced on 30th April 1946, and in spite of its aims and objectives and the crying need for such a Bill it did not then get the support of everyone. To this day a large number of people pay only lip service to it. I am convinced that deep down this is precisely the attitude of the present Government. To many of us, foolishly perhaps, it was a new Jerusalem, the foundation stone of something which was of paramount importance to the entire community that we had been talking about and working for for many years.
I attended my first meeting to discuss the setting up of a National Health Service 49 years ago, in 1933. It was a dream which came true, and with all its failings and limitations—and I accept that it has many failings and limitations today—it is still the envy of many countries, and, perhaps I could say, still the envy of the world as a whole. I can remember Aneurin Bevan, its architect, saying that money ought not to be permitted to stand in the way of attaining an efficient health service.
The noble Lord, Lord Hunter of Newington, to whom we are indebted for directing our minds today along the path of inquiry into the National Health Service, reminded us of the views of Lord Horder on this matter. Before I go on, may I say that I rather got the impression that the noble Lord, Lord Hunter of Newington, was suggesting to the Government that the time had come to separate the National Health Service from the social security side. I hope the Government will give consideration to it. I hope that when we form the next Government it will be one of the first things we shall do. But to go back to the noble Lord, Lord Hunter, and his reference to Lord Horder, I knew Lord Horder quite well and could speak personally of his intense feeling on the matter of providing adequate facilities for health care.
Adequate facilities cannot be provided without proper financing. It is no good the Minister saying to us that the Government have increased the expenditure in the health service by 3 per cent. or 4 per

257
cent. in real terms, knowing as he must do that the amount allows for no real advancement or improvement at all when one takes into account the increased use of drugs, their increasing cost and all the other matters involved. On paper it is true; in effect it is not so.
The noble Lord complained about the hostility that the Government have been receiving about cuts and so on, and went so far as to say that it was not true. It is true. Every national newspaper at some stage or other has said this. I do not deny the fact that the Government have given an increased sum and that in real terms more money will be spent, for example, in this year than last year. What I am saying is that it is a question not so much of the spending of money as of what you get for it. In that sense area after area has found it necessary to contract.
If I may say so, I was not very impressed—and I say this very kindly—with what the noble Lord had to say. I do not think that it helped this debate very much at all. It was merely a review of the present situation, with almost no hope at all for dealing with our medical problems in the future. Let me be the first to admit that this may have been the case in 1979: I do not deny it. But after three years with the present Government I think that things are worse than they have ever been for decades.
No one opposite who knows the facts can deny that the poor in this country today are getting poorer, and that the rich are getting richer. It was said so on the BBC last night by a very competent person, and I do not think that anyone will deny that the rich are getting richer and the poor are getting poorer. This Government, when it comes to deal with the National Health Service, are something of a disaster as far as the ordinary people are concerned. I believe that the Government lack real understanding of the needs of ordinary people. An effective and comprehensive National Health Service is of supreme importance to the ordinary citizen. I am convinced that the Government lack the concern which they should have for the National Health Service. The effectiveness of the National Health Service is being sacrificed along with much else on the altar of privatisation. Private health facilities and their progressive extensions appear to be the Government's aim. To us—if I may say so, to the ordinary people of this country—it is a creeping disease of the first magnitude.
I should like to ask the Minister: will he tell your Lordships how many doctors are engaged full-time and how many doctors are engaged part-time in the private hospitals? With the greatest respect, I do not want percentages; I want numbers. I think that we shall probably find that at present about 10,000 doctors are engaged in private hospitals and the private sector. May I ask the noble Lord whether he would be good enough to let me, or your Lordships, know how many nurses are employed in the private sector? The only information which I can get is that the Nuffield nursing homes, which control 32 places, employ about 2,500 nurses, but they form only a small part of the private sector.
I ask for that information because I imagine that it costs the state about £50,000 to produce a doctor at present-day values. One can imagine, if there are 10,000 doctors—I may be wrong so far as that figure is
258
concerned—the enormous amount of public money that has gone into the training of those doctors who are now serving the private sector, where people can jump the queue and get immediate medical attention because they can afford to pay for it. I know that your Lordships have heard me talk on this matter before, but I feel very strongly about it. I think that in principle it is absolutely wrong—morally and in every other way. Perhaps the noble Lord the Minister will tell us the cost of training a nurse. There are many people, of whom I am one, who feel that this Government intend to encourage the development of private medicine even to the point of the dismemberment of the National Health Service. I think that we are really moving along those lines.
The financial allocation is insufficient to meet the needs of the National Health Service. In Oxford, where I live, less than a week ago the regional health authority stated that it was getting so little money that it will become one of the most deprived regions in the country. That was said by the regional health authority in Oxford. Some of us think that Oxford is a very progressive city and has always had a very progressive medical section. But that was said by the regional health authority only a few days ago.
Perhaps the Minister can say whether private hospitals are still getting certain benefits from the National Health Service for which they ought to be paying. I do not believe everything that I read in the press, but one hears that there is a tremendous amount of blood, running into £1 million worth or more, that is going into private hospitals and for which they are not paying. One hears of all sorts of abuses that go on as regards the use of the National Health Service by (shall I say?) consultants and private patients. Will the Minister say how many private hospitals there are at present, and how many applications are being considered at present by the Secretary of State for extension of private hospitals and the erecting of new ones? If this goes on, more and more doctors will be lost to the private sector.
May I ask whether it is true that the Whittaker Foundation or the Whittaker Corporation of America is endeavouring to recruit 1,000 doctors and nurses from this country for Arab states? I hope that the Minister will be able to say whether or not that is true. Can the Minister confirm that opticians have made over £6 million from cut-price lenses which they bought cheaply abroad, by charging them at the standard rate.
There seems to me to be so much going on in the National Health Service that needs looking at. It may well be that the department knows the position, from my own experience I am sure that the department does not miss very much. But I think that we need in the DHSS—if there is not one already—a watchdog to see what is happening. It may well be that there are areas in which there can be co-operation, but it should not be at the expense of ordinary people.
I wonder whether the Minister can explain why 5,921 learner nurses withdrew from training in 1980–81, and why a greater number withdrew from training in 1979–80, and why a large number withdrew in 1978–79? Has it anything to do with conditions of work? Has it anything to do with conditions of employment? Has it anything to do with their living conditions? It seems to me that the answer is not as the noble Lord the

259
Minister was good enough to give me in a letter quite recently, that there were 77,000 new learner nurses up to such-and-such a date. I am concerned why so many embark upon training and at some stage withdraw, because it seems to me that there is something wrong somewhere.
On 31st March 1981 there were 628,333 people awaiting admission to hospital, of whom 601,848 needed surgical operations—over 600,000 needed surgical operations. I understand that no figures are available since March 1981 and I am not complaining about that; one cannot get them, except at the end of the period. But of that number, all the urgent cases—which numbered 26,621—had been waiting for more than a month. With the growth of the private sector, this is fine. If you can afford to pay, you can go in tonight or tomorrow once the diagnosis has been made. But here we have a National Health Service where over 600,000 people are waiting, and of that number, over 26,000 are considered to be urgent cases. They may only have a hernia, varicose veins or a bad hip; but if you have a hernia, if you have a bad hip or if you have varicose veins, you know all about it and so do the rest of your family, because you are a liability. I believe that the Government must find the money to deal with this.
About half an hour ago I looked at the teleprinter and it said that tomorrow the Cabinet is likely to authorise the expenditure of £7,400 million on the Trident. I am all for defence. I am not a unilateralist; I am a multilateralist. I believe that we must have a good defence capability. But society is full of people who must have a Rolls-Royce, although there are dozens and dozens of cars that can do the job just as well as a Rolls-Royce. We cannot afford a Rolls-Royce defence capability. As someone said quite recently, if necessary we must have an old "banger", and there is competent opinion in this country that we can have a proper defence system without spending that amount of money.
Since the Government have been in power, they have gone in for a tremendous amount of asset stripping, selling parts of very successful nationalised industries and concerns—industries and concerns that belong to the people. They have sold parts of it and done a good deal of asset stripping. By taking only a small part of that money we could—not tomorrow, not even the next day or next week but eventually—have a National Health Service that would meet our needs.
I want to conclude by calling your Lordships' attention to something that Sir Douglas Black, the present President of the Royal College of Physicians, said. He expressed his concern at the Government giving positive encouragement to a great expansion of the private sector which, in his view, is bound to lessen determination to make the health service work more efficiently. He also said that he was concerned at Government predictions that the public sector would eventually provide 25 per cent. of all health care. At whose expense?—not at the expense of the individual who can afford to pay for it, but at the expense of people who cannot do so. He went on to say this:
"I believe a doctor whose education has been largely at public expense should give some return by devoting the greater part of his time and interest to the Health Service, not through compulsion but from a sense of fairness".
260
I hope that members of the medical profession will be able to say that to some of their colleagues who are educated at the expense of the state and who then give the state little or nothing in return.
6.45 p.m.
Lord Porritt: My Lords, I think that it is probably poetic justice that I should have the privilege of following the noble Lord, Lord Wells-Pestell, in this debate, for it is the first time that this has occurred when we have been talking about medicine. On every occasion we have differed very considerably, which has not worried either of us because I believe that at heart we are aiming at the same end, and we have become firm friends. Despite the fact that it would seem that the noble Lord directs the busy little bee in his private practice bonnet directly at me every time he speaks about it, I hold no whatever and I shall not reply in kind, except very indirectly later in what I have to say.
Lord Wells-Pestell: My Lords, if the noble Lord will allow me to interrupt him, I would point out that it is much more convenient for me to look that way. I can look left, but as I have certain disabilities I cannot look over there, and I find it ever more difficult to look elsewhere. So I am afraid that he does get my glare most of the time. But I did not even know that he was exclusively in private practice.
Lord Porritt: My Lords, I appreciate the compliment. I am sure that I voice the feeling of all noble Lords when I say how much we owe to the noble Lord, Lord Hunter of Newington, for his very well-informed and very challenging speech which opened up this debate. I was glad to hear it, because when I read his Motion on the Order Paper I felt a little sad that we should, yet again, be considering how we could improve the National Health Service and how we could make a critical appraisal of yet another reorganisation, which incidentally is still not finished.
I naturally felt that one must recall all the many debates that have taken place in this House and in another place over the years, all the committees and commissions that have been set up to deal with the troubles and difficulties of the National Health Service, and the great number of meetings of interested parties that have been held, whether they are political bodies, medical bodies or social bodies. The net result is that, after all this time we are still struggling to achieve the purpose of the exercise—to find a system that is both financially viable and medically efficient.
Why is this? What has gone wrong with the initial, I am sure everyone would agree, excellent idea that started off the health service? When I thought what I was going to say and saw what I had, I felt that the years finally must be catching up on me, because I was going back. I wanted to take noble Lords back a little to what the health service was when it started and what has been happening to it in the meantime. It is a bad sign when one goes back and stays there but it is not a bad sign if, in going forward, one continues to use what one has learnt from past experience, and that is what I hope I shall be able to do.
I have always been a rather strong protagonist of a health service. I have always, from the very start,

261
had my doubts about the health service. To try to adjust these rather complicated and contradictory view-points, in the late 1950s I accepted the chairmanship of a committee of the top people in the profession—35 eminent medical men representing all branches of medical and all specialities. That committee, the Medical Services Review Committee, worked for four long, strenuous, and devoted years. In the end it produced a unanimous report. I think you will agree that that of itself is no mean feat for 35 doctors, who do not usually agree. This was the profession's very real and genuine attempt to make the NHS a going concern after its first 10 years of experimental work. To make it a service that could provide the maximum for the patient—which surely is the goal towards which we are still, 24 years on from that date, struggling. A service, also of which we could be proud as a country.
The report was duly presented to the then Minister of Health, who shall be nameless, and was shelved. But, on several occasions since that time, it has been taken down off the shelf, dusted, and some of its recommendations have been accepted by the then Government, the then Ministry of Health, and incorporated in our medical legislation. That, I think, has been the trouble all along: bits and pieces. They took bits and pieces out of our report, they take bits and pieces from everywhere else, and they put these bits and pieces into a quilt which hopes to cover medical care in this country. Bits and pieces.
There has never been any system that in toto will meet the requirements both of the profession and of the community. This is the theme that I am trying to get at tonight; that we should go back a little and see what was aimed at at first, and whether we cannot do something about it. Many of your Lordships will not agree with what I have just said, but to my mind one of the great sadnesses and tragedies of the health service is that it has become, and is still being used as, a political football. This is what does so much harm to it. It should not be a matter of party politics; it should be a matter of treatment in time of trouble.
To ahieve the original ideal, with which I am quite sure none of us would disagree in principle, we need a lot more vision, a lot more tolerance, a lot more intelligence, and a lot more understanding. There has not been a mixture of those things in the consideration that has been given to the health service over many years. What is required is some radical rethinking, and a cessation of non-productive, doctrinal squabbling; an honest, straightforward appraisal of the facts of NHS life, as evidenced by 35 years of rather painful experience.
We have learnt a great deal, and without doubt we have, as we have heard already this afternoon, a very good health service, but it is not the best. Do not let us run away with that. No country yet has seen fit to copy our system, and if we had had the best system, they would have copied it. We have great facilities, but are our priorities right in using those facilities? Already the noble Lord, Lord Elton, has made mention of this, and the importance of getting priorities right. It is no good having good facilities if you use them wrongly.
We have a good profession, but its motivation
262
has been permanently altered by its involvement in the service—an extremely interesting thought, which perhaps has not occurred to you yet. Can we at this late stage give up just plugging the holes in the fabric as they occur—and this is really what we have been doing for many years—and go back to the original idealistic concept, and, taking on board the hard lessons we have learnt, plan a service capable of facing up to the stark facts of today's world? It would seem to be still possible, but with a great sadness I have to say that I doubt if it will ever happen.
The grounds for this pessimism rest on the fact that over the years we have produced a new clientele of patients and a new profession. Both of them have come to accept the NHS as a fact of life. Both of them, while complaining of minor faults and drawbacks, nevertheless feel that the health service has justified, and is in fact still today justifying, its existence. This is a perfectly reasonable viewpoint, but of course it completely ignores the vast and ever-increasing costs, about which we have heard this afternoon, of the service. This increase, it should be pointed out, is far beyond what might be ascribed to global inflation. And yet we are still second to bottom of the league table of the EEC in the amount of money we spend on our health services.
No health service can afford to be comprehensive. The sooner we learn that, the better. The insatiable demands of the multifarious aspects of modern medicine make this a fallacy. They make it frankly impossible. Yet, while the demands on our National Health Service remain unlimited, as you know very well, the available resources, as you also know all too well, are limited.
As recently as 22nd February the noble Lord, Lord Elton, in our debate on junior hospital doctors said:
"The National Health Service is under pressure".
So it is. And so it will continue to be until the Government—any Government—are prepared to draw the line and define the limitation of their responsibilities and accept the necessity of calling upon adjuvant and parallel methods of supplying medical care.
One of these, of course, if I dare mention it, is private practice, but I do not intend to go into this in any detail today. Unfortunately, it still remains—quite unnecessarily, I think—a contentious subject. Let me just say about it that it is at the present moment directly, to the tune of £50 million a year, assisting the health service, and also indirectly to a very considerable extent. It is, as we have heard, booming and it would not do that if it was not fulfilling a need.
Let us remember that its clientele also now consists more of employees than employers, and let us recall—and do not let us forget this fact—that it was one of the prime requisites of the profession agreeing to the setting up of the NHS in 1948. Who insisted on that? The father of the National Health Service, Aneurin Bevan. He saw the great importance of this liaison. What a pity it has turned out to be that his idealism did not extend to allow him to see that his original premise—that the so-called free health service would reduce national ill health to an extent that the service would become financially viable—was untenable. Not surprisingly with him, surely a starry-eyed concept of human nature.

263
In the fond hope that something may still be done to put the NHS on a sound basis, it may be salutary if I conclude by mentioning briefly certain aspects of the service that I would say still urgently require consideration. Before I do that, oddly enough, although I admit that I did not originally think it possible, the intervening years since the inception of the NHS have shown that a profession, as against a business or an industry, can be nationalised. This again is an interesting historical fact.
I think it would still, however, be vitally important that the profession should be carefully monitored to see what effect this transformation has had upon it. I realise that what I am going to say now will probably be a pipedream to a few of you and anathema to more. I suggest that all the things I am going to mention are really worthy of study in depth—study with a long-term, open-minded vista, and without doctrinal bias.
As has already been mentioned by the noble Lord, Lord Hunter—and I was interested to hear him say this—is the conjugation of health and social security into one Ministry sound? Is it sound either governmentally or socially? It certainly exaggerates the effect of the massive bureaucratic machine that has tended increasingly to clog up the wheels of administration, to the extent even that it has already demanded two reorganisations, which so far—we have not got to the second part yet—have produced only a slowing down of practical results, with ever-increasing expenditure.
In that the basic purpose of a successful health service must be to get the doctor and his patient into a closer, more human and fruitful partnership, the more it is decentralised and the more it is devolved to the periphery, where that contact is established, the more productive it will be. The achievement of such a policy has certainly not been helped during the years by the frequent changes of Ministers of Health; we had another only last weekend. Continuity of policy has been conspicuous by its absence, as, for instance, in the priority given to large, fully-equipped, modern, expensive hospitals as against the small, local, well known community hospitals. We have swung from one to the other as the years have gone by.
Then there is the problem, also mentioned today, of the predominance of support (to the tune of almost 80 per cent.) given to the highly specialised, scientific and technological medicine of the hospitals as against primary care medicine, with its vitally important adjuncts of medical education and preventive medicine The initial, essentially political division of the profession into three parts—hospital medicine, general practice and public health—has never yet been satisfactorily dissolved. As for the present tenuous hold on life of community medicine, I agreed with what the noble Lord, Lord Richardson, said on the subject. It is certainly the impression the profession has, that community medicine is not very healthy at the moment, and it was good to hear the noble Lord, Lord Elton, mention its recrudescence, recovery or whatever else one might care to call it. I hope it is true because it is a very important part of any future service. Incidentally, community medicine is the modern terminology for the old Public Health Service; and it amounts to that, although it has developed considerably.
264
Then we have the contentious problems of the capitation system—if I dare mention them—based on quantity, not quality, a system avoided by every other nationalised health service in the world. Should we keep it? Must we keep it? By introducing a third party, a Government department, into the doctor-patient relationship, so primarily essential to good medical practice, is it not an insidious threat to the standards of that practice? If, as I think, in due course we are bound frankly to admit that there are limits to the extent the service can be funded from governmental sources, and we wisely decide to define those limits—that is, set priorities, as the noble Lord, Lord Todd, pointed out—should we not consider the many alternatives available to produce adequate funding, of which private practice (whether subsidised, given grants or backed by insurance schemes) is an obvious one?
Another sphere of activity that would seem to merit considerable rethinking is that of the nursing profession, revolutionised since the Salmon Report, which emphasised administration rather than bedside care. I have a feeling that the nursing profession, if given the chance, and particularly if they were somewhat better remunerated, would not be unhappy to revert to the primacy of individual patient care. The thorny problem of industrial relations between management and staff in our hospitals is crying out for solution. Some machinery must be found to prevent patient care from being jeopardised by strikes and industrial strife. Finally, let us not forget the great potential of organised voluntary help. We are at heart still a sympathetic and charitable people and there is much untapped and invaluable goodwill available, if and when required.
I feel, despite all my doubts and the difficulties that exist, that an honest, unbiased reassessment of the service, getting back to basic and fundamental principles, could still achieve results of enormous value to the future of the NHS. Which brings me to the 64,000 dollar question: Have we the ability, the resources or the will to do it? I hope so.
Lord Mishcon: My Lords, before the noble Lord concludes what everyone will agree has been a frank and delightful speech, may I ask whether, in his nostalgic recollection, he would include the fact that the old London County Council, on the basis of employing half a floor at County Hall, used to administer the hospitals of London?
Lord Porritt: I am glad the noble Lord made that point, my Lords, with which I entirely agree. In fact, I served in LCC hospitals for quite a while.
7.7 p.m.
Baroness Faithfull: My Lords, we are grateful to the noble Lord, Lord Hunter, for initiating this timely debate, particularly as there is a feeling abroad, an impression, that the National Health Service is at the crossroads, as was stated by the noble Lord, Lord Colwyn. I have been approached by members of the medical profession, the social work profession and voluntary agencies to speak on the balance as between the care of patients within the hospitals and the care of people in particular categories in the community, bearing in mind the present financial constraints.

265
In the 1980s should we not be clear as to those who require in-patient services? The noble Lord, Lord Porritt, referred to the wise use of the various sectors of the NHS. Should we not consider that those who are in-patients should be those who are required to be cared for in hospital, with their physical and mental condition being treated, enabling them to return to normal life in the community? In short, should there not be a treatability criteria for those who are in-patients? I submit that there are many people in hospital today who should be cared for in the community, thus leaving the hospital services for those who are in need of them.
The Green Paper issued by the Government in July 1981, Care in the Community, was a splendid document. It stated in the introduction:
"Most people who need long-term care can and should be looked after in the community. This is what they most want for themselves and what those responsible for their care believe to be the best".
The Green Paper went on:
"There are many people in hospital who would not need to be there if appropriate community services were available".
Who are those people who, if there was a different community service, could be cared for in the community and not in hospital? First, I would refer to the 2,000 mentally handicapped, now called mentally impaired, children who are being brought up spending their lives in hospitals. Of these, two-thirds have lost contact with their parents because in many cases they are placed in hospitals far from home.
I should like to congratulate my noble friend the Minister on showing so much concern for these children. I know this to be the case, since I am vice-chairman of Barnardo's, and the Minister's department is working closely with Barnardo's to set up small units in the community where the children can receive good, individual, residental care, which is not always possible in hospitals. I submit that there should be a directive—perhaps this sounds very harsh—that no hospital should be allowed to accept any mentally impaired child unless the child cannot possibly be brought up anywhere else.
Secondly, there is the ever-growing need for day and residential care for the elderly. Many people have asked, "Why is the health service in so many difficulties?" There are many reasons for that. One reason—referred to by many noble Lords—arises from the tremendous growth in the number of elderly people, in particular those in need of psychogeriatric care. I do not know how many such people are occupying beds in hospitals which could be used for treatable cases. In any case such people would be happier cared for in a small community in the area in which they live.
Thirdly, there are those people who surely should be cared for in the community, as was shown in the Acheson Report, and here I refer to primary health care by GPs, mentioned by many noble Lords. The noble Lord, Lord Wells-Pestell, referred to Oxford, and I would point out that in Oxford, with a population of 110,000, we have no fewer than seven health centres, five of which are purpose built. They give a service of primary health care second to none in the country. I would point out to the noble Lord, Lord Richardson, that the centres were set up by a medical officer of health, working in very close collaboration with the doctors in the area.
266
The practicalities of community care need to be better worked out. The problem lies in having divided responsibility as between the health service and the local authority social services.
Her Majesty's Government are surely to be congratulated, notwithstanding much of what has been said. In 1978–79 expenditure on personal social services was £1,460 million. The figure rose, and by 1980–81 it was £2,161 million. Those figures were obtained from the Chartered Accountants' Association, not from the Department of Health and Social Security. However, the figures do not allow for expansion to any great degree. What community services are required? As I have said, there is care in the community for mentally impaired children, in children's homes, and by way of adoption and fostering. There are units in the community, run by voluntary agencies and social services, for the elderly and the psycho-geriatrics. There is the home help service, the encouragement of voluntary effort, such as Crossroads, which has been mentioned, and home care assistants, as well as meals-on-wheels, and the need for social workers, which was mentioned by the noble Lord, Lord Todd.
Here the difficulty lies in the fact that local authority social services come under local government, while the hospital service comes under the health service. Local authorities are cutting back, and I would suggest that if the community services were what they should be, some people who are being cared for in hospital need not be there.
Some authorities have already set up joint planning committees following the circular. They have been only partially successful, for the very practical reason that there is joint financing of many projects between health service and the social services. The difficulty lies in the revenue consequences, which finally fall on the local authorities, who do not want to take on responsibility for something that they fear they might not be able to pay for in the years to come. I would suggest to my noble friend the Minister that this matter needs to be looked at very urgently.
Notwithstanding the very good Green Paper, I would point out that in Guy's health district the hospital services expenditure is £44.4 million and the community health services expenditure is £3.4 million. In the Lewisham health district the hospital services expenditure is £23.5 million and the community health services expenditure is £3.9 million; and the figures are the same for both the St. Thomas health district and the King's health service. If we are to provide a wise and better service for those on hospital waiting lists, a way must be found to develop community services. Only when there is an understanding, a partnership between the health services and the local authority social services and mechanisms by which they can work together will we be able to give the service which this country deserves.
7.17 p.m.
Baroness McFarlane of Llandaff: My Lords, I should like to add my congratulations to those already extended to the noble Lord, Lord Hunter of Newington, for initiating a debate that is so relevant to the quality of patient care, which I am sure is so near to all our hearts. I, too, have a great professional interest in the debate as a nurse, a midwife, and a health visitor,

267
as well as a member of the Royal Commission on the National Health Service that reported in 1979.
The commission set itself the task of answering the question: How good a service have we? It is a difficult question to answer. It is difficult to answer merely in statistical terms. One of the very frequent complaints that we received was that up until then the service had been very acutely orientated; that is, the preventive services and the services for health promotion had been under-resourced and underdeveloped. As members of the Royal Commission, we felt that far greater emphasis should be placed on encouraging people in self-care activities, that perhaps the whole British public should be re-educated in their own health care. I think it true to say that very often the great British public expect health to come out of a pill box or a medicine bottle, and members of the commission felt that far greater personal investment in self-care should be sought.
However, I believe that that requires a far greater investment in some of the things that we have been hearing about in the course of today's debate. There is, for instance, investment in health education. The noble Lord, Lord Colwyn, spoke, I thought in desparing terms, about the contribution of the public to preventive health measures. I think the situation arises because we have not adequately researched health education methods. It seems to me that giving information is not enough. The calorie counter never motivates me to do without calories, and I think we have to do a great deal more research before we have assured methods of health education.
Many noble Lords have talked a great deal today about the contribution of community physicians. That contribution has changed over the years and is not only orientated to the preventive aspects of medicine but also to medical administration. Certainly this was a sector of the medical service that we, as members of the Royal Commission, found was a real shortage specialty. Not only were there inadequate numbers of community physicians but their support was not adequate—support in terms of statisticians and secretarial assistance—and very often the community physician of a district would be working alone, virtually, in trying to carry out their work. We felt that they were an extremely important specialty to encourage.
A number of noble Lords have talked about the need for quality control in the health service. Lord Richardson mentioned things like tier review and medical audit. I think the medical profession are certainly to be congratulated in the progress they have made in this direction, but I would suggest that the progress has been not nearly enough nor wide enough, and that there is room for a great deal more development in this direction. My own profession has been seeking to make a contribution to quality control by being far more precise about the objectives of nursing care; to look at the expected patient outcomes when we are stating objectives for care, so that we can use these as criteria against which to judge the effectiveness of nursing care. Having said that, I should like to see the day when the professions were working together in quality control and when we were not working
268
separately as doctors, nurses, midwives and so on in this enterprise.
Besides the quality control factors, I believe that there are structural factors for the improvement of the quality of health care. I should like very briefly to mention education; and, again, I feel that there is far more room to support joint educational enterprises. My own chair of nursing is in the medical faculty, and I believe that nothing but good can come from nurses and doctors sharing common educational facilities and learning, as they are educated together, to work together later. I should like to see perhaps the older concept of the medical school replaced by the idea of a school of health service professions, so that those who will work together subsequently share common educational facilities.
The Royal Commission of course stressed the need for reorganisation of the Health Service, and this was supported by the research that was carried out by the commission. Now we are well towards implementing the reorganisation arising out of those suggestions, and removing one tier of management since the commission reported that obviously decision-making was slowed down by the numbers of different tiers and recommended that below the level of the regional health authority there should be only one operational level. But, given that, the commission found that the National Health Service is not a tidy structure, and great flexibility is needed so that the structure could serve the local function. It is this philosophy of flexibility in management structures that I should like to underline and plead that it be preserved. We seem to have a propensity for wanting a nice, tidy, neat structure that is the same in every place, and certainly the needs of the service are not the same in every place.
So I want to pass on to what I think are some of the problems arising out of the present reorganisation. Some of them were mentioned very cogently by the noble Lord, Lord Wallace. There are certainly many human problems suffered by those who are involved in the reorganisation. Many senior members of the nursing professions are now in the throes of competing for posts. Indeed, the posts of senior personnel have not been designated for the reorganised service that should be functional by 1st April. A leader in The Nursing Times on 3rd February indicated that of the 194 district health authorities, only 76 per cent. had appointed a chief administrator, 74 per cent. a treasurer 73 per cent. a medical officer and 65.9 per cent. a district nursing officer. Yet, very rightly, we now have problems of time-tabling, because the chairmen of the authorities are forging ahead in some places and pressing for details of management arrangements without, in many cases, the expert advice of nurses and doctors. Nursing is in a further difficulty in that the Whitley gradings for the nursing structure have not been agreed, so that it is very difficult to be definitive about the structure.
We were glad that the options for clinical units were provided for in HC88, making provision for specialist areas to be catered for. It is very strongly believed among nurses that special functional areas such as maternity care, mental handicap and psychiatric care certainly need a clinical expertise which is very special to those areas. So the tidy administrative structure that is co-terminous with the geographical location is

269
not always what is required, and there is a very strong feeling that we need to preserve functional entities in these areas. Besides this, in some districts very large jumbo units are being created, and once again there is a feeling that some of the needs of the health service are being sacrificed to administrative convenience.
But having looked at some of the problems that are arising out of reorganisation, I feel we should also look to the potential of reorganisation. Because in it I see some opportunities, first of all, to evolve a structure more suited to the functions of health care delivery; and I believe that if nurses and doctors can discuss together sensitively the need for services and receive administrative and financial support in so doing, then together we should be able to evolve more effective structures.
In all this, too, it has given us as a nursing profession an ability to develop a far better clinical career structure. The noble Lord, Lord Porritt, made reference to the Salmon Committee Report. I am certainly one of those who felt that the Salmon management structure was at that time, when it was implemented in the nursing profession, an outdated structure taken from the industrial world. I believe that the core of nursing is about clinical care of the patient, and I believe that the nursing profession is now quite clear about this and wishing to forge ahead and develop its clinical role.
Having said that, there is need for very good management and very strong management of the nursing service. There is need for involvement of nurse management at every level of decision-making in the health service because decisions at every level in the health service affect nursing care. But the most important nursing function is to me the clinical function. We as a profession have now had a number of conferences and reports on the possibility of developing a clinical career structure.
In the new statutory machinery that has been set up under the Nurses, Midwives and Health Visitors Act 1979, we are now looking very fundamentally at the kind of person that we want to see emerge from basic nursing education, and we are sure that in the registered nurse we want somebody who can assess the patient's needs for nursing care, to plan care, be able to prescribe care on a scientific basis and evaluate the nursing care given. We wish to develop educational structures that will allow this to happen. It means that this will be the basic level of training and that there will be need for continuing education of nurses in order to occupy the clinically specialised roles that we see as being more senior in the clinical function of the nurse.
So we have in the United Kingdom Central Council of Nursing, Midwifery and Health Visiting, and the English National Board in this part of the world, structures that will enable us to go forward on this educational front. I believe that these are ways in which we can move forward in improving health care and make a contribution from the nursing, midwifery and health visiting professions. So I plead that we retain great flexibility in our management structures and then perhaps we can maximise on the motivation of professionals in the service. I must apologise, my Lords, because, since I have to travel elsewhere this evening, I shall have to leave before the summing-up of the debate.
7.33 p.m.
Lord Hayter: My Lords, everybody in this House is an expert on health. Apart from the expertise which I get as a patient—past, present and no doubt future—my own expertise is as chairman of the King's Fund. I am delighted to have as my distinguished colleague on that management committee the noble Lord, Lord Hunter, who introduced this debate.
Just as the department in the course of its career, as you have heard earlier, my Lords, changed its name and its function and became the Department of Health and Social Security, so the King Edward's Hospital Fund for London broadened its scope and is now more popularly known—I hope—as the King's Fund, because we have a firm conviction that health is not just a matter of hospital but of the whole of the environment, and that prevention is better than cure, although of course there are some ills that can be neither cured nor prevented.
From time to time, the King's Fund has taken up special issues, one of them being the post-graduate medical centres which were talked about earlier this evening. We started those. One was just after the war, when the quality of food in the mental hospitals was appalling. We took that on. More recently another big job that we tackled was that of medical records, By a happy coincidence, in 1979 we tackled the problems of inner city areas just at the same time as the London Health Planning Consortium set up its study group under Professor Acheson. Nobody has any doubts about the problems of the inner city areas. There is the trade recession; the closing of some of the casualty departments; the social environment with one-parent families, the number of children in care, which I am astonished to learn is two and a half times the national average. There are also the gravitation to London of the homeless and the hopeless, the alcoholics and the drug addicts; the growth in ethnic minorities, which has been discussed several times in this House recently; the migration out of London of the young, leaving the elderly behind; and the growth of daily commuters into London. In connection with that, Professor Acheson, in his report, said:
"Public transport services are said to have deteriorated in recent years".
He can say that again, particularly today!
There is also the unfortunate effect of the recent changing of boundaries, the boundaries not only being set up under the reorganisation of the health service, but the boundaries that were altered in local government. As a result, sometimes one has to tackle at least three statutory bodies to get the provision of primary care in any given locality in the inner city of London.
Then there are the problems which have already been referred to about the general practitioners. The sizes of the lists vary enormously. I was astonished to learn that 25 per cent. of the population in certain areas are not registered with anybody. This is probably due to the ignorance of the family practitioner committee's role, which could help those patients find a general practitioner. Then there is the unsatisfactory siting and construction of many premises. What a simple observation it is that, if one wants to go to a GP these days, there should at least be some

271
parking facilities readily available. That is by no means always the case.
Then of course there is the complete lack at this moment of a viable retirement policy. General practitioners stay on for longer than they perhaps should from a medical point of view. The Acheson Report ended up with 115 recommendations. I felt that I could epitomise those into three categories. There were the ones which showed the vital necessity to keep a careful balance at the national level between the general medical services and the hospital services. We have of course been talking about that this evening. Secondly, there were those dealing with the need to co-ordinate primary health services. Thirdly, there were those relating to the realisation of the special problems in London and other inner city areas, such as the incidence of social problems and the generally weak tradition of primary care, as opposed to the needs elsewhere in the country.
What could or did the King's Fund do about this? Fairly soon we shall have devoted £500,000 to trying to identify, encourage and disseminate good practice in inner city areas, which we do by research projects, by conferences and publications. On the primary health care aspect, we funded a study of the accident and emergency department attendances, at the request, indeed, of Professor Acheson's committee, to see how much these substitute for the general practitioner. It again came as a surprise to me (though probably not to others of your Lordships) to find how often a patient does not know his GP and therefore always goes to the accident and emergency department. We supported two or three publications by the Royal College of General Practitioners dealing with these primary care patterns in London.
Then, an important current project: we are going to help the Medical Architecture Research Unit to help upgrade, renovate and convert GP premises in inner London. There are some wonderful ones but there are also some appalling ones, and we do not see why we should not try to help to raise the standard.
On the community development side, much has been talked about this evening. This is where we are trying to evaluate these inner city community projects. There can be no satisfactory pattern of health care without the active involvement of the community itself, and we realised that there was a need to coordinate these projects so that other communities could be encouraged to do the same work.
Again, on the long-term and community care side of the inner cities, several projects are in progress concentrating on the care of the elderly and on psychiatric illness. The community hospitals in the inner city represent a somewhat hopeful position because many small hospitals are now being scheduled for closure or change of use and there is perhaps a potential role as GP or community hospitals. This could have a great impact on inner city areas and we feel our role is to help such projects to maintain contact with one another and to assist in the evaluation. There is never any need to emphasise the information about London's needs. As your Lordships may know, the four Thames regional health areas segment the whole of London and we are trying to do what we can to cross this artificial boundary. One study we are doing
272
is comparing the needs of the inner city of London with those of Essex, so that we can suggest more sensitive ways of allocating funds between the different areas in this country.
Perhaps I should also mention that we now have seminars for a number of health authorities in the regions and we also invite the chairmen of the new district health authorities to help them to think out their priorities and plans. I may have given your Lordships the wrong impression—that with all this going on there is no need for the Government to do anything. That is absolutely wrong. We are only just scratching the surface. The task is immense, and it is becoming quite clear that as we are proceeding with our own programmes the needs of ethnic minorities and needs which come from various directions are forcing us to pick and choose the projects that we can tackle ourselves.
I have two questions to put to the Minister. The first is in relation to the Acheson Report. Perhaps I could give two literal quotations: one concerns the letter which set it up and said that it was to be "an urgent inquiry". The second was:
"It is of the utmost importance to find a solution to which early effect can be given".
The letter was written in 1949; the report came out about a year ago—and what has happened since? I think most of us know that nothing has happened.
Secondly, in the report itself it was stated that there were many examples of innovation and good practice, and it was hoped that the King's Fund, among others, would collect and disseminate information. The pressures are on us and we can go only so far. If there is any possibility of the Government sharing this financial burden, as I think they should, we would be very eager to collaborate and we would not relax in any way our own endeavours.
Finally, in debate after debate, week after week in this House we have come back to money. That is fair enough. What we have got to realise, as the noble Lord, Lord Bellwin, was saying recently, is the importance of getting value for money. Let us put a gloss on the figures relating to national health, taking up the point made by the noble Lord, Lord Porritt—that the proportion of gross domestic product spent in this country on health services is lower than it is in the United States of America, Australia, Japan and all the EEC countries, with the exception of Greece. As the noble Lord, Lord Porritt, said, that illustrates the need for keeping an open mind on the amount of money that should be spent, although I can remember him telling me that there is no country in the world which can afford the health services it wants.
Also, when we are considering in our own homes matters of health or, even more important, matters of life and death, we do not consider money. We get on with it; and I think, in the context of the inner city areas, so should the Government. Finally, we are talking in the inner city areas about spending money now which will save money in the future. I would suggest that positive action by the Government in these inner city areas is, to use a non-political phrase, just plain common sense.
7.45 p.m.
Baroness Gardner of Parkes: My Lords, I am sure

273
your Lordships would be quite willing for me, in speaking in this debate on improved medical care, to include some comments upon dental care, as I am a general dental practitioner. I know that my noble friend has earlier discussed a great many points concerning dentistry and I do not intend to speak for long. I am sorry that I was not able to attend the earlier part of the debate and therefore hope that I shall not be repeating things which have already been said. I was very interested in the comments just made by the noble Lord, Lord Hayter, and particularly his comment that money was being spent on the inner cities. Sadly, that is not the case in London, and RAWP, the Resources Allocation Working Party, was designed to move funds out of London and particularly to transfer resources to other areas. It was considered that Central London in particular was over-provided with good hospitals and good medical facilities and that the regions were under-provided, so this money should be transferred from the more fortunate to the less fortunate areas.
This approach also acts within the regions and certainly is seen very clearly in effect in the London regions, as money is being moved from the inner city, where the population is shrinking, to the peripheries of the regions. Conflict inevitably arises when the districts have to decide priorities in allocating their revenue budgets between community services and the acute services—for example, between health visiting and high technology medicine. In the light of the Acheson Report, which draws attention to the inadequacy of primary medical care in inner cities and to the great demands on the community health provision in those areas, some method must be found to make appropriate allowances for these problems in any reallocation formula such as the RAWP formula.
Although I should like to pass a few comments upon the inordinate hours spent by any patient attending an out-patient clinic—because waiting time seems to be nothing and you have to allocate a whole day for any attendance at a hospital—I had not really meant to speak on that point because I feel sure that it will already have been made by other speakers earlier. My intention is to discuss the primary care provision and to draw attention to the fact that there are so-called unattractive areas which, because they are unattractive, do not appeal to the practitioners who are needed to set up in those areas. For example, some parts of London are classified as open areas, and any doctor could go there. The time was when a doctor was expected to live within his area but now, in order to enable people to have a doctor at all in such areas, they have had to agree to a doctor living fairly far away from the surgery and simply being within driving distance if an emergency arises. Obviously, this is not a very good way of providing adequate primary medical care for the patients and it was certainly never the intention.
There is also the reverse problem. I have served since 1974—and I am just finishing—on the Westminster, Kensington and Chelsea Area Health Authority. We receive a very large number of complaints from patients in so-called affluent areas who cannot get a doctor to accept them on his list. That is usually because the doctors concerned have fairly small lists and restrict the number of their patients. In fact the Acheson Report draws particular attention to the
274
single-handed doctors aged about 70; and we have quite a number of these in this area. If these patients appeal to the health authority, they are told that there is an adequate number of doctors in the area, although the reality is that it is very difficult to get onto a general practitioner's list.
The Dental Strategy Review Group is the body which has recently put forward a number of recommendations on improvement of the general dental services, and it has highlighted some of the problems which general dental practitioners face. Perhaps I should declare an interest here, because I myself am in practice. One of the suggestions made was that there should be a manpower policy to direct dentists to areas where they are needed. But knowing my profession, and its contrariness, I am sure that the last thing in the world to produce the desired result would be any form of directive to practitioners. However, I believe that incentives to practitioners could create a situation were dentists would go to those areas which are sadly in need.
Dentistry is changing dramatically and there is a great increase in the number of general dental practitioners. This is not unusual. It is a world phenomenon and it is not restricted to this country. We are now getting a surplus of dentists throughout the world and quite a fall in dental disease, largely due to fluoride in toothpaste. This means that time and patience may allow market forces to solve this matter and direct dentists to where they are needed, but I do not think we can wait long enough for that to happen.
At the weekend, I was at the University of Newcastle-upon-Tyne and there I met someone from the local area health authority. He told me that they have a map of the pattern of dentistry in Newcastle-upon-Tyne, which shows all the dentists peppered fairly thickly in the nice attractive areas. He asked what they could do to make dentists go into the other areas where they are so badly needed, and where patients could then have the benefit of dental care. When I was on the Inner London Dental Committee some years ago, all kinds of health centres were built at considerable expense, and dentists were encouraged to go into them. It was greatly resented when dentists would not go into those premises and it became clear why that scheme would not work For the benefit of this House I should make some points on that, because if we recognise the difficulties and adjust the pattern to match the problems we shall have the dentists going in.
First, it is essential to make premises available in those areas and not to restrict the type of practice. This may seem a contradiction in the terms of this debate, which has to do with improved facilities in the National Health Service; but it is not a contradiction. The dentist is usually an individual who values his freedom and his right to treat whichever patient he wishes. Usually, when a conscientious practitioner takes on a practice, he takes on pretty well everyone in sight. For example, I always say to people who come to me that I would not refuse anyone, unless the patient was simply going to be a time-waster and did not want dental treatment. If all someone wants to do is to come and have a long conversation he should do that privately, because there is no National Health provision for that.

275
But most dentists accept patients who come in, although in those areas which are underprivileged or unattractive people will not be willing to pay out large sums of money for private treatment, so the possibility of private practice is virtually nil. I say this with experience of my own area where, at the most, there would be only 5 per cent. private practice. But the practitioner resents the thought that he does not have freedom, so past suggestions of writing into the contract conditions which restricted the type of practice were unsuccessful. Even more important, unlike the doctor, the dentist has the right to sell his practice if he wishes to move from an area or to retire, but in those premises which were previously provided none of those rights was to be given. That was not a good idea, because if a young dentist were encouraged to go to a poor area and build up a very good practice, he would find an automatic successor if he wanted to sell his practice. So we must certainly allow that freedom. If we did those things, we should have dentists going into those areas.
I do not want to speak very much on charges to patients, because I understand that my noble friend and colleague in the dental profession, Lord Colwyn, has already covered that point. But I would just stress that it is unfair that the regular and conscientious patient now pays pretty well the total value of his treatment, whereas the patient who neglects his mouth and lets a great quantity of work build up is getting a real bargain, even at the top £60, when he may be getting £1,000 worth of dentistry. The patient at the other end, who is getting £9 worth of dentistry, and with the new charges £10 or £12 worth of dentistry, is paying the total charge.
In the report of the Dental Strategy Review Group, there is a suggestion that within our dental services we need a lot more administrative dental officers, and I must deplore that proposal. I have been unable to find any evidence that administrative dental officers are necessary at either district or regional levels. I know that many organisations believe that to have an administrative dental officer adds status to the profession and to the health authority concerned. But this is a false belief. The real role of the dentist remains the treatment of the patients and the provision of primary care services. So we must look at our primary care services, in general, in the unattractive areas and see that patients are getting the treatment that they deserve.
There is too much pushing of work from one person to another, without the actual treatment being carried out. Some general practitioners—I am speaking now of doctors—run superb practices, operate appointment systems and have model arrangements. But in others, sadly, the patient is fairly unimportant. We want to get back to a closer identification of the patient with his own doctor. This direct personal relationship is very valuable.
Some of my patients have been coming in for more than 20 years, and are now bringing their own children. Very often, it is not treatment that they need—they may need virtually none—but they come in for the assurance that everything is all right, that little Johnny's tooth is not growing the wrong way and to ask at what age any treatment should be carried out. These patients should feel that they have a right to go to their doctor or
276
dentist at any time, and to receive the interested care and attention of the practitioner.
The practitioner, in order to be able to meet that demand, must be given good working conditions which are maintained, and he must really be appreciated. The primary care services must not be regarded as a rather poor relation of the hospital services. The hospital services are essential, and they do fantastic things in terms of high technology, but I stress that the basic bread and butter medical services are the primary care services in medicine and dentistry.
7.59 p.m.
Lord Molloy: My Lords, this has been a most interesting and fascinating debate with contributions from people who are expert in a variety of ways, and also from those who have a different philosophy. But running through the entire debate was a degree of unhappiness about what has been happening to our National Health Service in the past two years. That might account for the belligerent attitude of the noble Lord the Minister in his contribution earlier. I think he must have sensed it, and I am very happy that he made his contribution in the way that he did, because he recognised a great deal and felt a little upset about it. I hope that when he makes his contribution at the end of the debate he will promise us that he will at least do his level best—and if he will do that it will be no mean contribution—to get the National Health Service back on the proper road where it ought to be. No Government have ever given this great service the wherewithal which it deserves.
I am grateful to the noble Lord, Lord Hunter of Newington, for giving us the opportunity to debate this subject. Here we are, in 1982, debating the need for improved medical care in the National Health Service, a service which was created a few years after the most horrendous war in history. Its creation was opposed tooth and nail by the party opposite, stage by stage. But they have been converted. That is why I hope they will do something about it and will bring honour to themselves by maintaining support for the National Health Service. The fact is, however, that in 1982 we are having to debate the need for improved medical care in the National Health Service, a service which seeks to provide a healthy British nation.
A healthy British nation is the basis of all our industry, commerce, education, defence and all the fundamentals of a civilised society. A real enemy of this country of ours would wish the massive rundown and destruction of our National Health Service—not so much because of the grief, the anger and the pain that this would cause but because of the fact that if we keep going down the slope of a mean, mingy, nasty attitude to our National Health Service the result will be reflected, as I have already said, in industry, commerce, education, defence and all the great fundamentals of our nation. That is what is at stake.
There is another way of destroying the National Health Service and, alas! there seems to me to be evidence that the Government are using this crooked way of trying to undermine a great service which is based on the Sermon of the Mount and the Good Samaritan. In order to save money, they are giving aid, wherever they can, to private medicine. The noble Baroness who spoke a few moments ago men

277
tioned that people come to see her for a variety of reasons. Some of them have nothing particularly wrong with them. Nevertheless, they have adopted the good practice of going to see her. The noble Baroness said that she hopes that they will never be put off coming to see her by having to make a massive financial contribution. After an examination by a doctor had been made at home—this is how it used to be before the war—that was the end of the matter, because there was insufficient money with which to go to the chemist and buy the prescription. That was the crass, vulgar, absurdity which existed before we had the National Health Service.
It is clear from what has been said on all sides of your Lordships' House that it is hoped that those days will never return. Perhaps the worst thing of all would be if our National Health Service were to be sabotaged by the money grubbers who do not mind from what evil source their patients have got their money, so long as they have got the lucre with which to pay them. That is one of the worst evils. When one discovers that we are at the bottom of the league when it comes to paying for our National Health Service, one wonders where on earth we are going. What is the point of having a massive defence budget, of worrying about education, of trying to overcome the evils of unemployment if at the same time this great service is being undermined? It will prevent the recovery of this country, which we so desperately need.
With the introduction of the National Health Service in 1948, we saw a great principle made reality. Many noble Lords and noble Baronesses have paid tribute to the genius, ability and dedication of those who work in all aspects of medicine and hospitalisation. Their skills have been made available to all. There should be no discrimination when it comes to ability to pay. That is the great achievement of the National Health Service. Previously, one British family could afford a doctor while another British family could not afford a doctor, or any form of hospitalisation. The great "leveller" was the grave danger which we faced in 1939 and 1940.
This is part of the discussion that is taking place in our universities today. It is thought that we shall turn not so much into a corrupt society as into a cheating society if we go back to those pre-war days. Because of the National Health Service we have removed many other evil practices. In a civilised society it should not be possible to buy and sell patients. That evil has been removed. Nevertheless, the great fervour and impetus with which this service was launched after the Second World War has not been maintained. I believe that this will be detrimental to our nation. Let us face the fact—I am sure the noble Lord the Minister will—that many people who devote their skills and abilities to the National Health Service in a variety of ways are unhappy and, in many cases, very angry.
The noble Lord, Lord Colwyn, mentioned that dentists are opposed to extra charges. This will mean that all we are doing is storing up trouble, for we shall have to pay more and more for neglecting the teeth of our children and others. What we neglect today will cost us much more in the future. This is very simple logic which even Her Majesty's Government could understand if they really tried.
There is a much more serious aspect of deterioration within the National Health Service. Let us consider
278
kidney machines. If you do not know somebody who needs a kidney machine you are not, of course, particularly concerned. As the great architect of the National Health Service, Aneurin Bevan, said, the trouble with us all is that we seldom arrive at the frontiers of understanding until our own soul is smitten with grief. If you have a son, daughter, or mother who needs a kidney machine but none is available and death approaches much more quickly, with pain and agony, then you begin to ask what we are doing about it. We cannot wait for hundreds of thousands of people to need kidney machines before we do anything about it. Our job in the House tonight is to appeal to the Minister and to Her Majesty's Government to ensure that those who are worried this evening about whether they will be provided with a kidney machine, or even with a share in one, have that worry removed. That is the responsibility of a civilised society.
A number of speakers have mentioned, quite rightly, the need for more hospitals. The argument has been put forward, and I have a great deal of sympathy with it, that more health centres should be created. But who is going to build the hospitals and the health centres? Why, the construction industry. And which, of all industries, has a massive amount of unemployment? How many electricians, carpenters, joiners, bricklayers, architects, quantity surveyors are out of work because of the policies of this Government? This is the point which the noble Lord opposite ought to note. Those who are out of work, and who, for doing nothing, are being paid a pittance, could well be building the hospitals, the health centres and perhaps the training schools where people could go to make their contribution, either in terms of preventive medicine or curative medicine or in terms of some other form of aid, help and expertise within the National Health Service, besides building the hospitals and the health centres.
When the United States were affected by the curse of the mid-1930s—as we are being afflicted now by the curse of monetarism, which is the policy of this Government—the way out they found was provided by British and Canadian economists who simply said to the then President of the United States, President Roosevelt, "What you have to do is to spend and prosper". We did the same thing in this country. Great works were initiated and great hospitals were built, both in the USA and in this country. Some of our greatest town halls were built and some of our finest hospitals were built, not out of any desire to aid the sick or the suffering but to get people off the scrap-heap and give them a useful job for which they could be paid. Why can we not do that now? It is quite right and proper to link this argument to the creation of a really good National Health Service. When one realises the number of construction workers and steel workers who are doing nothing—some of them having been forcibly made redundant—and yet here we are needing more hospitals, health centres and schools, it does seem to me and to ordinary people outside this House that we are bordering on lunacy.
I hope that something will be done by this Government. I do not want to see this Government returned at the next election, but if I was an evil person I might

279
say, "You are doing fine. Carry on doing what you are doing". They would learn the lesson in time, but I do not want that to happen. I am much more concerned about the economy of this nation and the maintenance of our great health service. We have to improve medical care in the NHS. That means that the NHS must be allocated the funds which are necessary. There is also a need for more training in hospitals in conjunction with developments in new technology. New technology can make a massive contribution. The problem is, as I understand it from those who know much more about this than I do, that we are neglecting to train people in the use of this new technology. It seems that we are concentrating on producing new technology. Now that the new technology is there, what we have to concentrate on as well is how to make full use of it in the health services.
It also has to be said that financial rewards in the NHS are somewhat out of balance. Registrars, consultants, doctors and specialists are all absolutely vital and are entitled to their rewards—but so are those who work in the nursing and ancillary professions. There is some unease and unhappiness in that vital sector of our NHS. The motion we are debating calls attention to the need of a better health service but apart from the need for improved medical care in the NHS, there is a need for improved conditions for those who work in it. If we can achieve both, we shall be on our way to a very good National Health Service indeed.
With regard to nurses and ambulancemen, when one attends their conferences, discussions and negotiations, much of their time is taken up not only with debates on improving their own conditions but, between their trade union representatives and the staff side of the Whitley Council, there is also much discussion on how to improve the National Health Service. I have heard debates on child care, mental health, preventive medicine, and after-care for those who leave hospital—be they young or old—as part of discussions initiated by trade unions, in addition to those on all that they require for their members.
The overwhelming majority of those who serve in this great service welcome the unanimous report of the Royal Commission. Had the Royal Commission not been set up, we should probably have been asking ourselves, "What shall we do? There are many criticisms of the NHS and ought we not to look at what can be done? Let us set up a Royal Commission". There is much in the report of the Royal Commission with which I, with my little knowledge (although I have talked to people with much more knowledge than I have), do not agree. Nevertheless, the Royal Commission did agree unanimously that we should return to the first principles of the architect himself, Nye Bevan—that is, that the NHS should be provided totally free from the moment a child is born, and that he shall be guaranteed the best medical service that can be provided right through his lifetime. We have not progressed far enough with that. If this is the recommendation from the knowledgeable people who sat as members of the commission, then we ought to try to implement it as quickly as possible.
I believe that improved medical care means improved
280
medical care both before and after hospitalisation. Patient care can only be first class if we demonstrate our sense of responsibility as legislators by caring for those who work within the National Health Service. I should like to see established a permanent national review body to submit regular reports on the National Health Service to Parliament. I would also like to see established within our parliamentary set-up a National Health Service completely divorced from the social services. It has been my experience in another place that dealing with the NHS and the social services is too much for one Secretary of State. I do not intend to argue this point at great length, but I do believe that the NHS is of even greater importance than social security, and that there is a fundamental necessity to return to the days when the social services were the responsibility of a Secretary of State—that we should now have a Secretary of State concerned solely with the National Health Service.
I want to compliment the Government on their reorganisation. The Government are absolutely right to abolish the present tier system. So much damage was done when this incredible system was introduced by Sir Keith Joseph. The Labour Party said that it was going to do something about this, but did not. At last, this Government say that they are going to do something about it. It was an appalling bureaucratic nightmare and there was no need for it. Nye Bevan launched the National Health Service without affecting the autonomy of small groups of hospitals, and his system worked admirably. Now we have a massive weight of administration which is costing a lot but contributing nothing whatsoever. I hope that the Government will pursue their aim very strongly in this field.
Why I feel as strongly as I do about our National Health Service is because, in this world in which we live, we read of so many evil things. We hear of a nation's entire people living in the equivalent of concentration camps and that, in other parts of the world, a person who can purchase an aspirin is almost regarded as being well off. We in this island still have a great role to play and a great example to set—not so much in the manufacture of nuclear weapons but in how to behave in a sane and civilised manner. The pursuit of happiness and the greatest good for the greatest number starts with the one thing that frightens us all; are we in good health or not? When it comes to someone who is stricken with a cancer or some other horrific disease, whether he is a multi-millionaire or a coal miner living in a small cottage the grief is the same. I want to see both cured, or ways found to cure them both. That is why I believe that is what the health service will do. That is why I do not want to see it gnawed at, either by meanness or by the creation of any sort of private medicine, because it does enable people to pursue happiness and it is for the greatest good of the greatest number. Therefore, if we want an efficient health service, we have to see to it that it is well financed, and, equally important, that it is staffed by contented men and women prepared to devote their lives to this great service to which they belong.
8.21 p.m.
Viscount Chandos: My Lords, I, too, am very grateful to the noble Lord, Lord Hunter of Newington, for

281
introducing the debate on this important subject. I am particularly grateful for the fact that he has introduced it in this week, since coincidentally this is National Kidney Week, the week allocated by the Charity Commissioners to the National Kidney Research Fund.
My father was one of the earliest patients in this country to be treated by haemodialysis, and enjoyed to the full, despite inevitable difficulties, 15 years of life which he would not otherwise have had. I should like to say at the outset that the quality of treatment and care provided to him through the National Health Service by one of London's principal teaching hospitals was the subject of deep admiration on the part of myself, my family and all those others who witnessed the treatment.
The noble Lord, Lord Elton, gave haemodialysis as an example of the Government's commitment to expenditure, however heavy, on medical care. At the risk of being categorised by the noble Lord as one who looks only at the emperor's clothes, I would suggest that that commitment is not enough. I believe that the prospects of other sufferers from renal failure now receiving the same treatment as my father did ale being inhibited by this Government's policies, and that the position in this country has already deteriorated substantially compared to that in nearly all other Western European countries.
I would like, therefore, in view of the contributions made by other noble Lords today, to speak principally about this specific example of renal treatment, not so much in order to make special pleas for this area of medicine—although I believe it may justify a greater proportion of total resources being devoted to it—but much more as an illustration of the specific damage being done by this Government's attitude towards public expenditure.
I would draw the attention of your Lordships' House to the two-pronged squeeze on the services provided by the teaching hospitals, through the low growth in the Department of Health and Social Security's budget, combined with the cuts imposed on the University Grants Committee and passed on to the teaching hospitals. It is not generally appreciated by people outside the medical profession that the UGC's support of the hospital system in this country is not restricted solely to training and research, but to actual treatment of patients as well. The Select Committee on the Social Services has been hearing in another place of the tragi-comical stalemate between the DHSS and the UGC, with the DHSS unwilling to indicate whether it will take over the financing of posts that the UGC feels it cannot afford to support following its own cut in budgets, since the department feels that this will encourage the UGC to decide definitely that it will not finance those posts under consideration. While this stalemate is allowed to continue, vacancies for vital medical posts will not be filled and the services available to the public will deteriorate further. In effect, the teaching hospitals, with the central role which they play in the health service, are being squeezed twice over.
Renal treatment is one of those areas where the contribution of the teaching hospitals is particularly important. There are in this country less doctors per renal patient that in any other country in the western world, and, while this productivity might be laudable,
282
it is at a cost to the patients, potential patients and the doctors themselves. What is more, the UGC cuts, if they are not balanced by an increase in the department's support, will lead to a position worse still.
In the teaching hospital where my father was treated, which has one of the foremost renal units in the country, four times as many patients are now treated as at the end of the 1960s, with hardly any increase in the number of doctors or nursing staff employed. The UGC cuts are likely to cause two of the senior six doctors posts in the renal unit to be eliminated, at a time when, as I have already suggested, the resources within the unit are already stretched to breaking point. I hope that your Lordships find it easier to reconcile this sort of evidence with the figures which the noble Lord the Minister gave us earlier on the Government's expenditure on the health services. I would suggest, with respect, that the effect of the UGC cuts might perhaps be considered by the noble Lord the Minister in assessing the true increase, if there is one, of the Government's expenditure on the health service.
My Lords, I would like very briefly to summarise the position of renal treatment in this country and how it compares with that available in some of our neighbouring European countries. Studies have shown, both in this country and throughout Europe, that the treatment of what is called end stage renal failure is successful in trems of the survival of the patient, compared with the treatment of other serious diseases such as heart attacks and cancer. What is more, the quality of life for patients saved by either transplant or haemodialysis is comparatively high—again I can add my personal confirmation of this—and certainly higher than that of people suffering many other chronic illnesses or disabilities. Between 80 and 90 per cent. of renal patients are deemed fit to work and can thereby make their economic contribution to the country and mitigate the costs of the treatment.
What is more, although the continuing costs of dialysis, and to a lesser extent the care of transplanted patients, is high, as the noble Lord the Minister observed, the additional call on hospital resources that are responsible for their treatment is not high. A recent study showed, for instance, that of those who had been receiving some form of chronic renal treatment for 10 years or more, two-thirds were not hospitalised at any time during the course of the year when the study was done. I believe, therefore, that it can be shown that renal treatment such as heamodialysis merits, on humanitarian and economic grounds, a fair share of the cake. On the whole, I believe it is getting it, more or less. What is wrong is that the cake is not big enough and is being eaten away by the current policies of the Government.
Because Britain started early in the treatment of patients with renal failure, the number of patients receiving treatment, as a proportion of the population, was reasonable at the beginning of the 1970s in comparison with some European countries, including France, which had lower levels of treatment. At the beginning of the 1980s almost every country in Europe had overtaken Britain in the proportional number of patients receiving treatment, and, as one would suspect, the figures for new patients being treated are, therefore, correspondingly worse.

283
This can be most effectively illustrated by looking at the treatment of patients in different age groups. For patients suffering renal failure up to the age of 44 the United Kingdom provides a level of service not far from that provided by France, West Germany and Italy. But once patients in the older age groups are considered the appalling consequences of the limited resources available become apparent. In the age group 45 to 54 the number of patients per 1 million of the population accepted for renal treatment in the United Kingdom is about half of that in France, West Germany or Italy. In the age bracket of 55 to 64 the figure is less than one-third, and in the age bracket of 65 and over, the difference is so large as to make a mockery of comparisons. Of course renal treatment of older patients is not so successful as treatment of younger patients, either in terms of their survival rate or of their ability in some cases to adapt to those problems which inevitably follow the treatment. If resources are limited, therefore, doctors have inevitably to choose between potential patients on grounds of age.
We have grown used to regarding ourselves as the poor nation of Europe, so perhaps your Lordships will not be surprised that the treatment provided in France and West Germany is better, since their resources nationally are greater. But how can we justify the same disparity existing between the United Kingdom and Italy? If any of your Lordships were interested in seeing these and many other depressing figures in greater detail, I would commend to them the various annual reports of the European Dialysis and Transplant Association. I hope, at any rate, that the noble Lord the Minister will read the most recent reports before he gives haemodialysis again as an area of the health service of which the Government might feel proud.
This afternoon's debate has been long and so I shall not go into greater detail about this particular area of medical treatment. I do not propose, either, to say much about the many other important points that have been raised about the National Health Service by other noble Lords far more expert than I am. However, I would like in particular to support the views of my noble friend Lord Perry of Walton on the need for leadership both at the top of the DHSS and within individual hospitals. I feel, perhaps more than my noble friend Lord Perry, that there is also a problem of money, and I would like to make one point in that respect. The standards of the National Health Service have been declining relative to those of most other developed countries, and I have illustrated that in one specialist area. The present Government's policies seem likely not to halt the relative decline in the quality of services, but even to accelerate it. This position must be reversed and the target of comparability with countries of similar prosperity is the very least that we should aim for. It is the duty of the Government to provide the funds to allow this, and anything which allows the Government to shirk this responsibility is to be avoided. The growth of the private health sector should, perhaps, be seen in that context.
None the less, I believe that we should be realistic about how much can be achieved, at least within a short space of time, given the constraints that any Government will suffer on the level of public expenditure.
284
The noble Lords on this side of the House think agree that this Government are imposing unnecessary constraints on themselves in this area; but those of us on this Bench believe that there are, and will be, constraints of some sort for any future Government. In view of that, I believe that it is important that the National Health Service does not turn its back on other sources of finance for projects relating to treatment as well as to research.
It is, of course, difficult for the National Health Service to admit that any particular piece of expenditure is desirable but cannot be afforded. But in the real world—particularly as the technology available in some areas becomes more expensive and more complex, as the noble Lord, Lord Hunter, said—this seems unavoidable. There is enormous enthusiasm among people in raising funds for medical purposes, and it is not surprising that a specific, tangible project often has greater appeal than some rather more intangible research. In the past these enthusiasms have sometimes been misguided or misplaced, and equipment has been purchased that has not been effectively used and, moreover, has subsequently led to a drain on the resources of the National Health Service in financing its continuing use. More importantly, the health service must not be allowed to avoid expenditure it would otherwise have undertaken, through reckoning that voluntary funds are, or might be, available for that project. Furthermore, the level of voluntary contributions to medical research must not be reduced either.
But having listed the problems, I still believe that the potential benefits of harnessing the energy of voluntary fund-raisers more directly to the needs of the health service, would justify the time needed to devise a satisfactory method of co-operation. Perhaps the noble Lord the Minister could consider with his advisers whether an undertaking by the Government to match any voluntary contributions greed projects, pound for pound, might not be a useful start. Not only would this achieve a net increase in the health service's resources, but, at least as important, it should foster greater involvement and pride in local hospitals among their potential patients. I would suggest to your Lordships that this would be a far fairer and more widely acceptable way of increasing the total resources of this country's health system, than encouraging the growth of the private sector.
8.36 p.m.
Lord Pitt of Hampstead: My Lords, I, too, wish to thank the noble Lord, Lord Hunter of Newington, for introducing this debate and also for the way in which he did so. The noble Lord's speech was extremely interesting. He took us right back and gave us a good historical background to the service and then he brought us right up to date. We are all very grateful to him for doing so. This debate has enabled us to hear many very good speeches on the subject of the health service, and in particular the speech of the noble Viscount, Lord Chandos, who has just preceded me. The noble Viscount made a remarkable speech for which I should like to congratulate him and I think that your Lordships would also like me to thank him.
The hour is late and I do not intend to delay the House for long. I would not impose a long speech on your Lordships tonight. However, I wish to draw

285
to your Lordships' attention two matters with which I hope the Minister will deal. The first concerns the proposal that overseas visitors should be charged. I believe that that is a mistake. It would not bring in much in the way of revenue. I gather that the Secretary of State said that he would receive £6 million. As I view the situation there will, in fact, be expenditure involved in collecting that money as well as a fair amount of bureaucracy. I can assure your Lordships that this proposal creates a lot of ill will. Therefore, I hope that the Government will think again before pursuing it. In particular, I hope that the Government will not charge overseas students. I understand that the plan is to include overseas students in this programme and I hope that, whatever the Government do, they will at least exclude overseas students from this charge. That is the first matter to which I want the Minister to direct his attention.
The second matter which worries me is one to which I wish to draw the profession's attention and it concerns drug addicts. The area where I practise has a lot of drug addicts and for the past five years I have deliberately attempted to treat them. I shall not go into any of the details now as to the difficulties involved because it would take too long. But there have been grave difficulties. I was reading the General Practitioner a couple of weeks ago and I noticed that a doctor in Uxbridge was experiencing the same type of problems there. He too was trying to deal with the situation, also with difficulty.
My own observations led me to the view that more attention should be given to the treatment of drug addicts. I have been told by many of my colleagues that one cannot treat drug addicts, that they will give it up when they want to; that if they do not want to, they will not give it up and that there is nothing one can do about it. I do not necessarily agree with that, although it is true of many of them. I believe that there are some drug addicts who can, in fact, be motivated gradually to give up the drug.
In any case, my own findings are that one can motivate them to work, to hold down a job and to lead a reasonable life. One must recognise, of course, that the alternative is that they turn to crime, not only the crime of dealing in illicit drugs, but crimes which they commit in order to get the funds to pay for the illicit drugs. If one can motivate them sufficiently to get them to work and to lead a straightforward, regular life, that in itself would be progress. My own findings is that one can even get some of them to give up the habit.
But it is hard work and, frankly, I have had to give it up because I cannot cope with it—it is too much. But there is no doubt that there is a need for treatment of that sort. I know that the department may say, "We will provide more clinics". Yes, that will help, but I believe that what is required is more personal attention to these addicts. In other words, they need to have the attention of some physician who would really motivate them. Therefore, my suggestion—and obviously it is something which the department will have to negotiate with the profession—is that there should be an attempt to motivate more general practitioners to take on drug addicts, but that those general practitioners should be trained.
In other words, the situation should not be that any GP could proceed to try to deal with an addict, but,
286
just as in other branches of general medicine, certain doctors should be trained and, as a result of that training, registered as doctors who deal with drug addicts. They should be given a financial reward for doing that job.
I throw that out. I do not want to make a long speech. It was one of the matters about which I wanted to talk tonight. I preferred to talk about those two matters in the few minutes available to me, rather than to make the speech that I was going to make about the service in general. In fact, I hope that the Minister will give some serious thought to the particular point that I have made about drug addicts and initiate some discussion with the profession (because it cannot be done in any other way) with a view to getting some programme for dealing with this matter.
On the service in general, I shall not say any more than this. In my view, we have spent too long on the question of structure and not enough time on the question of function. I hope that from now on the accent will be on function and that we shall try to recognise that the service is a service for patients, that it is how the patients get the best service that matters. The question of whether we have the right structure, although important, is of secondary importance.
8.45 p.m.
Lord Auckland: My Lords, the noble Lord, Lora Hunter of Newington, has received a large number of accolades today and, by any standards, the noble Lord has certainly earned them. This has been a marathon debate, but I think an extremely valuable one. I suppose that since 1958 I have taken part in about eight or nine debates in your Lordships' House on the National Health Service. Some years ago I initiated one myself. This has been the longest, but I believe the most productive, and at the end of an almost Wagnerian-type opera, it is almost time for Wotan's Farewell, so to speak, before the Front Bench reincarnate themselves, if that is the way to put it.
This is an especially timely debate, particularly after the very important Mental Health (Amendment) Bill, which has gone through your Lordships' House, not that this particular Motion is directed primarly to mental health. It is, of course, directed at the health service in general. My family and I are consumers solely of the National Health Service which, generally speaking, we find very satisfactory. Indeed, the admirable document, Patients First, which is the corollary to the report by Professor Merrison in 1979, in paragraph 6 says:
"The National Health Service is only one part of our welfare services. Families may need help from the services of local government, the social services, education and housing. We attach high importance to the National Health Service working together with these services, but we have come to the conclusion that this does not necessarily mean that they need to do this within common administrative boundaries. What is necessary and what will, we know, be readily forthcoming is the will to work together".
Possibly one of the problems of the National Health Service has been that the various organisations within it have not always managed to work together, not because I believe there has been a lack of will; part of it may be lack of communication, co-ordination or finance.

287
The noble Lord, Lord Molloy, in the course of a very colourful speech, mentioned the building of new hospitals. My mind goes back to 1972, to the hospital plan of the then right honourable gentleman the Minister of Health, Mr. Enoch Powell, who I believe, in many respects, was a very good Minister of Health. I think that this hospital plan was very well thought out.
However, the building of a new hospital is not merely a question of bricks and mortar. I must declare a minor interest here as being very much an associate, non-executive director of a small civil engineering company, which is not concerned with building hospitals. But I have seen one or two hospitals in course of construction, and there are, indeed, some very good new hospitals. But the problem with new hospitals, as with new houses, is that the standard of construction and workmanship is not of the same high quality as it undoubtedly was in Victorian days, because, old as many of these Victorian hospitals are, they have weathered many storms, both literally and metaphorically, and one wonders whether the newer hospitals will.
It is important that a hospital is cost effective. It is not only a question of bricks and mortar, but of the appliances in the hospital. Several noble Lords have mentioned highly sophisticated new technical equipment. Indeed, only this morning I paid a short visit to a famous teaching hospital only three or four hundred yards from here and I saw some of the equipment there.
The noble Viscount, Lord Chandos, in a moving speech, mentioned the important question of renal dialysis. I wonder whether my noble friend can inform the House as to how many London teaching hospitals still have a renal dialysis unit. My understanding is that at least one teaching hospital not far from here no longer has a unit of this kind. I hope I am wrong in my supposition because this is an important factor. The cost of these units may be high, but not only in the live-saving potential of these units but in getting people back to work, they surely must save the country an immense amount of money. Of course, in many cases the skills of people working these machines, at least in the initial stages, may be very high and therefore training is needed, but this is a vital part of our National Health Service.
The real question—and I think this is the whole gamut of Lord Hunter's Motion—is as to how effective treatment can be given under the National Health Service in the 1980s. One problem is reorganisation. Whether the Merrison Report has got it right this time remains to be seen. One thing is quite certain: there has been no lack of trying on their part. It is an interesting report, and a long report. As I have said before in your Lordships' House, the National Health Service has perhaps been bedevilled, if that is not too cynical a word, by reports and Royal Commissions of various kinds.
I should like to make it clear that this is no disrespect to the worthy gentlemen who have chaired these Royal Commissions and given valuably of their time. But, as the noble Lord, Lord Porritt, in his admirable speech, stated, the trouble is that bits and pieces have been taken out of these reports, rather like a child nibbling at a meal which he does not very much like
288
but knows that he has jolly well got to consume, or else. It seems to be part of the trouble of the National Health Service at the present time that there has been this surfeit of reports which various Governments and their advisers have had to look at and examine for their financial and other implications, and we seem to have had various pieces picked out, but perhaps not always the right ones.
The question of payment in the National Health Service—and this is far too late an hour to go into that matter in any detail—is one of great importance. The 62½ per cent. payment to nurses—I believe that is now the figure—will be welcomed so far as it goes. I must declare an interest here as my youngest daughter is a staff nurse at a London teaching hospital just beyond the City of London.
The last thing that the nurses would do is in any way to withhold their labour. She and her colleagues love their job. But the fact is—and I think that this Government must be given credit for having done quite a lot towards increasing nurses' pay—that the pay is not enough when compared with that of other people in the community. We talk about these words "student nurse". Most students learn largely by theory. A student nurse, or a medical student, often has a life in his, or her, hands. If there is not a staff nurse or a registrar handy there have been times when they had to take decisions. It is important to bear in mind, within the ambit of the National Health Service, that there is a first class back-up team.
Perhaps my noble friend can give the House some information as to the policy now for recruiting nurses within the National Health Service. Are the cuts, which are all-round cuts now in the various services in the country, having a serious effect on recruiting nurses? I know that my noble friend gave me an answer to a similar question recently, but I have to tell the House that the feedback that I have had from more than one hospital is that there is still much worry and concern. This is not so much particularly in London, but in the more remote areas outside London there are shortages caused through not enough finance being available for recruiting.
There is much else that I could say. Noble Lords from all sides of the House, I am sure, have been given very much ammunition. However, looking at the time now, I merely once again thank the noble Lord, Lord Hunter, for the admirable service which he has given to your Lordships' House. Now the big guns will come on to finish off these most useful discussions.
9 p.m.
Baroness Jeger: My Lords, we are indebted to the noble Lord, Lord Hunter, for giving us the opportunity for this debate. We have strayed down long byways and highways, perhaps beyond the intention of the noble Lord when he first put down this subject for discussion, and I will deal as briefly as I can with a few of the important questions which concern particularly noble Lords on this side of the House.
It is important to remember that it was basically through the concern of the public for preventive medicine that the National Health Service came into existence. Or, to put it another way, there was a consensus that there should be concern for health by collective action, built up through a system of social

289
habits which are indispensable to civilisation. I am, of course, thinking of the early days of public concern for health, and that was in a way protective—one was anxious to protect the public against lunatics and infectious diseases, for example, rather than being concerned for the patient. It is interesting to see how the balance has shifted, and I am sure there is no one in your Lordships' House today who would feel that concern for the patient was not the primary concern.
In that concept of the National Health Service there was, of course, no room for individual commercialisation. People like the old sanitary inspectors and medical officers of health, as we used to call them, who insisted on social codes for collective wellbeing and not for individual greed, were really the pioneers of the NHS, as were the great names in medical research in the history of this and other countries. As I see it, the purpose of the NHS—this has been an underlying theme of today's debate—is to bring a similar sense of community concern to curative medicine. It has always puzzled me why there should have been a much more socially conscious understanding and acceptance of preventive medicine than curative medicine, and it will be for the good of the NHS if we can bring the two attitudes closer together.
I wish to refer briefly to the problem of private insurance, a topic which has received attention during the debate. The problem is complicated and difficult, and I do not pretend otherwise. However, the difficulty seems to be that the private schemes aim at the consumption of the apparatus of health but not at the creation of that apparatus. Many of the institutions involved do not want to know about mental health, geriatrics or incurables. They all make a profit—they have to, otherwise they would not be in business—and if they worked on the basis of the old friendly societies they would probably have a more conscientious case.
I make that point even at this late hour because I have seen so much distress among people who are not wealthy, who do not want to queue jump and who have a desperate and conscientious concern that they are doing their very best for their child, husband or old mother or father as the case may be. I recall how, in our very poor practice in Shoreditch, people would come and say, "If I took all my savings out to go private, would he do better?" I want to be able to say, "No, all the money in the world will not mean you will do better than sticking with the National Health Service", and we know that is true in many disciplines and cases of casualty and other cases of serious illness.
I was very impressed by the views of Aneurin Bevan. Indeed, I could not help but be impressed because when he came to talk to my husband, who was one of the few GPs in the House of Commons at the time (in those days we were working on the framework of the National Health Service) they would keep me up late into the night as they argued about the NHS. If there was one thing Aneurin Bevan was passionately keen about, it was that there should be amenity beds, by which he meant the purchase of privacy. It was not to be a purchase in order to queue jump or for any special extra kind of health service. If you were the sort of dotty person who could not bear anybody else around when you felt sick, you would then have the right to say, "Go away. I want to be alone". It is a pity that there seems to be less emphasis nowadays on the provision of amenity beds and too much public
290
concentration on the provision of private medicine. We should not exploit the feelings of many people who want privacy in illness and force them to take the alternative of going completely private, which might be against their principles, might not be what they need and does not answer the problem they face.
The noble Lord, Lord Hunter, referred to the question of organisation and, while it is too late to go into the matter in detail, I must say that we do not have it right. There should be a much closer relationship between local government and the NHS structurally, especially as we are trying to bring the two closer together, so bringing the social services and community services closer together. It seems absurd that we should have the two different structures.
To refer again to Aneurin Bevan, he admitted that when the NHS was first brought into being it was thought inadvisable to attach it to the local government structure because, as he often explained, there was such a variegated pattern of hospital provision all over the country that it would have been unfair to base the service purely on the resources of one local area rather than another. To quote from his essay "A Free Health Service" at page 115 of his book In Place of Fear:
"A solution might be found if the reorganisation of local government is sufficiently fundamental to allow the administration of the hospitals to be entrusted to revised units of local government".
Many of us hoped that when the noble Lord, Lord Redcliffe-Maud, and others were considering changes in local government that might have been an opportunity to place the structure of the health service within the local government pattern so that there could be an elected responsibility and an answerability to the people who live in the area. Much more thought needs to be given to that point.
I have informed the noble Lord the Minister that I propose to mention one of the fatuous results of the reorganisation of the NHS in the area that I know best. In Camden there is a proposal for a NHS reorganisation which will produce two authorities; one of them will be in Hampstead and the other will be called Bloomsbury. But when we look at the map we find that bits of Bloomsbury are in Westminster. So there is an overlap from Bloomsbury into Westminster. One is not concerned merely about lines on the map. The stupidity of the situation is that it cuts across the borough boundaries, so that part of the Bloomsbury health area is to be in Westminster. Thus it will be partly accountable to Westminster Council and partly accountable to Camden Council. Those two councils have very different attitudes and very different policies, and I want to know what is to happen to my friends in the Westminster end of Bloomsbury compared with my friends in the Camden end of Bloomsbury. I tried to find out the reason for the proposal and it appeared that it had something to do with hospitals. It was a question of sorting out the Royal Free Hospital, Middlesex Hospital, and University College Hospital, and making sure that they had the right kind of catchment areas.
I think the trouble with the National Health Service is that it is too hospital-dominated. It is not a national health service at all, it is a national disease service, a national illness service. So long as we think in terms of a structure that suits hospitals, which provides them

291
with proper catchment areas, rather than of the problems of the health and wellbeing of the community, we shall not get it right. I shall mention only one or two points which bear that out. I want to see the National Health Service much more orientated to prevention. Why have a Government who agree to sport sponsorship by tobacco firms while at the same time the Health Education Council is supposed to be conducting propaganda against smoking? That seems to me absolute rubbish.
I think that the attitude of the Government, and of the previous Government—let us be quite fair about this—to the question of the lead in petrol is absolute hypocrisy. Last year I was in America, where there is lead-free petrol, and all the new cars have to be manufactured so as to take lead-free petrol. As my noble friend Lord Wallace of Coslany said earlier, there are many environmental problems and questions of unemployment and bad housing that are really fundamental to the health of our people.
I should like to say a few brief words about the nurses—and I must admit that I am glad that the noble Baroness, Lady McFarlane of Llandaff, has left, because as I never got further than being a VAD I am terrified in the presence of even a ward sister, let alone so eminent a matriarch of the nursing profession as Lady McFarlane. I feel that the whole machinery of wage negotiations for nurses is wrong, bad, unprofessional, and undignified. We really ought not to perpetuate a system where nurses have to come up time after time, always trying to catch up with the wage levels and standard of living of others. I understand that conversations about changing the whole machinery are taking place and therefore I do not want to go into details about the present offer. But I think that the whole conception must be altered if we are to get this straight. It is undignified for the nurses and demeaning to the whole population. No one likes to sec a situation in which annually nurses come up for market bargaining. It is quite wrong.
I want to make just one point on a matter which was brought up by my noble friend Lord Pitt, about the charging of foreign visitors. I think that this is humiliating and disgraceful, and we have made our position clear. Sometimes people have said, "Why should we look after other people if they do not look after us?" There was a time when we liked to think that we led the world in this, that we were giving an example rather than a precept. It seems to me that this Government are levelling down the international concept of care. What is more, we are going to get into all sorts of practical difficulties. We are going to look after people from France, but not people from Austria; we are going to look after people from West Germany, but not from Switzerland, not from Sweden—not now from Greenland, I take it.
We are going to be in a situation where hospital workers are going to meet tremendous difficulties. I have read very carefully all that has been said in the official records and in the official documents, that questions are to be asked very tactfully: but no one has made it clear what happens if a person who is deemed to be chargeable tries to leave hospital without paying, perhaps because he cannot pay. Are we going to have policemen at hospital doors stopping people from
292
leaving? Are we, as happens in some places in America, not to let them in until they produce their cheque book? This is a wrong path to be going down, my Lords. I could produce many more arguments against it, but I hope there will be another opportunity for us to go into this in more detail.
The other thing that terrified me about this debate was that I had to listen to two dentists. Of all the unloved people in the world, dentists come out on top so far as I am concerned. Quite seriously, I was glad that the noble Lord and the noble Baroness made their contribution tonight, because this is one of the most neglected parts of the National Health Service. Certainly, in inner London, where I live, it is almost impossible to find a National Health Service dentist. They are almost disappearing in certain areas of the country.
I was particularly glad that the noble Lord, Lord Colwyn, referred to the question of disabled people. I have had quite a few cases brought to my attention where I have been completely unable to help totally housebound people who have needed dental treatment; and when I have asked at various DHSS offices no one could tell me—perhaps the noble Lord the Minister can—how a totally housebound, perhaps geriatric person can get dental care. I think that these are some of the things that we need to be looking at.
I would say only this to the noble Baroness, Lady Faithfull, that I think she is a bit of a dreamer. She talked of some splendid document about community care, as she always does, and we know she has great experience; but, my goodness!, I wonder whether she has had as much experience as I have had of people sent out from hospital because they are supposed to get community care while the local council is being pressed by this Government to cut down on home-helps, on meals-on-wheels, on day centres and so on.
The last time I spoke to a neighbour whose husband had been sent out because the hospital said he was ready for community care she said, "Don't you know that the community does not bloody well care?" I apologise for the language, my Lords, but this is how this desperate woman felt. She said, "I am the community; there is nobody else but me—and that is what the hospital calls community care". As we are trying to emphasise the need for more care outside hospitals, I think it is all the more imprtant that we should try structurally to bring the local social services and community medicine together with the hospital services, but that we should also see that the allocation of finances is fair enough for the community to do its job.
My Lords, we are all very much indebted to the noble Lord, Lord Hunter, for bringing this matter before us and for giving us the opportunity of this debate. I am only sorry that there have been so many aspects raised that it is not possible to go into them more fully. I know that it seems late to your Lordships, but to those of us who were bred in another place the night is young and we will go on and listen at length to the noble Lord the Minister, who I am sure will reply in great detail to this debate.
9.20 p.m.
Lord Elton: My Lords, perish the thought that I should reply in great detail at an hour which your

293
Lordships who are accustomed to this House only regard as being rather late.
Anybody who takes a copy of tomorrow's Hansard in one hand and a copy of Who's Who in the other, will very soon discover that the noble Lord, Lord Hunter of Newington, has in fact raised an astonishing constellation of talent and knowledge relevant to the field which he has put before it. We have a Nobel Prize-winner in the person of the noble Lord, Lord Todd; we have presidents or vice-presidents of Royal colleges and Royal societies, the noble Lords, Lord Richardson, Lord Hayter, Lord Auckland and Lord Porritt. We have noble Lords intimately connected with medical or nursing university education. I shall not go on giving the names, my Lords; they will be obvious to the reader.
We have heard noble Lords with wide experience of the management of the National Health Service through being chairmen or members of health authorities or boards of governers, who have been chairmen or members of Royal Commissions on health-related topics, who have been presidents of other vital medical associations such as the General Medical Council and the British Medical Association, many who have served as doctors, dentists and as members or chairmen of important health organisations, committees or councils, and even, indeed, the spouses of doctors. This is a formidable expertise and I include in that constellation the noble Baroness who has just sat down.
It will be obvious to your Lordships that I cannot reply to many specific questions, but the noble Baroness was kind enough to give me notice of a particular question before this debate, and I think it proper to address myself to it. She referred to Camden; and, unless I am mistaken, she is referring to our decision to create a Bloomsbury District Health Authority out of the current South Camden Health District, which includes University College Hospital, and the North-East Health District of Kensington, Chelsea and Westminster Area Health Authority (Teaching), which includes the Middlesex Hospital. These two districts are currently in different regions.
We felt it would be wrong to keep these two major hospitals, whose medical schools are now linked, in separate regions and districts, bearing in mind that these hospitals have begun to co-ordinate their clinical activities very closely. We appreciate that there may be some transitional difficulties, but we believe that this decision will encourage the integrated planning and development of both hospital and community services in the district. If the noble Baroness does not altogether agree with that, I must ask her to bear with me because there is no time to enter into exchanges on particularities.
On the question of nurses' pay, my right honourable friends the Prime Minister and the Secretary of State for Social Services have emphasised at meetings of the staff side of the Nurses and Midwives Whitley Council last December this commitment to developing long-term arrangements for settling nurses' pay. The noble Baroness has accepted that, and my right honourable friend the Secretary of State has now circulated a paper to both sides of the Whitley Council outlining possible approaches for handling nurses' pay in the
294
longer term and suggesting a timetable for taking matters on. I understand that my right honourable friend hopes to discuss this paper with the Whitley Council shortly.
Some of the barbs which the noble Baroness propelled across the Table at me were a little fanciful. I am very tempted to rise by the spectre of Government directing local authorities to cut down on meals on wheels, and policemen wielding truncheons at the hospital door. However, I had better turn to more substantial and real dangers and opportunities.
We have been looking at an area of interest which occupies a very big slice of public expenditure, and it has been looked at by 20 speakers of vast distinction and very diverse approach. I cannot pick up every point, though I will write to noble Lords whom I do not address in my concluding remarks. I think it better to try to identify a theme.
The National Health Service is a structural part of our society, and we are all agreed on that. It will always be hungry for resources, no matter how much it receives, and it will always be expected to give a service better than it does give, no matter how admirable it may become. I am therefore not dispirited, as was the noble Lord, Lord Porritt, by yet another debate on improving health care. I do see the advantages of looking for value for money. Even the good Samaritan—quoted again, I believe, by the noble Lord, Lord Molloy—paid four pence to the innkeeper—and think what 2,000 years of inflation must have done to that hotel bill!
The noble Viscount, Lord Chandos, will understand perhaps better than anyone that we do want and need to extract every last fraction of value from every last fraction of a penny available to the service. There always will be acutely difficult choices to be made between research programmes, between treatments and even, I regret to say, between patients, no matter how great our resources. My concern is to get the best value we can for all treatments and for every patient. The Government's concern is to improve our total available resources so that this health service, as well as other services, can benefit from the return of prosperity. That is the reason why we must look for efficiency at every stage.
This leads me immediately to take issue, as kindly, I hope, as he took it with me, with the noble Lord, Lord Wells-Pestell, over the role of the private sector. He referred to hernias, bad hips and varicose veins. I say that the private sector, by its existence and its work, increases the capacity of the country to repair hernias, replace hips and deal with varicose veins, not at public expense, just when the country is most short of funds. He talked about a queue: my Lords, the private sector shortens the queue. We cannot pay for this out of an "Austin Seven" defence programme. Our potential opponents do not have Austin Sevens: they have, to use his analogy, Rolls-Royces, and, in this context, competition is not a matter of pride of place or keeping up with the Joneses. It is a matter of preservation of the peace and the survival of the country; and failure makes all our other efforts really rather pointless. We are all of us multilateralists now—I hope the noble Lord does not want to draw me into a debate on defence policy. I can give way just once, and as he is an old friend I will give way to him.
Lord Wells-Pestell: My Lords, I want the noble Lord to come to 1982, because we have not had Austin Sevens for years.
Lord Elton: My Lords, I do not know what his chosen vehicle would be, except that it would not be a Rolls-Royce. I can think of many other analogies but he has succeeded in throwing me out of my stride: he cannot want any more, and so I shall proceed. Nonetheless, we believe that there needs to be a greater involvement of the private sector, especially in training; and the Government have been discussing with the private sector a range of options for increasing its contribution to staff training. We have not ruled out the possibility, mentioned by noble Lords, of a voluntary levy, but we feel that the best way to proceed is by working with the private sector through its representatives to see how its training potential can be expanded. Apart from an extension of its own arrangements for basic nurse training, if that proves feasible, other possibilities are joint arrangements with the National Health Service, post-basic courses and sponsorship of lectures.
The noble Lord, Lord Wells-Pestell, asked me a whole series of specific questions, to which I will reply in writing. At one stage he threw out the line that,
"the department does not miss very much".
I can tell him—and your Lordships, having heard his speech, will understand exactly why—that, whatever the department does not miss, it does miss the noble Lord very much. The private sector is important and I hope it will become more so, but I do not want my reply to be dominated by a sector which at present deals with substantially under one-tenth of our patients.
Therefore, for the same reason that I welcome contributions from the private sector, I welcome every word of support for the voluntary sector, and I was glad to initiate last year a pound-for-pound scheme on exactly the lines that the noble Viscount, Lord Chandos, commended to your Lordships. The fund with which the noble Lord, Lord Wallace of Coslany, is associated, and to which he gave such a well-merited, I do not doubt, piece of publicity earlier this evening, is typical of what is happening across the country. I recall with pleasure being at Stoke Mandeville with Jimmy Savile to see the laying of the foundation stone by HRH Prince Philip. Also, of course, services are provided by voluntary organisations of immense importance—hospital car services, hospital shops and so on. And, of course, my noble friend Lady Macleod and her League of Hospital Friends must figure here.
But, to come back to my main theme, for the same reason that I welcome the contribution of the private sector, I welcome the contribution of all noble Lords who have emphasised the importance of preventive measures, of good primary care, whether springing from the planning and other work of community health specialists, which was endorsed by many noble Lords; and of increased care in the community, which was endorsed by my noble friend Lady Faithful!, who is charming but no dreamer in this field. She is a practical worker with great experience in it.
It is for the same reason that I welcome the contribution of the noble Lord, Lord Richardson, and I will, in particular, note the passage in which he linked
296
clinicians and managers in the Health Service in a two-fold quest for increased efficiency and effectiveness in clinical and support services. Work is progressing within the department on these matters, including the development of performance indicators. I join him in urging clinicians to take a greater interest in the information collected about activity and costs in the National Health Service, which provide the database for this initiative. It cannot be stressed too highly that performance indicators are tools to aid the search for more effective use of resources, and not sticks for beating consultants with. But their usefulness depends on the accuracy and timeliness of the data, and I have noted his comments about the value of involving clinical staff more directly in management. I think we shall see this increasingly as the unit becomes a focus for day-to-day management of services.
He and others also referred to the Achtison Report on primary health care in inner London. That report was published last May, and the then Minister of Health asked all the responsible authorities to consider it as a basis for action. He also asked health authorities, professional organisations and other interested parties for their comments on the report, and on the report of the joint working group on the primary health care team—the Harding Report—which was published simultaneously. A large number of comments on the two reports have been received, and we hope soon to be able to make an announcement about our response to the recommendations for which my department is responsible. This, I think, will be of close interest to noble Lords opposite as well as to my noble friends. Not only are there very powerful arguments in humanitarian terms for prevention and primary and community care: in many cases, they can represent a cost-effective alternative to hospital care.
Coming back to the reason which is behind everything I say, which is so close to what the noble Viscount, Lord Chandos, said, I welcome the interest shown by noble Lords in the reduction of management costs. Central control of management costs was introduced in 1976 by the previous Administration, and from 1976 to 1980 the proportion of National Health Service resources spent on management fell by around 10 per cent. We believe that, without detriment to patients, we can achieve a further 10 per cent. reduction, as a result of cutting out two tiers of management and a general streamlining of management structures. I do not believe that we are thereby coming to that level where cheap management becomes expensive management, if I may so put it. I do not think that the comparators which the noble Baroness, Lady Robson of Kiddington, quoted are strictly comparable. I believe that there is room for this improvement. We are not alone in this belief.
Coming back again to the same reason, I welcome the approval of the noble Baroness, Lady Robson of Kiddington, of our reduction of the level of decision-taking on many matters. There is general approval of the Patients First policy, though it must continue to be allied with flexibility. I cannot agree with my noble friend Lord Colwyn that we should be giving directives about the status of individual posts in the team beyond the absolute central core and minimum. That was a fault of the organisation as it was before.

297
It denies flexibility of management. You cannot ask for a reduction of management costs and then dictate a whole hierarchy of places.
I welcome also, with a little more surprise, the support which we received from the noble Lord, Lord Molloy, for this. It takes me time to get used to the approval of the noble Lord, Lord Molloy. In his concluding remarks he very properly compared, I will remind your Lordships since the noble Lord is not here to do so himself, our condition with the whole population of the third world. We really do have a health service which is outstandingly good in world terms. Here I must say, as I have said before, that this Government have a good and a creditable record in this field. If it does not annoy noble Lords, and particularly the noble Lord, Lord Wallace of Coslany, I must remind your Lordships in the least contentious terms I can find, that health authority current expenditure is planned to be some 5¾ per cent. higher in 1982–83, in real terms, than the amount spent in 1978–79. Health authorities are also expected to generate additional growth through increases in efficiency. This has been achieved at a time when public expenditure generally has been restrained and most programmes have had to be cut in real terms as part of the battle against inflation—and while we have continued to redress the imbalance in resource terms between regions. That needs to be put in its demographic context.
The increase in demand for the elderly varies a little from year to year. The noble Baroness and others have referred to this question. We estimate that the increase will be about 0·8 per cent. in 1982–83 while the Government have provided for 1·7 per cent. of growth in services. In 1983–84 the additional demand is expected to be ½ per cent., roughly, and the savings which health authorities are expected to make by better use of existing resources will pay for this. As a faint reprise, we have had Wagner quoted as our model. I think he concludes with crashing brass. I want to be more tactful and just to say the words: more money beyond demographic need, more nurses doing their nursing, more doctors treating patients, and above all, more patients being treated and cured. I do not say that in any spirit of contention, and I hope that it will not be taken in that spirit. What I think all noble Lords will agree with is that all those who work in the National Health Service, whether clinicians, or nurses, or managers or ancillary staff, are partners in a vital part of our national life, a part upon which almost all of us are dependent at one time or another in our own lives. Plainly they have the close interest of every Member in this House today, and for that I think your Lordships should be grateful to the noble Lord, Lord Hunter of Newington, for moving this most productive Motion.
Lord Wallace of Coslany: My Lords, before the noble Lord sits down—I fully appreciate that he has had a very difficult job in replying to a long debate—may I say that I raised a very important issue regarding nurses and the crazy way in which the re-selection of nurses is being made. It is a very important matter. Will he therefore give me an undertaking to look into it? If necessary, I will assist him.
Lord Elton: My Lords, I thought I had reached an elegant conclusion in 18½ minutes. I am now going to stumble into an untidy finish after 20. If I take the noble Lord's question aright, the gift of ministerial posts, if it is in the hands of anybody, is not in the hands of Under-Secretaries of State. From the expression on the noble Lord's face I have obvioulsy misunderstood his question. The best thing I can do is to talk to him immediately after this debate and sort it out with him then.
9.40 p.m.
Lord Hunter of Newington: My Lords, all that remains for me to do is to congratulate all noble Lords who have taken part in this debate and particularly the noble Lord, Lord Elton, for rounding it off in his usual fashion. I was glad that the noble Lord, Lord Porritt, finished his speech in hope because he has given me and a great many others hope and encouragement for the past 40 years. I suspect that he was one of the people who persuaded the medical profession to go along with the National Health Service at its very beginning, although I suspect also that he would deny this.
Listening to the debate, two or three things occurred to me which I should like briefly to mention. I shall study carefully what was said by the noble Baroness, Lady McFarlane of Llandaff, about district authorities. I got the impression that one or two of them are getting a little ragged, that chairmen were getting out in front, and that difficulty was being experienced in forming the teams. One realises that the juggernaut is moving almost as we are thinking.
My second thought has to do with the regional authorities. I would have thought that they should each be concerned from the beginning with research and development in one part of the health service and that, between them, the authorities would cover every part of the health service. This should be a part of their lives for the future. Thirdly, I believe that the advisory services need to be reorganised and properly linked with the centre. Perhaps a great deal of protocol is necessary in respect of the distinction between the department and the regions and their advisory systems. I believe there should be one efficient channel of medical information at the right place in the whole service, and that we should get rid of this separation. Finally, I believe that in the future units should know what they cost and must be able to get the benefits of their savings. I would consider the whole question of matching funds if they achieved this.
These are only some very rough comments but I am left with one last lingering thought. It concerns the point made by the noble Lord, Lord Perry of Walton. I have a great regard for him because he has created one of the great centres of education in this country, which is being copied all over the world—unlike the health service. It was his point about consensus management. I wonder if we really have got management right? But then, there will be lots of time to talk about that another day. My Lords, I beg leave to withdraw my Motion.
Motion for Papers, by leave, withdrawn.

Lloyd's Bill
Brought from the Commons, read a first time and referred to the Examiners.