The National Health Service: Conditions of Employment

HL Deb 26 January 1983 vol 438 cc295-328

5.45 p.m.

Lord Molloy

rose to call attention to the need to improve conditions of employment for staff in the National Health Service; and to move for Papers.

The noble Lord said: My Lords, I beg leave to move the Motion standing in my name on the Order Paper and to say immediately that I believe that it behoves us all in Parliament, as well as the Secretaries of State and Ministers of State, constantly to ask ourselves of our great National Health Service: How good is the service at the moment, and how much have we adhered to the command of Parliament when on 5th July 1948 Aneurin Bevan introduced this great service which was, To promote the establishment in England and Wales of a comprehensive Health Service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illnesses and for that purpose to provide or secure effective provisions of services in accordance with the provisions of this Act"? Of course, there was a similar Act to apply to Scotland.

In this connection I take the view that a vital element in Great Britain's National Health Service is all those who work and serve in it. The purpose of this debate is to draw attention to the conditions of service under which they work and to hope that some of the irritations which I believe exist, and which are brought to the attention of your Lordships' House, will be noted by the Ministers who have responsibility. I believe that we ought to do this pretty regularly. We cannot, on the one hand, say that we are proud of this great service, a service of which the rest of the world is jealous and which many have tried to emulate, without saying that Britain created it and that we in Britain have a responsibility, to maintain its fundamental principles and look after the staff that serve it.

The National Health Service, with regard to its manpower resources, has to compete for staff with other services in industry. In consequence, I believe there is a responsibility on those at all levels of management to see to it that there are proper career prospects for those who contemplate joining the service and that when they do join the service every effort is made to see that they have job satisfaction. I believe that there must be fair and just remuneration at all levels and that we must endeavour to remove irritations. These may appear trivial to us, but to the people working in the service they are irritants which they believe can be removed.

I should like to give two small examples. Time will not permit me to go into details. First, we in this country are proud of our great emergency services. When there is a fire, the fire service is involved, the police are involved, and sometimes poignantly also involved are those who man the ambulance services. Upon them often rests the ultimate responsibility, when the fire is put out and order is restored, for the succour of the injured and the prevention of death. Yet the ambulancemen in this tripartite service feel most aggrieved because their remuneration is at a much lower level than that for others in the service.

There is a similar situation with regard to the nurses' pay. Why is it that agency nurses recruited from outside, with possibly the same qualifications, are paid a higher rate than the nurses who go directly into the National Health Service? I submit that there is something wrong. There is the rake-off for the agency, which takes a week's or a couple of weeks' initial pay, but the agency nurse is paid more than the National Health Service nurse. I submit that, in all fairness, this should be looked at.

My next point refers to part-time staff. Most part-time staff in the National Health Service are women and the overwhelming majority are ex-full-time staff with qualifications; and of course they play a vital and most important role. But there are dangers and problems because of this to all staff. It has been drawn to my attention that particularly some managements are inclined to tailor the duties of the full-time staff to suit the part-time staff. I frankly admit that this is a very tricky situation, but I believe it is getting so serious. We have two excellent parts of the service; part-time nurses with full qualifications and full-time nurses with full qualifications; but, despite certain attitudes, surely local managements can work out a scheme which would be acceptable to both. This situation could be eased if there was much more genuine, real consultation and examination at hospital level. We must acknowledge first that both the part-time nurse or sister and the full-time nurse or sister are required. We must take advantage of their abilities to serve and use them to the full, but I believe that this can be best done by effective and planned use, by sensible hospital management. I should like to submit this proposition to the Minister who will reply. As I have already said, a large majority of the part-time nurses and sisters are married women. Some of them have children. Why can we not go back to the days of the initial conception of this great service when in the larger hospitals at least crèches were provided so that these women could take their small children with them and have them looked after? Bearing in mind their contribution to the sick, the maimed, the wounded and the ill, I believe that that is something which is well worth doing.

I turn now to the proportion of nurses in training. This varies from year to year and because it varies from year to year it is bound to have an effect when ultimately a state enrolled nurse, a state registered nurse, or a state certified midwife becomes qualified to operate in her capacity, or his capacity, in full sway. Sometimes there are tricky moments or, more than moments, there are tricky months when the supply is not quite ready to fill the gaps. This fluctuation is causing concern, I believe, because the gap between the trainee nurse and the student nurse becoming a state enrolled or state registered nurse can create difficulties for the service. I believe that that is something which should command our attention.

I was saying a moment ago that much of the part-time staff consists of married women, who nevertheless are very important to the service. Of course, because they are married women, from time to time many of them have babies. That has been going on for millions of years, not only in the Health Service. The fact of the matter is that when we look at the statistics marriage and childbirth account for no less than half of these magnificent women leaving nursing. I believe, therefore, that recruitment should be a constantly on-going thing. There should be much more propaganda and explanation. There should be much more—to use the word in its proper sense—enticement for young people to enter the service.

I turn briefly to the situation regarding general practitioners. There seems to be very slow progress in assuring this great service that it will always have sufficient GPs for the future. I leave it at that, but it is a very important aspect of the NHS. I have to say that there is a danger of our not having enough general practitioners in the not too distant future. It would appear that the medical staffs in hospitals have a much more encouraging result in their recruitment than that for general practitioners.

Allied to these problems is the location of medical schools. From my researches I must give credit to those concerned in Scotland. The Scots seem to do amazingly well, but here in England and Wales it is not so good. A high proportion of medical staff are trained in London. I want to say immediately that the teaching hospitals in this great metropolis are excellent. But I believe that there is a need to give much more consideration to the provinces. They are entitled, and indeed I believe they want, to provide their centres of excellence. This is another thing which is very difficult. This particular aspect is not necessarily the responsibility of the NHS. But whose is it? Where does the responsibility for liaison rest so that we can see more teaching hospitals and more centres of training in the provinces as well as in London?

I refer now to the labyrinth of responsibility for administering and financing training. First we have the General Nursing Council. Then we have the Central Midwives Boards. Doctors and dentists train in various medical and dental schools, all funded by the Department of Education and Science, via the University Grants Committee. Opticians and pharmacists are also graduate professions. Therefore, it is easy to see that the situation is somewhat confusing, particularly when one considers the supplementary and allied grades to medicine such as, for example, dieticians, physiotherapists, remedial gymnasts, orthoptists, chiropodists, radiographers, and speech therapists—all vital segments of this great service where the initial source of training is incredibly varied and involved.

It involves certain NHS schools, local education authorities, universities, polytechnics and colleges of further education. In some instances such training is a mixture of two or three of such establishments. I concede immediately that there is no real chaos, but I believe that there is a need to abolish the confusion that arises from time to time, and that perhaps there is a case for a more logical system of training in the interests of both the staff of the NHS and the staff of all those who train them when they are pupils.

Briefly I want to refer to an issue that concerns consultants. I must confess that I do not know a great deal about it. I have tried to follow some of the arguments that have been put to me. Although I do not understand these arguments fully, they are put to me by people who know a great deal about the subject. I therefore feel it is right and proper to draw this issue to the attention of your Lordships' House. It is that much irritation is caused by what is called the distinction award system. Even to people with knowledge who have spent a great deal of their lives within the National Health Service the consultation distinction award system has a peculiar mystery about it. Let us unravel it and find out what it is all about. That can only be done by the representatives of the Government. There is a feeling in the service of favouritism, and sometimes injustice.

I shall not take up time talking about the drugs bill. All I ask the Minister is this. Is it true that almost 50 per cent. of the cost of the NHS goes on drugs? He will probably be aware of the massive press and TV campaign that has been going on, and of comments and specific programmes on the wireless, on TV and in our newspapers, all revealing—and there is only one way of expressing it—an appalling, distressing scandal on the issue of drugs for the National Health Service. I believe that this must be investigated, as it is causing public concern.

I turn now briefly to the issue of morale. Morale in our National Health Service, both in hospitals and special units, has been affected by the attitude of the Government in their policy regarding closing hospitals and special units. I shall tell your Lordships what the staff suffer from—and I speak with some authority: I am very close to a vast range of them. It is rumours to close a hospital, proposals to close a hospital and actually closing a hospital. This is very serious indeed. It is not only bad for our people, it is bad for the nurses, doctors, consultants and specialists that serve in these hospitals.

When there is a rumour that one hospital is going to be closed, there is in microcosm the whole sector of our National Health Service, anxious, worried and wondering whether they now are going to be dispensed with and join the dole queue. I am bound to say this Government seems bent on increasing the numbers in the dole queue every month that goes by. It will be a very sorrowful thing if we put people who work in this service in the position that they should be worried. I am empowered to say that if she had been able to attend the House the noble Baroness, Lady Masham, would have made a similar point regarding morale, and how morale is being affected by the threats of closure, or actual closure, of many of our hospitals.

I wish to conclude by saying that this great service of ours in the field or preventive and curative medicine is naturally linked to caring with compassion. It is unique, not in Britain's history but in mankind's history, and can only be of tip-top excellency through the devotion of the staff that serve it. I believe that all in this House and in another place, and all who value and are concerned and involved with Britain's National Health Service, have a responsibility to be concerned about the welfare of its staff, and that they should command our constant attention at all times.

6.3 p.m.

Lord Winstanley

My Lords, the noble Lord, Lord Molloy, has raised a matter of immense concern to all noble Lords who have the interests of the National Health Service at heart—and I like to hope that that means all noble Lords in the House. In that case, we should all be grateful to the noble Lord, Lord Molloy, for raising the matter. Before I cover rather different points than those which were raised by the noble Lord, Lord Molloy, I should like to underline one or two of the matters to which he has alluded.

First of all, he referred to the question of the number of general practitioners and the importance of ensuring that we perpetually have an adequate number of general practitioners. All I would say at this stage in that connection is that it seems very odd to me that at the moment there should be something like 300 or 400 would-be general practitioners unemployed —the Minister will know the actual number—when in point of fact it is extremely difficult in certain urban areas for patients to get on a general practitioner's list at all. That is a matter which we can pursue at some length, but it is worth underlining.

I should also like to emphasise what the noble Lord said about morale. He is right, morale at the moment has sunk fairly low. There is a lot of uncertainty, doubt, fear and speculation. I cannot offer ways in which morale could be restored overnight, but in my recollection morale seems to have sunk a little in the service ever since the days when we actually had a Minister of Health responsible for the National Health Service, and sitting in the Cabinet, with Cabinet status. I tend to believe that the movement and the establish ment of this conglomerate of a Secretary of State for Health and Social Security with responsibility for pensions, and for all sorts of matters which are very much Treasury matters rather than health matters, has not had an altogether good effect. I recollect one Minister of Health—almost the last who was solely Minister of Health; Mr. Enoch Powell—who spent a lot of time every year sending out a personal letter to all National Health Service employees with the object of raising their morale. I noticed that later Ministers did not do that. Perhaps they had run out of things to say. I feel that had we still had a Minister with specific responsibility for the National Health Service, perhaps morale might have remained a little higher than it now is.

We are dealing here with Britain's largest and most complicated industry; an industry in which relations between managers and staff are generally good. In that industry the "we" and "they" attitudes are much less marked than in industry as a whole. The great majority of staff at all levels have a sense of identification with the purpose of the National Health Service, and they take pride in their own contribution to serving people. That has always been a factor in recruitment. When jobs were plentiful, those in the National Health Service were generally less well paid than those on offer elsewhere, but vacancies were filled. To maintain or restore that situation we must attend to some of the anomalies of the kind to which the noble Lord, Lord Molloy, pointed.

We must surely do something to try to restore team spirit. I think a fairly savage blow was dealt to team spirit at the time that we had the settlement of the last dispute in which it appeared—only appeared—that the Government were seeking to drive a wedge between different workers in the industry; people who ought ideally to be working closely together in partnership.

There are many individual groups of workers who feel aggrieved in one way or another. The noble Lord, Lord Molloy, has referred to several; I shall refer to one other example. He touched on it briefly. That is the situation of auxiliary nurses. My attention has been drawn to a report in the Nursing Times of 22nd December which refers to a new report on the European region issued by the World Health Organisation which calls for improved status and improved recognition of auxiliary nurses within our health service here in Britain. I have not had an opportunity to inquire into the details of that, but if the World Health Organisation is sufficiently concerned to issue a report about it, surely we should be sufficiently concerned to have a look at it and see whether we can do something about it.

The noble Lord, Lord Molloy, has exercised a masterly restraint in making almost no reference to pay. I cannot continue to be quite so restrained, because I believe that while morale may be good in certain areas, and while there may be many causes for resentment, if there is resentment basically about pay, the way in which pay is settled and about anomalies in methods of pay, whatever is done about the other things, that resentment and dissatisfaction will remain. So we ought to turn our attention a little to pay. It is my view that the best method of ensuring fair treatment for public service employees on a permanent basis would be by establishing comparability based on job evaluation. That theme was developed very fully by Mr. Aubrey Jones in his publication, Reform of Pay Determination.

In thinking about pay, we must consider basic rates of pay rather than take-home pay. This contributes to the problem. Basic rates in the National Health Service have often been too low to permit recruitment of staff of adequate calibre, particularly male staff, unless those basic rates are enhanced by overtime and other payments. For example, the basic pay of a porter, in ASC Group 3, is very little over £60 a week for 40 hours: of course, his actual take-home pay is very much greater. Ideally, a higher proportion of earnings should come from improved basic rates and a lower proportion from enhancement for working at weekends and on public holidays. Surely overtime should be reduced to a minimum and used only in exceptional circumstances. It seems to me that, with something approaching three and a half million people unemployed, it would be far preferable to increase target levels and reduce the hours worked.

Attention has been drawn recently to an example occurring within British Rail. I am reliably informed that at the moment, because British Rail have ceased recruiting into certain jobs, they are paying more money out in overtime to certain existing staff members than they would in fact have had to pay to somebody newly recruited. If recruitment had continued, those people would in addition have been taken off the dole. So I hope that when we think about pay we shall think in the main of improving basic rates.

In this connection, I think we ought also to look at Whitley Councils. The Whitley Council machinery is very much at the heart of the whole pay structure in the health service. It is my view that the machinery has not worked all that effectively. Failures of the Whitley Council system have produced delays, anomalies and inconsistencies. In addition, I think that managers in the service have become exasperated by inept handling of negotiations at departmental level. Perhaps I may take one contemporary example, where at departmental level there has been interference with the Whitley Council negotiations in a new kind of deal. The Guardian, in referring to a deal which was done with junior hospital doctors some time ago in 1978, had this to say: The deal which was agreed for the juniors has cost twice as much as was expected, basically because various consequences which were predictable were never predicted. The result has been a fiasco, with some junior doctors earning more than consultants. That has created unnecessary bitterness and envy within the profession, distorted the staff structure and left the National Health Service with less resources for other services.

Let me now say a few words about the history of the Whitley Councils. At the outset, the bodies purporting to represent the staff concerned were allowed to settle among themselves the allocation of seats on the staff side of the appropriate Whitley Councils. No yardstick for membership seems to have been applied, and some tenuous claims for representation were accepted. In the early days, when the important thing was to get the system started, this was perhaps understandable. Subsequently, Ministers have always maintained that claims by staff organisations to be represented on a Whitley Council were a matter for the staff side alone and have refused to intervene when complaints of lack of proper representation have been made. Because no other organisation can gain a seat on the staff side of a Whitley Council without the consent of the existing members of that side, the existing staff organisations hold a self-perpetuating monopoly of representation on the Whitley Councils. Membership of the staff side of a Whitley Council confers recognition for other purposes which is denied to other staff organisations. For example, individuals can appeal against grading to regional or national appeals committes only through an organisation represented on the appropriate Whitley Council. At hospital level, staff representatives on joint consultative committees must be members of an organisation represented on the Whitley Councils.

We are clearly dealing with the whole question of pay and we must look at the whole Whitley Council machinery, which is in need of repair. I think I must say here and now that I personally do not believe that there is any way in which we can legislate to stop strikes. Some countries on the other side of the Iron Curtain have tried. There are some countries where there are no strikes at all, but if we looked we should tend to find that productivity in those countries was very, very low indeed, and I think attempts to stop strikes by legislation are doomed to failure. Neither can we legislate to make people happy and contented at work. But there would be less discontent if a method of pay determination could be found which was fair and equitable. That is the sort of matter on which we must focus our attention.

Many thoughts have been given to this. What should we do? I think it will be no secret to many noble Lords here that many of my colleagues on these Benches believe that in this country we should be moving towards a statutory incomes policy. Lest noble Lords should say, "We have tried that and it did not work", let me say at once that it has never been tried by anybody who believed in it. Mr. Wilson's Government, who did not believe in a statutory incomes policy, and said so, tried to introduce one. Later, Mr. Heath's Government, who also said they did not believe in a statutory incomes policy and were not going to have one, tried to introduce one. Is it any wonder that when one was introduced it did not work? So I still say that this is something we must look at. But, if not, we cannot legislate for just one sector of the community: the public sector. We cannot move in and have an incomes policy just for public sector workers and not for anybody else.

What, then, must we do? I shall try to be brief, my Lords. The Megaw Report, dealing with nonindustrial civil servants, has suggested a possible means of dealing with the whole matter of pay within the National Health Service—a means which they suggest should be applied to non-industrial civil servants. It seems to me that the methods recommended there might with advantage be applied to workers within the National Health Service.

If we are not going to follow that route, we must look for another, and I think it would be right to remind your Lordships of what my noble friend Lord Rochester said during the debate on the gracious Speech when he referred, on 10th November 1982, at col. 285, to a method he was thinking about. I will quote from what he said. He recommended the establishment of an independent standing commission, distinguished from a mere arbitrating body by being empowered to call for evidence other than that of the parties themselves. It could also be required to give reasons for the awards it made … Might not members of the Commission be chosen not by the Government of the day but by an electoral college established by statute? … That would ensure that it was independent, that there was continuity of office for its members and that it was acceptable to the Government, the main Opposition parties and to organisations representing both employers and trade unions. Only thus would it be reasonable to expect people in these key occupations to repose sufficient confidence in such a body to give the necessary prior undertakings that its findings would be observed. The right of such people to withdraw their labour would not thus be outlawed; rather they would voluntarily surrender that right in return for the privilege conferred on them. If subsequently they failed to honour the undertaking the privilege would be withdrawn … There would be the need for a corresponding commitment on the part of the Government to accept the findings of the commission, withdrawal by the Government being possible only after the passing of a resolution to that effect by both Houses of Parliament, who must remain the sovereign authority". I do not say that that idea, which has not been fully thought out, would necessarily work, but, if we are not going to take up what Megaw recommended or move to a statutory incomes policy, we must look for an alternative, and if we do not do so I am quite sure that we shall be in very great difficulty.

I really must conclude, but I should like to say before I sit down that there is rather too much talk about the National Health Service being full of administrators. I wonder, my Lords. I think that, if we really look at all the administrators, we shall find that administrative workers within the Health Service are only about 5 per cent. of the whole. The vast majority of them are people like ward clerks, medical secretaries and people very closely involved with patient care. This idea that the health service is bursting with idle bureaucrats is misleading, I believe. If you want to find bureaucrats, I believe the place to look is the Elephant and Castle. If the Government would genuinely devolve power to the family practitioner committees, the area health authorities and the district health authorities, we should then find that the administrators we have got, who are very capable, would be able to do a very much better job if they had not got other people on their backs. We should also find that we could save quite a lot of money.

Finally, we really must iron out anomalies regarding superannuation, grading, recognition, opportunities to earn overtime, status and that kind of thing, and we must try in the service to recapture the team spirit. We must sort out and reform the Whitley Council machinery, which is creaking badly, and we must take steps to establish a new and genuinely independent method of pay determination in which all parties have confidence. That will not be easy, but it is essential that we should try.

6.20 p.m.

Lord Auckland

My Lords, the House will be grateful to the noble Lord, Lord Molloy, for having, in a thought-provoking speech, initiated this important short debate. Though my noble friends may not agree with all of his conclusions, that does not in any way minimise the importance of the topic which he has raised. I should like to correct one point which is often made quite erroneously; that is, that those of us who sit on this side of the House are against the National Health Service. That is very far from true. As many of your Lordships will know, I have served on hospital committees in both paediatric hospitals and mental hospitals. My late uncle, my father, my mother and others in my family did the same, both under the National Health Service and before it. I happen to believe, as I think most parliamentarians do in all sections of both Houses, in the need for a strong and effective health service.

I do not intend to go into the realms of private medicine in the course of this debate; that is not part of the subject under discussion. Suffice it to say that I believe there is a place for both private medicine and the National Health Service in this country; and, indeed, the two services exist in almost every country in the world, including the East European bloc. Having said that, I should like to ask my noble friend one or two questions of which I have given him very short notice, for which I have apologised.

One factor is that if a nurse, particularly a staff nurse, has a baby her job is kept open at the hospital for only 18 weeks. I know that this has been a longstanding arrangement and I can see certain reasons for it. I have an interest to declare here, because I have a daughter who is shortly to have her first baby and who is a staff nurse at a hospital not so many miles from here. Though I say it myself, she is a very conscientious nurse doing a course in obstetrics. The trained nurses are the really devoted ones, particularly if they have had a baby themselves. This gives them more experience, not only in obstetrics but in other forms of nursing. So I wonder whether, despite the fact that nurse recruitment is on the increase in this country, particularly in our teaching hospitals, there is a wastage (if I may use that word) of a lot of very good talent because of this rather inflexible ruling.

I turn for a moment to the problem of accommodation, which is very much linked with this subject. It is true that only a very small percentage of nurses live in nurses' homes; they are largely nurses from overseas. But there are some student nurses, particularly in the very early stages, who live in nurses' homes. Some of the homes are very modern and very well equipped, but others are very old. I have mentioned this point before, and I am sure that my noble friend has taken on board some of the points which I have made in previous debates. But I believe that this is a very important topic.

My understanding is that something like £600-plus a year is paid by a student nurse for accommodation charges in a nurses' home. The amount may vary according to the area or the condition of the home—and, certainly. the latter is something which should not be quarrelled with. But that charge together with the cost of food—which, admittedly, they agreed some years ago to pay for themselves—of laundry, which is another very important expense, and of shoe repairs, cuts very much into the salary which they are paid. There is an urgent need for this matter to be looked into, whether by the Whitley Council or some other body. I am not a medically qualified person, while there are a number of distinguished medically qualified noble Lords who are to speak in this debate, but I believe that this point is of some importance.

I should like to say one or two words about medical schools, to which the noble Lord, Lord Molloy, referred. It seems that, in our hospital building programme, we have only one new university hospital and that is in Nottingham. Are any more planned? I read in yesterday's papers—it was certainly in the Financial Times—about a fairly large amount of money being spent on hospital improvements. I believe that these relate to buildings, and that is fine. But I should like to ask my noble friend—I have not given him notice of this question—how much of this money will be spent on hospital equipment, kidney machines, chemotherapy machines and other equipment to deal with the scourges of kidney disease, cancer of the blood and so on. This is all linked with this question.

If the staff of these hospitals know that they will get modern equipment, which they can use for these diseases, then morale, which has been mentioned by the noble Lord, Lord Molloy, will improve enormously. I do not necessarily accept, from my experience of National Health Service hospitals, that morale is very low at the present time; it varies very much from hospital to hospital. But there is no doubt that in some hospitals there is a feeling of depression.

That brings me to the whole question of the recent dispute. Much has been said about that and I do not think anybody wants to rake over old embers. I would only make this one controversial point. I believe it was rather unfortunate that the pay of nurses and the pay of ancillary workers were linked together. That is not to say that the ancillary workers did not deserve an increase in pay, and I want to make that quite clear. But I believe that nurses' pay was, and is, of paramount importance. The increase which they have received is a reasonable one, in view of the prevailing economic condition. Far be it from me or anybody else to say that they are overpaid: they will never be; they never can be. But I believe that the settlement, painful as the situation was in trying to reach it, is in the present climate at least reasonably fair.

We have to look to the future and improve the channels of communication. Much of the problem lies here in that the nurses, particularly the senior nurses and the representatives of nurses on the various councils, are not themselves sufficiently informed about the situation. This is a problem which has faced all Governments, and I believe that the present Government could well look into it.

I conclude with a passage from the admirable Royal Commission, chaired by Sir Alec Merrison, in 1979–and heaven save us from any more Royal Commissions. We want action, not Royal Commissions. But this was a very sound one, and it said: One aspect of the National Health Service which is unlikely to change is the importance of its staff. By nature, the National Health Service is labour intensive and this places a special responsibility on it to enable its members to make an effective contribution". I hope that at the Elephant and Castle, whoever is in tenure, that will be pinned upon the wall.

6.32 p.m.

Lord Hunter of Newington

My Lords, I, too, should like to express my thanks to the noble Lord, Lord Molloy, for giving us the opportunity to debate this important matter and for expressing the great concern which I know he feels, and which many of us feel, about many aspects of it.

I spent a good many years attending the manpower committee of the National Health Service, which was concerned with medical staffing. This has always been a source of anxiety. The training of doctors and the provision of the right balance of experience, education and work presents difficulties. There is now—I think rightly—increasing control from the centre. As noble Lords may have read, it is proposed that consultant staffing should be increased over a period of time and that the trainee grades should be reduced to a level which gives doctors a reasonable prospect of career fulfilment. The noble Lord, Lord Molloy, mentioned the distinction award system. It will be helpful to your Lordships if I read a very brief section of the Pilkington Report of 1960, which looked at this system 12 years after it came into operation, because it summarises the reasons for the system: Two common methods of securing differentiation of income are not open to the consultant so far as his health service work is concerned. Unlike some professional men in private practice, he cannot vary his fees in accordance with his professional standing, and unlike the salaried employee in most fields he cannot look forward to promotion. In these circumstances, we consider the award system a practical and imaginative way of securing a reasonable differentiation of income and of providing relatively high earnings for a significant minority, to which the Spence Committee, who originally recommended this, referred. We therefore unreservedly support the continuation of the system. Somewhere in the region of one-third of doctors are paid additional salaries for the reasons which have been mentioned.

I should like to say a word or two about the nurses, but first let me say a little about the background to the situation and the present state of the health service. In December 1979 the present Government set out their plans for devolving power to local health services. The document was called Patients First. There was to be minimal interference by any central authority. In contrast, two major select committees in another place urged more centralised policies. The Select Committee on Public Expenditure criticised the department's failure to evolve a coherent social policy, and, under pressure from the Public Accounts Committee, the Secretary of State in 1982 tightened central control of regional health authority spending by requiring annual reviews of long-term plans. The new district authorities, which had only begun to settle down to Patients First, would in future be strictly accountable to the regional hospital chairmen.

The implication of this seems to be that health authorities will have greater autonomy to decide how to follow central policy and that hospital medical and surgical services will be strictly monitored by the regional health authorities. But the line between administration and policy is not clear. Perhaps it does not exist. The health service is in a state of flux. Its hands are tied in many ways and it is struggling to make attempts to control expenditure by the whole of the service, including control of expenditure by doctors. The point about all this is that, on top of a second reorganisation of the health service in 10 years, the distinction between administration and policy remains unclear and that attempts at determining a priority list of clinical services remain in a somewhat primitive and ineffectual state. It could be argued that this affects the morale of the health authorities and the hospital staff. Uncertainty is infectious and it may have contributed to the events of the past year. The turbulence of reorganisation has sadly affected administrative staff. Some of the ablest, sick of it all, have taken retirement in their fifties. Applying for one's own job is not conducive to effective administration.

May I now say a word about the nurses? Sick and worried people turn to the National Health Service for help, sympathy and understanding. Many of them feel more able to talk to nurses than to doctors. And, if they are ill, it is the attention of nurses which is the most important of all. Such is the nature of things that the front-line staff of the National Health Service are doctors and nurses. Other staff are vitally important, though their jobs may be in a supporting role. Mainly, they do not take direct responsibility for the sick, nor are they trained to do so.

Traditionally, people looking after the sick do not take industrial action. The recent action is, I believe, a blemish on the reputation of health service staff. What happened is simple. If you have no responsibilities, or few, for the sick, you can convince yourself that you can do this. It is extraordinary how callous a caring society can be. The definition of emergencies and cases that can be delayed are made by people without medical knowledge. Doctors and experienced nurses are more often wrong in deciding this than they would wish to be. What of others?

The effect of industrial action in the health service was to make the jobs of doctors and nurses more difficult while they continued to take responsibility for the sick. This was only possible because the nurses refused to strike. So the strikers could continue in their action, safe in the knowledge that the nurses were looking after the patients. And the nurses, to my knowledge, never complained. They did their job. In spite of this, people died, and many suffered immensely.

Even now, waiting lists are twice as long as they should be. Do the Government intend to give any advice to the health service authorities that this backlog should have priority, even to the extent of delaying much needed improvements in the care of the elderly and the mentally handicapped? One wonders whether the Secretary of State is in a dilemma in discharging his responsibilities for social services. Care of the mentally handicapped is not a therapeutic service and should fall squarely on the social services. Does the noble Lord the Minister not agree?

One result of the dispute in the National Health Service was the establishment of a review body for nurses to settle their pay in future. My own profession has had its pay determined in this way for the past 12 years. The results have not always been to the liking of the profession but, by and large, this system is acceptable to most of us and preferable to the alternatives. I believe that most people in the National Health Service will welcome the extension of this system to nurses, thus recognising their status among the caring professions. Her Majesty's Government are to be congratulated on taking this particular initiative in the course of the dispute, and they have the right to be believed when they say, in reply to certain cynics, that they would not have set up such a body simply to overrule its findings. I hope and expect that the actions of the Government will match their words.

Finally, whatever the rights and wrongs of the arguments on either side of the pay dispute, there is one aspect that has received little comment. As a newsworthy item the dispute came to an end a week or so before Christmas. Since then there have been various reports of this, that and the other settlement reached for different staff groups. These should serve to remind us that although there was agreement at that time on the total amount of money to be made available for pay, the translation of that into new pay rates for the vast array of National Health Service staff has still to be accomplished.

As has been said in the House tonight, we often forget how complex a body of staff the National Health Service comprises. My understanding is that this process is virtually complete. It must be much to the credit of management side negotiations that this task has been completed in so short a time, especially with Christmas intervening. To a large extent, the negotiators are unpaid members of health authorities up and down the country, who have many calls on their time but who have clearly done a most responsible job in a very short time. I hope that the noble Lord the Minister will find a suitable way of thanking them for their efforts.

6.42 p.m.

Lord Perry of Walton

My Lords, we all agree that there is clearly a need to improve conditions of service in the National Health Service, but which conditions are most in need of improvement? I wish to emphasise only one point. There is an abundance of evidence that morale among all grades of staff is low. There are many reasons for this, some of which have been mentioned, and no doubt they vary greatly between grades of staff and between places. But despite the recent industrial dispute, I think that rates of pay in themselves are not the most important.

As the noble Lord, Lord Winstanley, said, it has always been true that in the medical and paramedical professions or vocations satisfaction in the job done is far more important than the reward, monetary or otherwise, for doing it. But job satisfaction can be strained when staff are trying to do that job under difficulties which they see as being unnecessary. Sometimes they are doing the job in buildings which are decaying or are ill-cared for; sometimes they are doing it with inadequate equipment; sometimes with colleagues who are apathetic or frankly uncooperative. Furthermore, as the noble Lord, Lord Molloy, pointed out, National Health Service staff are at present working in a service which is seen to be under threat. Everywhere the local press is full of reports about local cuts in services and facilities, and there are frequently fears of redundancy. This situation is not calculated to build confidence and enthusiasm.

A further factor affecting morale was mentioned by the noble Lord, Lord Hunter of Newington, and that is the uncertainty engendered by the second major reorganisation of the service. One other really important point that has not yet been mentioned (but I mentioned it in the last debate on this subject in your Lordships' House) is that there are no leaders to help counteract these influences. In no hospital is there any one person who is fully responsible and accountable for all that goes on. There is, instead, a committee. Committees seldom give leadership.

We are supposed to have a comprehensive health service, but no one has defined what "comprehensive" means. Let me give an example, albeit perhaps a silly one. If a hospital is equipped in its emergency department to cope with two concurrent emergencies and three happen to occur at the same time to create three admissions, is there a failure to be "comprehensive"? The third patient will think so. But if a department is staffed to cope with three concurrent emergencies and for 99 per cent. of the time there is one or less, the cost to the public will be very much higher than it ought to be. In other words, there are two lines of accountability, and it is difficult to balance the one to the patient and the one to the taxpayer. To reconcile these responsibilities requires day-to-day decisions. This means a man or a woman, and not a committee.

Most organisations have found that the only efficient way of running themselves is to give one person the responsibility of making such decisions. If the confidence of the staff is lost, that person must be replaced; but if there is confidence, morale is restored and maintained. This is recognised and acted upon in business, in schools and in universities. Why is it not recognised in hospitals? However much we pay doctors, nurses and auxiliary staff, it will not substitute wholly for lack of leadership.

The same applies, as the noble Lord, Lord Winstanley, said, at the very top of the service. It seems to me that there, too, there is a gap. The noble Lord suggested that when there was a Minister of Health that filled the gap a little, but I wonder if that is really enough and whether he could possibly give the leadership that is needed. If there were a restoration of leadership it might do something to reconcile the arguments about pay, if not everything. It would certainly do something to remove some of the irritations to which the noble Lord, Lord Molloy, referred. I hope the Government will give serious consideration to this particular facet of conditions of service in the National Health Service.

6.48 p.m.

Lord Rea

My Lords, the National Health Service now employs one million people, and it is one of the major sectors of Government expenditure. To keep this very large body of people content would be a major success in its own right, but we have to remember that this section of our population is paid in order to help the other 55 million of us achieve health or speedy recovery from illness where possible. While we are talking about working conditions of National Health Service staff, we must always view this aspect in the wider context—that they are there to give good service to the rest of the community. Good industrial relations, however, usually lead to a better product, and I am sure this applies also to the National Health Service, even though its products are so difficult to measure quantitatively.

Industrial relations in the National Health Service have gone through a bad patch in the last year. I believe that many workers in the NHS only reluctantly accepted the Government's terms, and were not particularly happy about the outcome. It could be said that the Government managed by using the old principle of divide and rule, aided by a bleak economic climate, to win this round; but I am afraid that more troubles may be brewing unless better measures —such as some of those mentioned by the noble Lord, Lord Winstanley—are quickly and urgently undertaken.

In this debate I want to speak mainly about the position of doctors in the National Health Service, of which I have first-hand experience. I will touch briefly on the situation of hospital consultants and junior doctors, mention that of general practitioners, and then go on to discuss some ways in which savings and hence additional funds for the National Health Service might be found. These funds may go some way towards meeting the problems which I shall outline.

There is a great range in the rewards of the different professional group within the National Health Service. Doctors usually get about twice as much as other health professionals and three or four times as much as less skilled health workers. This is usually accepted, with varying degrees of reluctance, since doctors do make most of the expensive decisions and take final responsibility for patient care. They also have the most intensive and prolonged training. Nevertheless, resentment remains, especially if doctors in the National Health Service are also seen to be earning substantial sums in private practice, particularly of course if they use National Health Service facilities.

This led to the closing of the pay beds in 1976, a mistaken move, in my view, which I think has misfired somewhat and has been a factor in the subsequent expansion of private practice.

A further cause for resentment, and I may say some incredulity, is the unique British system of distinction awards, which has been mentioned by Lord Molloy and described by Lord Hunter. These amount to a substantial increase in salary for a group of consultants. As the noble Lord, Lord Hunter, said, about one-third of consultants hold these awards at any one point and about half will hold one at some point, usually towards the end of their career. At present A-plus awards at the top of the scale amount to very nearly the equivalent of a consultant's salary, so that those who are fortunate enough to get one of these awards practically double their income.

This merit award system was designed to retain in the National Health Service particularly able and eminent doctors who would otherwise have become part of the transatlantic brain-drain or continued in private practice. There is, however, nothing to stop a part-time National Health Service consultant from both getting a merit award and engaging in private practice. A maximum part-time consultant could earn, say, £20,000 as National Health Service salary, nearly £20,000 as a distinction award, and another £20,000 or so in private practice, making £60,000-odd. It is probably quite justifiable for very able doctors to earn this sort of money. Captains of industry earn far more. But it does seem to me a misuse of the original intention of the scheme, which was designed to hold especially able people for the benefit of the National Health Service. It seems to me that justice would be better served if this interesting scheme, unique in the world, could be restricted to those prepared to work all their time in the National Health Service; that is, full-time consultants.

The committee which decides who shall receive the awards meets in private and no list of award holders is published. However, some information is available and this shows that at present two-thirds of the merit awards go to those in the so-called glamour specialties such as thoracic surgery, neuro-surgery, cardiology, et cetera: the holders usually have positions in the major teaching hospitals in the big cities where there are often opportunities in any case for private practice. Only one-quarter of the awards go to those in the less popular specialties living in industrial or provincial areas where there is little opportunity for private practice. The system I feel should, if it is retained at all, show a reverse discrimination, encouraging able doctors to join unpopular specialties and to work away from the prestigious centres. Those places in themselves provide sufficient attractions for both fame and fortune.

I will now consider briefly the problems of junior hospital doctors. A new contract was negotiated some six years ago which I feel was a defeat for the Government of the day. Junior hospital doctors are now entitled to extra duty allowances; in other words, overtime, as mentioned by the noble Lord, Lord Molloy, and the noble Lord, Lord Winstanley. They have become rather like any other industrial worker. One result has been that some registrars with responsibilities out of normal working hours can actually earn more than the consultants they are working with, whose contracts do not offer such generous overtime arrangements. To me this represents a step away from the traditional role of a doctor, who should assume the total care of his patients regardless of times of duty or other commitments.

I am fully aware of the dangers of junior hospital doctors having to make difficult decisions while working late at night, having already worked a 12-hour day. I myself have been in this position. But I do not think the solution should have been to pay them more for the extra hours worked, or for holding themselves on call. Surely the answer should have been to recognise that more hands were needed on deck; in other words, to create more junior hospital posts. Of course, this would have cost money and there would perhaps have been other snags to overcome, such as disproportion between numbers of doctors in the training and junior hospital posts and the eventual final posts available. But these are soluble problems.

There is now legislation to make sure that long-distance lorry drivers do not do more than eight hours at a stretch. Junior hospital doctors often make decisions which involve much risk to life, as do lorry drivers, I think all your Lordships would agree, and the Government, I feel, are perhaps shirking responsibility by allowing the very long hours which junior hospital doctors now have to work, even though they are compensated for it.

I will say little in this debate about general practitioners. Their interests as independent contractors are rather well looked after by the family practitioner committees, which I consider to be rather inward-looking bodies, shortly—if the Bill completes its Report stage next week—to have their status even further upgraded so that they are even more remote from the district health authorities and community health councils representing the population they serve. I would like to see some features of the distinction award scheme which applies to consultants applied to general practitioners. This idea was floated some 15 years ago, but general practitioners could not agree on how it should work, so the idea was dropped. I think the Department of Health itself should, in consultation with the profession, propose the criteria which should enable doctors to qualify for a special award, and these awards should go towards the provision of services which are likely to be of benefit to patients and relieve pressure on hospitals. Examples are general practitioners holding diabetic clinics or doing minor surgery in their own practice, or, in the preventive field, those who acquire special skills in child assessment, or undertake geriatric and hypertension screening.

Finally, I would like to look at ways in which doctors could save the National Health Service money, some of which could go towards creating the new posts and awards I have suggested, thus helping to remove the spectre of medical unemployment which is now looming, and also improving the service to patients. The Greenfield Report, which is to be published by the DHSS shortly, is reported to support "generic substitution" for general practitioner prescriptions. This means that if a general practitioner prescribes a proprietary drug, for example valium, (perhaps the best known of all) made by Roche—whose generic or chemical name is actually diazepam—the pharmacist will be entitled to substitute the cheapest form of diazepam which is marketed. Several manufacturers other than Roche now make this at a less cost.

Many general practitioners use the proprietary, that is, the drug manufacturer's name, because of the advertising influence of the drug companies, and because the names are more convenient or easier to remember. For example, "librium" is easier to remember than "chlordiazepoxide" or "valium" easier than "diazepam". Those of your Lordships who watched Panorama last week will have seen the intensive pressure that drug manufacturers put on doctors to prescribe their products. I receive five unwanted magazines each week, free of charge, each quite expensively produced and each of them employing staff and journalists. It has been estimated—but we await Dr. Greenfield's report—that about 10 per cent. of the cost of the general practitioner drugs bill could be saved by using this kind of generic substitution.

Incidentally, the cost of drugs prescribed by practitioners equals the cost of the rest of the primary care service. Doctors involved in the generic substitution scheme would still be enabled to indicate if they particularly wanted a patient to have a specific proprietary drug. There should be little controversy over this measure since hospitals already operate the system and many GPs are entirely in favour of the scheme.

I see that I have already spoken for 13 minutes, so I shall now come to a close. Some of the measures that I have suggested will lead to increased morale, possibly better distribution of talent throughout the country, and provide better services to patients, particularly preventive services. Most of the extra expenditure involved could be provided by the changes I have suggested, which would cause hardship to no one. If the drugs companies were to find the going a little bit thinner I, for one, would be relieved, because it might save the cleaners in my health centre having to empty heavy waste-paper baskets full of advertising material every day.

7.1 p.m.

Lord Harris of High Cross

My Lords, I join with other speakers in thanking the noble Lord, Lord Molloy, for this opportunity of discussing ways of improving conditions of employment for staff in the National Health Service. I fear that he will think it a poor return that I should, from the Cross-Benches, adopt a radically different approach from his own. Despite his enumeration of irritations and discontents, I believe that he tended, perhaps untypically, towards complacency in this matter.

On training, he spoke, if I remember correctly, of the "labyrinth of responsibilities" which was something short of what he called "real chaos". I believe that such criticisms might apply more widely throughout this over-centralised service. Plainly there is much discontent among the staff and many previous speakers have talked about the poor morale that has developed.

It was left to the noble Lord, Lord Winstanley, to introduce the question of improving pay. I think we must face the fact that successive Governments, both Labour and Conservative, have badly mismanaged the whole issue of public pay. All the trade union talk about negotiations, comparability and arbitration has, in my view, served, like the patter of conjurors, to conceal the great levitation act of raising labour costs throughout the public sector without bringing great content in its train.

Nowhere are the deplorable results more evident than in the National Health Service. The official figures could hardly be more damaging. Since 1960, staff numbers have more than doubled from 565,000 to above 1¼ million. The average cost of each worker in 1981–82 was just under £7,000, and, of the total current expenditure of £11 billion last year, 75 per cent. was on wages and salaries.

I would guess that the National Health Service is the largest employer of labour, not only in Britain but in the whole of the free world, yet all the evidence points to a deplorable lack of skill in the crucial art of man management. The latest account I have read was provided in a series of articles by one of our most experienced and scrupulous of reporters, Mr. Graham Turner. The picture that emerged was of committee ridden, bureaucratic paralysis, with buck-passing between areas, regions and districts. The fundamental management rule of short clear lines of responsibility was everywhere set at nought. One Labour Party activist in a Midlands hospital was quoted as describing the administrators as "puppets controlled by other puppets." Mr. Turner also interviewed former National Health Service employees who were then working in army and naval hospitals as well as in private hospitals. They all said that they knew where they stood. They were more cost conscious and they preferred working effectively under purposeful management with a proper chain of authority including, I was glad to see, the matron.

What has all this got to do with the Motion before us? Conditions of employment include much more than pay. But, even if we are thinking of pay, it seems to me that the aim which should unite us all is to improve conditions of work without simply raising the cost to the taxpayer, which already averages over £12 per week for every family in the land. The chief method of improvement should be through increasing efficiency in the use of manpower. That is the way that competitive industry, even today, is reconciling higher wages with lower unit costs of production.

If the noble Lord, Lord Molloy, will sit back comfortably on his Bench to minimise the impulse to violence or apoplexy, I should like to offer an economist's solution. In addition to encouraging the spread of private health insurance, it would be to put out all non-medical work in the National Health Service to competitive tender. This may at first sight seem unacceptable, but I believe the logic is unassailable. The noble Lord, Lord Hunter, referred to a "complex body of staff". Very well. Why should politicians who are rightly concerned with health care wish to monopolise the completely different business of scrubbing floors, cooking meals, running laundries and even tending the often extensive grounds?

I know that the noble Lord, Lord Molloy, is a student of economics. I should like to remind him that more than 200 years ago Adam Smith diagnosed the secret of economic progress as the division of labour and the specialisation of function. Management calls for special skills. Above all, in a labour-intensive employment such as the NHS, it is necessary to measure the work, to motivate the staff, and to monitor the results to ensure satisfactory performance. There is no disgrace in the fact that doctors, nurses, even financial controllers and politicians lack these special skills. But in Britain we have a growing number of specialised service contractors who train and manage labour forces to do jobs more efficiently than when they are performed as part of an unwieldy conglomerate such as the NHS.

Your Lordships may recall that one contractor recently took advertising space to allow the Southend dustmen to say publicly how much more job satisfaction and pay they got from Brengreen than from the old Southend Council. Yet the saving to the customer in that case was £500,000 which equals 1½p on the rates. Another contractor, is called Pritchards and, I understand, has a company specialising in hospital services. Like Brengreen, it is a leading performer overseas, especially in America and the Middle East. It has recently renewed a contract to clean Stoke Mandeville Hospital. It would welcome the freedom to go above the Whitley Council rates of pay as well as looking forward to the exemption from VAT on the contracts. I hope the Minister may find time to refer to that matter.

The contractors commonly aim to save 20 or 25 per cent. of the labour costs. Indeed, the latest contract, which was reported in the papers just before Christmas, was for the new Redhill General Hospital. It was said that it would save £50,000 on a contract of £200,000 for the cleaning, thereby paying for 10 additional nurses.

These contractors already do cleaning for thousands of shops and offices, including Government departments. I hope that it will not upset the noble Lord, Lord Molloy, to know that the Palace of Westminster is cleaned by a private contractor. One estimate is that contracting out the non-medical services of the National Health Service could save perhaps £500 million a year, which would be available either to give back to the taxpayers or to spend on additional facilities within the service. All that stands in the way of a dramatic advance is the usual unholy mixture of Conservative indolence and Socialist ideology. In conclusion, I appeal once more to the Front Benches to declare a truce and join in this most constructive way to improve the conditions of employment throughout the National Health Service.

7.11 p.m.

Lord Wallace of Coslany

My Lords, I am not so sure that we would readily agree to do so, but that is a matter of opinion. First, let me thank my noble friend Lord Molloy for raising quite an important issue as regards which we have had some very excellent and authoritative contributions from noble Lords. As other speakers have indicated, there is no doubt whatever that the morale of staff in the National Health Service is today very low, particularly at hospital level. There are two main causes, and the first is the bitterness still existing over the recent pay dispute. Strong-arm tactics may have given the Government a victory, but they have left a legacy of mistrust which is, indeed, souring industrial relations.

Not only must the Government act quickly to make clear their proposals for a nurses' pay review body, but it is also essential that the intentions regarding the need for a review mechanism for the other health staff should be made clear as soon as possible. If, as so many people claim, hospital staff should not take industrial action because of the nature of their work and responsibility to patients, then in common fairness their pay review bodies should be adequate and fair.

To be successful and to achieve results, as in business, and more particularly in hospitals, teamwork and team spirit are essential factors. Any consultant worth his salt will freely admit that the results of his skills and ability depend considerably on effective daily backing by nursing and ancillary staffs, mainly in the nursing field. Reduced morale has a vital, adverse effect on teamwork and team spirit. As a result, patient care is bound to suffer.

Another factor affecting morale is further reorganisation. In time—at least, I sincerely hope that this will be the case—it should adjust itself, but it will take time. Many senior nursing officers have been forced to opt for voluntary retirement after the traumatic experience of applying for their own jobs and failing to retain them. A similar situation has been faced by some hospital administrators. People in these categories are key figures, and in the main they are widely respected at all levels for their qualities of leadership. When, as has happened recently, these people are, in the mind of their supporting staff—nursing and ancillary—kicked out of their job, a mood of resentment and depression spreads downwards among staff. I know what I am saying is true, because I have seen it happen in a certain respect. This situation also arose during the previous reorganisation, which was a disaster and should never have taken place. Financial stringency and hospital closures, actual or projected, are factors fomenting the idea of the National Health Service, particularly hospitals, being deprived and neglected—hardly an encouragement for teamwork, and a fertile breeding ground for rumours to which hospitals are particularly prone.

One way in which to assist the restoration of morale is to encourage the setting up of joint consultative committees for all grades of staff, except doctors, at hospital level. Doctors are excepted simply, as one would naturally expect, because they wish to be separate and already have their own organisation. The setting up of such joint committees, consisting of elected members of staff together with representatives of the district health authority, could achieve a great deal to destroy rumours, to remove irritant factors and, more important, to yield constructive suggestions to improve efficiency and save money—improving, in the process, working conditions for all. Similarly, at DHA level joint consultative committees should have among their members representatives from the various hospital JCCs, providing contact right through from hospital to district level.

From my experience it does work, as I was responsible for the setting up of such an organisation at my local hospital after the previous reorganisation. I might add that there was some opposition from officials and the chairman of the AHA. But in the end we won. There was an improvement in morale, and many constructive ideas came forward to save time and money. I want to make it perfectly clear that there is no involvement in day-to-day management, but there is contact—and this is a very important factor—at all levels. I am glad to say that the new DHA has now set up a JCC at district level, with representatives from the hospital JCC. I am referring to the Bexley health district, which I submit is an excellent example to follow.

Yesterday's press announcement of extra cash for the NHS and the Minister's words in his Written Answer at column 119 on 24th January, that: The Government have once more been able … to expand services for patients. The additional 1.2 per cent. growth represents nearly £100 million more over the year". sound fine, until one examines the small print. In point of fact, due to uneven distribution of finance many areas will be worse off, particularly London and the Home Counties, which means further cuts in services and facilities for training, delay in raising standards of accommodation, and more hospital closures.

I refer next to residential accommodation. Many of our hospitals are very old, and accommodation for resident medical and nursing staff verges on the appalling, as is the provision for medical staff on night duty, on call. However, residential accommodation in new hospitals is, in the main, a great improvement. In one case that I know very well it is absolutely excellent.

There is no doubt whatever that urgent action is needed for the older and often decrepit accommodation existing at older hospitals. My experience some years ago at one hospital, which is now demolished, was that we had nurses living in converted hen houses! I thought that that was an insult to the nurses, apart from the fact that we did provide temporary accommodation. There is a suggestion in today's press that staff residential accommodation should be taken away from hospital administration, and the responsibility placed elsewhere. If this is true, I hope it is not a suggestion for further privatisation, as charges to nurses and junior doctors are already high—in fact, in my opinion, far too high; a factor not generally taken into account when discussing nurses' pay.

My noble friend Lord Molloy mentioned créches or, as some of us know them, day nurseries. Some time ago I had to fight for one at a new hospital, but I am afraid economy measures came along and it had to be rescued from closure. However, fortunately, the people involved themselves managed to get an organisation together and to run it themselves. This question of day nurseries at hospitals is a very important point, because in point of fact many fully-trained and experienced nurses and members of the nursing staff are lost to the profession due to pregnancy alone. Some provision should be made for this. Naturally, an experienced nurse who is married would want a family. She may have one, and good luck to her! Incidentally, I should like to congratulate in advance the noble Lord, Lord Auckland, on the future birth of a grandchild.

As I say, this is an important factor, and we must provide the means and the way for these people to return to the service to help and guide younger nurses coming out of training; because these older nurses know their stuff, as many consultants themselves will readily admit.

I would also advocate the need for facilities to train in new technology in hospitals. Indeed, a great many remarkable developments are taking place. I would link it with the need for periodical refresher courses for GPs. The extension of postgraduate medical centres in hospitals to cover this is obvious, although some, but not many, are already fully geared to meet the need. The trouble is that such centres have to be provided partly or wholly out of voluntary funding, and raising such money today is not easy bearing in mind the intensive efforts of leagues of hospital friends to raise money for urgently needed hospital equipment, as indeed they are doing. By providing not only medical equipment but other items for the comfort of staff as well as of patients, the leagues of friends are giving valuable help in improving working conditions of hospital staff.

I am not sure how many doctors are unemployed at the moment—and I here refer to qualified but unemployed junior doctors—but it is a fact that at the moment medical cover at some hospitals is short of requirements due, not to a shortage of available candidates but to a shortage of finance. This applies not only to junior doctors but to unfilled vacancies for consultants. This is a very important matter when we are talking about the backlog of cases to be dealt with which resulted from the unfortunate industrial action, and on on. When a regional authority says that there is room for another consultant, that is all right; but, unfortunately, when it says so it does not provide the money required. This is a very serious matter that must be faced.

I should like to say a few brief words about nurse training schools. Nurse training schools at hospitals are very important, and should be extended and treated as a necessity rather than as status symbols for certain hospitals. It is an accepted fact in hospital circles that if you have a nurse training school you are one up on someone else. I think that is entirely wrong. Nurse training should be at hospital level, and should be attached to most of our main hospitals.

There is also another question on training, which I have come across in the last few days. There is a very severe shortage of trained midwives. I wonder what thought is being given to training facilities to provide them, and to meet what is a possible emergency? I know of one extended maternity unit, which will be ready for use next year, where they will have the facilities but not the midwives to run it. So thought must be given to the provision of staff.

Other points come to mind, but this is a short debate and one naturally wants to give the Minister adequate time for reply. Whether or not he will thank me for that afterwards, I do not know. I frankly admit that I have been critical and pessimistic in my remarks, but I have tried to be constructive as well. I shall conclude by stating that, with all its imperfections and undoubted needs, treatment and care in our national health hospitals are equal to, and in some cases better than, alternative facilities available in the country. Certainly—and this needs to be said—there are not many countries in the world, if any, that can give the same high standards of treatment and care that we give in the National Health Service, irrespective of class, colour or creed.

I know that my family and I have benefited tremendously from the care and dedication of health service staff, and I am not the only one here tonight in that position. Before we embark on too many disruptive criticisms we should at least give credit where credit is due. The medical and nursing staff in our hospitals deserve a great deal of credit, particularly bearing in mind the frictions and the difficulties urged upon them by a higher administration. They deserve better, and I think that our responsibility is to give it to them.

7.27 p.m.

Lord Trefgarne

My Lords, I add my voice to those of other noble Lords in thanking the noble Lord, Lord Molloy, for raising this matter tonight. The noble Lord's Motion is: To call attention to the need to improve conditions of employment for staff in the National Health Service". Implicit in his Motion and, indeed, explicit in his speech is that there are both general and particular matters to do with pay and conditions of health authorities' employees which require amendment or remedy. During this debate other noble Lords have developed particular themes or drawn attention to particular problems, which either directly or indirectly are associated with the general thrust of the Motion of the noble Lord, Lord Molloy.

Before I deal with particular issues, I should like to go back to first principles. The National Health Service exists because duties are laid by Parliament upon Health Ministers. Section 1 of the National Health Service Act 1977 recalls the words of the 1946 Act, which brought the National Health Service into being in England and Wales. I paraphrase a little for brevity, but the essence of the matter is that it lays upon the Secretary of State a duty to promote a comprehensive health service which will secure the improvement of the physical and mental health of the people and the prevention, diagnosis and treatment of illness. Put more plainly, in practice it is for health authorities to develop, to the best extent that resources allow, services to prevent ill health and to cure and care for sick and handicapped people. That was the essence of some of the remarks of the noble Lord, Lord Rea.

Despite their number and diversity, National Health Service employees, the health authorities and the Government have a common interest. Together we are concerned that, within the resources of money and facilities available, the health services provided should be as comprehensive, efficient and effective as possible. This involves striking a balance between the primary objective and raison d'etre of the service, which is the health of the people and the welfare of the patients, and its corollary, which is that the attainment of this objective depends upon employees who must be paid and provided with conditions of service which enable them to carry out their work and motivate them to do it well.

As for resources it is necessarily for the Government to decide how much the country can afford to spend upon its health services. Inescapably this depends upon the state of the economy. But, despite the recession, this Government's spending on the National Health Service has risen from £7¾ billion in 1978–79 to £14½ billion this year; an increase which outstrips the movement of the retail price index by almost 16 per cent. Much of this extra funding has provided increased pay for staff and shorter hours for nurses. At the same time, and over the same period, it is estimated that there will have been a real growth—a real growth, my Lords—of about 5½ per cent. in services to patients, and manpower is expected to have increased by about 7 per cent.

The public is entitled to expect that levels of pay in the National Health Service will be sufficient to attract and retain the many grades of staff required to provide health services. The Government accept and believe that they have discharged this responsibility. Some evidence of this is to be found in the fact that the National Health Service has recruited and retained an increasing number of staff ever since its inception in 1948. Nor are there any general difficulties in recruitment and retention at the present time. This applies equally to general practitioners—although they are not, of course, National Health Service employees, but independent contractors—as to other groups.

What, then, are the arrangements for ensuring that the rates of pay and conditions of service are sufficient to attract the staff that we need to the National Health Service? In the case of grades who are employed mainly, or entirely, by the National Health Service, such as doctors and dentists, pay rests on the recommendations of the independent Review Body. In the case of many grades of non-medical staff—for example, clerical, domestic and catering grades for whom the health service is only one of many potential employers—pay is the subject of negotiations between unions and management in the Whitley Councils. These can take account of the market rates for similar occupations and also of the conditions of service, job security, and ease or difficulty currently being experienced in recruitment.

Turning to the future, the Government very much hope that as a result of two initiatives which they have launched, pay in the NHS will be put on to a more satisfactory and stable long-term basis. These should maintain morale in the Service, which is vitally important if we are to make the developments in patient care which we all want. The first of these initiatives is of course our decision to establish a new review body to report on the pay of nurses, midwives, and the professions allied to medicine.

We intend that the review body's first report should cover the pay settlement due on 1st April 1984. The Government will shortly be entering into wide consultations with the interested parties, including the professional bodies and trade unions involved, on a number of issues including the coverage and terms of reference of the proposed review body. Our view is that the new review body will be analogous to the Doctors' and Dentists' Review Body, which has worked well over the years and given satisfaction both to the Government and to the professions. I was happy to hear the noble Lord, Lord Hunter, confirm that view.

Of course, we shall have to reserve the right not to accept recommendations in full where there are compelling national reasons for this, but that would be the normal position with review bodies and we are not setting up a new one with the intention of ignoring its findings. I think that that was understood by at least one noble Lord who spoke earlier.

The second initiative is our offer, which I am pleased to say has now been accepted by the trade unions, to discuss more permanent arrangements for determining the pay of the other health service staff. We hope that discussions on this will begin shortly. I must make it clear that the new review body, for the nurses and professions allied to medicine, whose pay has been traditionally linked to that of nurses, recognised the special skills and responsibilities of these groups, and the review body principle cannot be extended therefore to other NHS staff. I am sure that your Lordships will agree that we must concentrate our minds on the future rather than rake over the past, and that it is vitally important both for the Health Service and for its staff that the initiatives which I have just outlined should both succeed.

Health authorities are, of course, expected to take account of all their statutory duties as employers, and in general the employment legislation of this country applies to National Health Service employees in the same way as to the employees of any other organisation. There are exceptions, and in these cases there are National Health Service conditions which parallel the generally applicable ones. The welfare of employees is of course affected by other statutory provisions besides employment legislation.

In addition to matters which are regulated by statute, the National Health Service provides, as do other good employers, a range of facilities which contribute to the welfare of employees, although they are not strictly bound to do so. Depending on local circumstances and needs these may include both residential and non-residential facilities, assistance with travel to work in outlying units, day nurseries, and recreational and leisure facilities. Where charges are made these are normally related to the actual cost of provision, or to charges made by other public bodies locally.

May I turn now to as many as I can of the points that have been raised during the course of this debate. The noble Lord, Lord Molloy, in his opening speech referred to the large number of part-time staff employed in the National Health Service as a source of aggravation—I believe he thought they were—to full-time employees.

Lord Molloy

My Lords, will the noble Lord give way? I cannot let the noble Lord get away with that. Let him read Hansard. I stressed how vitally important are people who have qualifications, particularly women, who have a vital role to play, but that management— and this was the gravamen of my case—do not seem to be concerned with fitting in the vitally important part-time worker with the full-timer.

Lord Trefgarne

My Lords, I am happy to accept that clarification. There are indeed a large number of part-time staff, as the noble Lord recognises, in the National Health Service. Indeed, 38 per cent. of all employees are part-time, providing about one-quarter of the service's staffing resources. But there is no evidence to suggest that employment of part-time staff on this scale is a cause of friction. Indeed, their interests are strongly looked after by the trade unions active in the National Health Service.

The opportunities for part-time work afforded by the health service provide scope for employment to people who might otherwise find it difficult to take up a job, such as mothers who have children to look after. Part-time staff can afford additional flexibility to management in fixing rotas to provide, for example, a round-the-clock service seven days a week. Indeed, many full-time consultant posts are offered to part-time staff to encourage women doctors, in particular, to take up appointments. The noble Lord referred to the question of crèches. I understand that there are some available in the health service, although doubtless there are cases where more ought to be provided.

The noble Lord, Lord Molloy, also referred to the question of the proportions of trained staff to those in training. I understand that the ratio of nurses and midwives, for example, under training compared with qualified staff is 1 to 2.6. There are of course many other staff in the National Health Service for whom there is a formal training qualification, such as medical laboratory scientific officers, catering staff and ambulance men, and the proportion of people in training compared with the trained will vary from group to group and from time to time. The number of staff who are in training depends not only upon the number already trained but on a number of other factors such as, for example, the length of training, the age pattern of those already trained, and the planned provision of the service to be undertaken by the trained staff. All these factors need to be kept under continual review.

The noble Lord then referred to the question of geographical balance in medical training. The Government have been concerned for a number of years to provide a more balanced distribution of medical school places across the country and this has led to a policy of expanding some existing schools outside London—for example, Sheffield, Newcastle and Leeds. We have, furthermore, built some new medical schools at Nottingham, Leicester and Southampton, and I recall visiting the medical school at Southampton recently on the occasion of their tenth anniversary. In addition, we are planning that there should be no expansion of places at London medical schools above what has been agreed as a long-established target. The results of this policy are evident from the 1982–83 pre-clinical intake into medical schools, where schools in the five central English regions—that is, Trent, Mersey, West Midlands, North-Western and Yorkshire—accepted over 35 per cent. of the total intake into English medical schools.

The noble Lord, Lord Molloy, then dealt with the question of hospital closures. He and I have discussed that matter across the Floor of your Lordships' House on more than one occasion. I will not again remind your Lordships of the very exhaustive procedure which exists in these cases. Suffice it to say that this procedure takes the fullest account of local considerations and in the event of a disputed decision the matter comes before Ministers, in general, for a final decision.

The noble Lord, Lord Molloy, then turned to the question of the training of the professions supplementary to medicine. Largely for historical reasons, the training of the professions supplementary to medicine—by which is meant, as the noble Lord said, physiotherapists, radiographers and the like—is carried out in a variety of institutions. In some professions the training is predominantly in schools set up and run by the NHS. In others, polytechnics, universities and privately-run institutions play their part. But there is a common thread running through these arrangements, and that is in the work of the Council for Professions Supplementary to Medicine. That independent council, together with its eight registration boards, is responsible for the regulation of professional education—the validation and inspection of courses and so on—and the maintenance of lists of those who have reached the required standards for state registration. Only those who are state registered can be employed in the NHS. I will not go into further detail on that, but I think the fears which the noble Lord expressed were not well-founded.

More than one noble Lord referred to the question of distinction awards. Distinction awards give consultants a powerful incentive to do their utmost for the NHS and its patients. They also give rewards according to professional renown without which many senior consultants might quit the NHS entirely in favour of private practice. The system is not the distribution of public monies by a medical cabal in its own interests, as has sometimes been suggested. The Advisory Committee is comprised of distinguished medical and lay men who have no personal interest in the awards they bestow, having, in the case of medical members, already achieved the highest levels.

The membership of the committee is public knowledge and it operates solely as an adviser to the Secretary of State. It controls neither the number nor the value of awards, which are set by the Secretary of State on separate advice from the Review Body. The names of award-holders are not published because patients might, quite unreasonably, refuse to be treated by someone who did not have an award, rather than because there is any intrinsic secret about who has them.

I come to the remarks of the noble Lord, Lord Winstanley, who raised, among other matters, a point about the membership of the staff side of Whitley Councils. This is, of course, not a matter for the health department specifically. The essence of the system is that membership of the staff side is decided by the staff sides themselves and it is for newly emerging unions or professional associations to make their own case on its merits to the constituent bodies of the staff side.

The noble Lord then referred to some ideas about determining pay in the health service which I think largely amounted to a system for arbitration. I remember during the recent dispute the noble Lord, Lord Molloy, and others pressing me from time to time to accept that we should have put that dispute to arbitration. I accept that negotiating within fixed amounts creates particular problems, and, as will be apparent from this year's pay round, the initial decision of what can be afforded cannot, and indeed should not, always be maintained inflexibly, even if some of the money has to be found by authorities through greater efficiency or forgoing improvements in services.

However, we have made it clear that we do not feel able generally to return to the more or less open-ended arrangements of the past whereby, in many instances, comparisons with analogous groups of staff outside the NHS tended to determine the percentage increases which were eventually awarded. In the last analysis, as I explained to the noble Lord, Lord Molloy, in reply to his oral Question on 23rd November last, the Government cannot sub-contract their obligation to determine the sum of money available for pay purposes in the Health Services. Once the sum was settled, it was for the Whitley Councils to determine its allocation. As for the future, I have already explained Government's decision in regard to both nurses and midwives and the other staff groups.

Lord Molloy

My Lords, one of the irritants was that the Government did not apply that criteria to the police, the forces and many others; they applied it simply to those working in the NHS. As I say, the forces, the police and other Ministry-controlled institutions did not have that yoke placed on them. They selected to put that yoke only on the NHS.

Lord Trefgarne

Your Lordships may forgive me if I do not follow the noble Lord down that path. He and I exchanged our views on that matter and matters related to it ad nauseam during the course of the dispute, and your Lordships may think it better if the noble Lord and I agree to differ.

I turn to a question raised by the noble Lord, Lord Winstanley, but touched on by others, and that is the problem of low pay in the NHS, a problem which I believe should be seen in perspective. The health service employs a large number of staff covering a wide range of skills and levels of responsibility. Pay rates must be competitive to attract and retain essential staff. There is no indiction that NHS staff generally are paid less than workers doing comparable work elsewhere, and in general there are no problems over recruitment and the retention of staff.

Many of the lower rates of pay are paid for relatively unskilled work or to new entrants, many of them school-leavers who will undergo initial training. The pay to those trainees will automatically increase as they gain experience and qualifications. The service, as I have said, also employs many part-time staff whose pay, of course, reflects the number of hours they elect to work. Gross earnings, rather than basic pay, represent the appropriate measure of pay in the NHS, and here I must disagree with the noble Lord, Lord Winstanley. The nature of the service which is provided affords many opportunities for enhancing basic pay, often within the standard working week. Manual workers, for example, often benefit from bonus schemes which help to promote efficiency. These additional earnings often significantly exceed basic pay. In the case of full-time ancillaries, average earnings exceed basic pay by 60 per cent. for men and about 36 per cent. for women. Higher earnings are not generally dependent on excessive levels of overtime being worked; the average for full-time male ancillaries is five-and-a-half hours a week.

The pay profile of the NHS in 1981 was not significantly different from that in the economy as a whole. Then, about one-fifth of all full-time adult employees in Great Britain earned less than £80 a week. Most are in the private sector and do not enjoy the job security or the prospect of indexed-linked pensions available to NHS employees. Low pay in the NHS is part of a national problem and can be overcome only by improving the performance of the country's economy.

I turn now to some points raised by my noble friend Lord Auckland; in particular, the question of nurses' lodging charges, which I know was raised also by at least one other noble Lord. Lodging charges are not determined by the Government but by the Nurses' and Midwives' Whitley Council. Their agreements have, technically, to be ratified by the Secretary of State, but it is I think misleading to imply that he is responsible for setting the level of charges. In 1981 the Whitley Council reached agreement on a revised system of charges, which for the first time related to the actual costs of providing the accommodation. It was also agreed jointly that fully economic charges would be phased in over four years (up to 1984) and the formula for determining what is a fully economic charge was fixed. The economic charge is recalculated each year in line with the RPI, and the resultant charges are agreed by the council.

Abatements in the charges—and this is important—of up to 40 per cent. are available for students and others under the age of 22—who constitute a large proportion of those who live in—and for those in lodgings not meeting the required standard. It is estimated that only 10 to 12 per cent. of nurses—that is, 50,000 to 60,000—actually live in. Very few ward sisters and nursing officers live in.

I have in front of me some figures which may be of assistance to your Lordships. For example, a third year student nurse pays £8.65 as a weekly lodging charge. That is the recently agreed increased charge, and I think that your Lordships will agree that it is a fairly good bargain. Reference has also been made to meal charges paid by nurses and others in the National Health Service. Your Lordships may like to have some examples of the meal charges, too. Breakfast, I see, is 39p, lunch is 69p, tea is 19p, and snack supper is 32p. Those figures compare very favourably with charges paid by your Lordships in your own Dining Room.

Some reference has been made to the question of accommodation for junior doctors, which is perhaps not the same point as that about nurses' accommodation, but it is related to it. I should perhaps mention that accommodation for junior doctors is free if they are on a one-in-three rota, and abatements also apply for doctors on rotas between one-in-four and one-in-seven. The charges are made only when doctors are voluntarily resident. I have some more details about nurses' accommodation, but perhaps that may be kept for another occasion.

My noble friend Lord Auckland also asked about funds for new equipment within the National Health Service and for upgrading hospitals, and nurses' accommodation, too. These detailed matters involve decisions that are essentially for district or regional health authorities. However, I would draw my noble friend's attention—if he has not already seen it—to the Written Answer that I provided to my noble friend Lady Lane-Fox on 24th January. I think that it actually appeared in yesterday's, or perhaps today's Hansard. In the Written Answer, we referred to the increased funds that are being made available to the National Health Service for next year. The noble Lord, Lord Wallace, also referred to that point, so I have no doubt that he has seen the announcement that was made.

In referring to the announcement, perhaps I should underline it in the following way. Health authorities will be asked to give particular attention to the maintenance of the estate by improving the condition of existing hospitals, both to provide better conditions in which to care for patients, and to make more effective use of the resources available to the service. In addition, health authorities are asked to improve the quantity and quality of services, in particular services to long-stay patients, as well as community services, and to ensure that priority is given to regional services, such as renal dialysis. I hope that my noble friend will be satisfied with those assurances.

I now turn to the remarks of the noble Lord, Lord Hunter of Newington. I was grateful for what he had to say about a number of matters. Incidentally, I can assure him that all the major staff groups have now settled on the basis of a two-year pay deal, in accordance with the understanding reached between the Government and the TUC in December of last year. The only exceptions are ambulancemen and regional works staff, who I understand are meeting today for this purpose.

The noble Lord, Lord Hunter, also referred to the question of care for the mentally handicapped. The Government have taken major initiatives towards developing care in the community, which I think is what the noble Lord was seeking, in particular with regard to mentally handicapped patients. The Government do not see it as a question of "either/or" where NHS facilities and social services are concerned. What we want to foster is a constructive partnership.

The Motion of the noble Lord, Lord Molloy, has enabled a most useful debate to take place on an important subject. It has provided an opportunity for the discussion of specific issues of concern to particular groups of employees, and the wider and the more general issue of the way in which the National Health Service discharges its responsibility to be a good employer of its own staff. In what I have said, I have tried to strike a balance between comment on particular matters, and setting the basic issues in the wider context of the public interest and the primary purpose for which the Health Service exists.

The Health Service also has to strike a balance—a balance between providing services for patients, whose interests are paramount, and providing appropriately for the welfare of its own employees. It has been suggested that there is inherent in the system an enforced and unnatural polarisaition of interests, that the welfare of employees can be secured only at the expense of services to patients, and vice versa. I do not agree. The means cannot be set in opposition to the end. The National Health Service depends on its employees, who must be paid and provided with conditions of service that enable them to carry out their work and motivate them to do it well.

Before I sit down, I should like to deal with one or two points that I still have in front of me; in particular, a point made by the noble Lord, Lord Rea, who asked me about merit awards for general practitioners. On these proposals, GPs already receive seniority payments for long service to the National Health Service. It has never been considered by the department, or indeed the profession, that general practice is an appropriate field for separate distinction awards

The noble Lord, Lord Harris of High Cross, raised a most important issue in what he said about the management and control of manpower. We have introduced a system of up-to-date quarterly—instead of annual—returns on manpower figures for the National Health Service. Last July we required regional health authorities to provide revised non- medical manpower estimates for 31st March 1983, and we have also asked regions to provide by the end of February projections of manpower in each major staff group for 31st March 1984, derived from district health authorities' service plans for that year. Those projections will be used as a basis for agreement on manpower targets for each region for March 1984. In addition, my right honourable friend has announced his intention to set up a management inquiry, led by people from private industry, to reinforce the other measures taken to improve efficiency in the National Health Service.

I much agreed with the noble Lord, Lord Harris, in what he said about the possible merits in contracting out services. We are currently looking at the advice that we can offer health authorities on testing the cost-effectiveness of, for example, laundry, catering, and domestic services. The National Health Service already spends £160 million on contracts for a wide range of support services, but if, by extending the use of outside contractors, further savings can be achieved, that will release additional funding for patient care. We have considered that direct labour services and the private sector should tender competitively for services and that contracts should generally go to the cheapest. This is commonsense housekeeping, and makes the best use of limited resources.

In our advice to health authorities we shall be stressing the need for staff interests to be fully consulted before a decision to invite tenders is taken. Incidentally, the staff concerned will be invited to co-operate in the preparation of an in-house tender. Even where contracts are let, the hospital employees concerned will mostly be taken on by the contractor.

I believe that I have now covered as many of the points as I properly should, and I hope that the noble Lord will see fit to withdraw his Motion—

Lord Wallace of Coslany

My Lords, before the noble Lord sits down—and I am not going to make a Second Reading speech—will he write to me in due course on the question of joint consultative conmmittees? It is very important.

Lord Trefgarne

My Lords, I shall certainly write to the noble Lord.

8 p.m.

Lord Molloy

My Lords, I think it fair to say that we have had a very useful and constructive debate. I only wish I had the full right of reply for another 20 minutes, but, of course, I do not. I should like to thank the noble Lord the Minister for his very full response to the points that were raised in this debate, and to congratulate him on his anticipation. I am pleased in particular because of the seriousness with which the noble Lord, Lord Trefgarne, treats these debates when he has to respond to them. Also, I thank my noble friend Lord Wallace for his piercing examination of many points which I had not made but for which I am grateful; the noble Lord, Lord Winstanley, for his experience and knowledge, which he makes available to us all and the noble Lord, Lord Auckland, with his considerable knowledge drawn through family contacts and family links very similar to my own.

The noble Lord, Lord Hunter, went into the field of disputes. All I would say about that is that it is by no means a one-sided argument, as he seemed to imply. I believe the nurses have a very strong case. To the noble Lord, Lord Perry of Walton, with regard to his submission that we need leadership, I would say that this, I believe, is fundamental. We had never had the proper leadership of anyone in government with regard to the National Health Service except from the great man who created it—with the aid, I might say, of his then Parliamentary Private Secretary, now my noble friend Lord Bruce of Donington.

I give my thanks, too, to the noble Lord, Lord Rea, for his speech on behalf of the doctors for which I am sure they will be grateful—we most certainly were—and to the noble Lord, Lord Harris, whose economic arguments I always enjoy. Much in his arguments I agree with; much in his submissions I find bad; and, therefore, as always when I listen to him, I personally end up with a curate's egg.

If we are to appreciate the importance of this great National Health Service, I think that what we have also got to get down to is to speak in all things the language of priorities. When we do that in a right and proper manner then all those in the National Health Service will have their just deserts and the honour paid to them which they so richly deserve. My Lords, I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.