Health and Social Security Bill

HL Deb 15 June 1984 vol 452 cc1382-452

11.40 a.m.

Lord Glenarthur

My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.

Moved, That the House do now again resolve itself into Committee—(Lord Glenarthur.)

Lord Henderson of Brompton

My Lords, I wonder whether I may ask the question of which I have given the noble Lord notice, although very recent notice: that is, how far does he expect the Committee to go today? I ask this particularly because there are certain people who are especially interested in Clause 11 in Part II, which deals with the severe disablement allowance. It would particularly help the disabled if the noble Lord could give some indication as to whether it is to be reached today and, if so, at what time. I know how difficult it is to make these forecasts, but I shall be grateful for any help that he can give.

Lord Glenarthur

My Lords, I want to go as far as we possibly can, and I am sure that other Members of your Lordships' House feel the same. I certainly hope that we shall get to the severe disablement allowance, but I honestly cannot give an undertaking as to exactly how far we shall go. It is up to all those who wish to take part in the debates on the amendments.

On Question, Motion agreed to.

House in Committee accordingly.

[The LORD ABERDARE in the Chair.]

Lord Ennals moved Amendment No. 16: After Clause 1 insert the following new clause:

"Retirement pensioners. ( . All retirement pensioners shall be entitled to purchase lenses and frames under the provisions of the General Optical Service.")

The noble Lord said: My impression is that the general public does not realise what are the intentions of the Government and that, in fact, there will be 15 million of our population who up to now have been entitled to benefits from the General Optical Service and who, if this Bill is passed through in its present form, will be denied that; and of those 15 million, nearly 7 million will be retirement pensioners. I believe that if the public knew that there would be a very strong reaction, and it is our job in your Lordships' House to reflect on what the consequences will be. It will be noticed that I am not seeking to replace the whole of the 15 million people who are cut out, but only the pensioners, though I should have liked to go further.

I believe, first, that this is a very dangerous precedent. It would be the first time in any section of the health service that we had consciously decided to withdraw a service which has been available over many years. Inevitably, when an action like this is taken by the Government one has to ask whether it is the beginning of other steps to reduce the service provided by the National Health Service to people needing assistance.

The proposal to withdraw NHS optical dispensing from the adult population, with the exception of the exempt groups, was announced in a pretty surreptitious manner. As consumer and other bodies became aware of the proposal, there was a steady barrage of protest. Not even the Office of Fair Trading, on whose report on opticians and competition the Government place such great reliance, contemplated the withdrawal of NHS optical dispensing. They based their conclusion on the premise that in optics NHS dispensing would remain an option available to all patients.

Public concern has been expressed by groups such as Age Concern, Help the Aged, the National Federation of Old Age Pensioners and others who are particularly involved with pensioners. Perhaps I may quote from the Consumers' Association who said: There are more than 8 million people in the United Kingdom aged 65 years or more, a large proportion of whom can be expected to need spectacles, since eyesight deteriorates with age. Some of them will only require simple lenses. But eye health problems, such as cataract and glaucoma, also increase with age and these people will need more complex and frequent replacement lenses. At present they can choose NHS spectacles in the knowledge that they will not have to pay more than a specified amount. The current maximum price paid by anyone for NHS lenses is £31. The elderly do not, at present, qualify for total exemption from NHS charges, except on grounds of low income. Under the new proposals, they would lose their right to choose NHS spectacles, unless they qualified on grounds of low income, and would therefore have to pay the full cost of spectacles. Evidence suggests that the actual cost now of providing complete NHS spectacles can be between £5 and £10 more than the price paid by the patient, and in some cases even more…If the NHS subsidy is removed, prices would inevitably be higher at this stage".

Age Concern, who are specially concerned with the problems of the elderly, also made a very strong protest. They said: The Bill particularly affects elderly people since ‥. about 75 per cent. of all registed blind and partially sighted people are over the age of 65. Furthermore some 27 per cent. of all elderly people have a visual impairment of some sort. The chance of serious visual impairment increases with age and some eye conditions are more widespread in later years".

That therefore means that, as the population continues to age, the expectation is that that ageing population will continue to have need of the National Health Service optical service. They go on: It would be a great pity if older people were to suffer eye complaints and poor sight either because they felt they could not afford to buy glasses or because there was less of an incentive to have their eyes tested. Visual impairment occurs more gradually in older people than a sudden acute loss so people may be less ready to seek help. Serious complaints, more prevalent in old age such as cataract and glaucoma, can be treated if detected at an early stage. Often cataract patients need two or three changes of glasses in the 18 months following an operation. These people and others will suffer financial hardship if they are no longer eligible for NHS glasses". I claim that it would be a very retrograde step if visually impaired people were in future to be required to pay for their disability, because that is what it means.

I very much hope that the Minister will consider this again. It would be a very serious matter affecting some of the most needy, though I am not making any pretence that all retirement pensioners are in great financial need. What I am saying is that this is a group of people who are more in need of support from the National Health Service for eye health and for spectacles than any other group in our society. It can be fairly said that, even above the supplementary benefit level, there is an economic case to be made for older people in this category to have the option of NHS dispensing at controlled prices. Otherwise, they may have to bear a far heavier burden in the way of material costs than their middle-aged sons and daughters, whose need for expensive lenses is much less. I hope that these arguments will impress themselves upon your Lordships.

Lord Banks

I should like briefly to support this amendment. As the noble Lord, Lord Ennals, has made clear, this will allow all retirement pensioners to continue to receive National Health Service spectacles on the present terms. It is true that 2 million of the 9½ million retirement pensioners are on supplementary benefit and that they will get national health spectacles as now. But there are very many more just over that limit, and only 36 per cent. of existing National Health Service spectacle-users will qualify under the new rules. I think, in particular, of people on small incomes, perhaps with a small occupational pension.

It is true that the lowest price spectacles are likely to rise in price under the new regime, even if the more expensive spectacles come down in price. We should bear in mind that 75 per cent. of the registered blind and partially sighted are over the age of 65 and that 27 per cent. of all elderly people have some visual impairment. As the noble Lord, Lord Ennals, said, old people often need very complex lenses, which can be expensive. On those grounds, I would ask the Committee to support the amendment.

Lord Mottistone

Before speaking to this amendment, I hope I can mention an impending interest: that in 18 months' time I shall be an old-age pensioner.

This problem was brought to my notice by my optician in the Isle of Wight and we discussed it at some length. I pointed out to him, as I pointed out to your Lordships at Second Reading, that we do not buy new specs every day; we buy them every two or three years. Therefore, it cannot be seen as a great big threat of enormous expense, except at the time that they are needed. I suggested to my optician friend—I have also suggested this to the Association of Optical Practitioners who are advising me regarding the Bill—that there is one course of action which might lead to the right answer.

The principle underlying the Bill would be seriously undermined if this amendment were carried. As the noble Lord, Lord Ennals, said, some 7 million people—about half the number of people getting specs on the National Health Service—are pensioners. The solution which my noble friend the Minister might bear in mind is that either the Government or the professional bodies could run a system which would enable people to buy stamps, in just the same way as people can buy stamps for their television licences. If people were allowed to buy a £1 stamp per month, over a period of three years it would pay for what I understood the noble Lord, Lord Ennals, to say was the cost of a new pair of specs. Old-age pensioners may be able to afford a little more than £1; they may be able to afford £1.30. I would suggest to my noble friend the Minister that, as the television licence stamp was designed to help old-age pensioners to pay for the relatively high cost, in a lump sum, of their television licence, he ought to bear this point in mind.

Lord Kilmarnock

It is important for the Committee to realise that the noble Lord, Lord Ennals, has shifted the debate on to a very important aspect of the Bill. We have spent most of our time so far debating what restrictions there shall he upon the unqualified dispensing of glasses, for which category of person, and whether or not it should be possible to buy unprescribed or undispensed glasses. These are all matters of great interest and importance, but by far and away the most important and wide-ranging measure in the Bill is the abolition of the general supply of National Health Service spectacles under the general optical service. This in effect busts up the National Health Service so far as optical care goes. I should like to remind Members of the Committee that at the general election the Prime Minister pledged that the National Health Service was safe in her hands. This is an integral part of the National Health Service. It is, therefore, a very curious way of showing that the National Health Service is safe in the Prime Minister's hands.

Turning to the suggestion made by the noble Lord, Lord Mottistone, I know that he intended to be helpful; he always does. He referred to the high cost involved in restoring the umbrella to 7 million people. Therefore, he proposed the fall-back position of buying stamps at £1 or £1.30 per week. But the fact remains that even if the payments were deferred the pensioners would still be paying the full cost of their spectacles. Therefore, we on these Benches are grateful for the noble Lord's suggestion—we know he wants to be helpful— but do not believe that it goes far enough. On all those grounds, we strongly support the amendment.

11.55 a.m.

Lord Wallace of Coslany

I appreciate what the noble Lord, Lord Mottistone, has said. I give him credit for putting forward his suggestion in a most helpful and constructive manner. He certainly does not deserve any discredit for his remarks. But there is an administrative problem. People are already buying stamps for this, that and the other, and it can be very confusing when you are getting on in age.

Elderly people need assistance, particularly over spectacles. Spectacles come into the same category as chiropody, which unfortunately is very much under the weather when it comes to the allocation of resources. Chiropody and spectacles mean freedom of movement. Unless old people have adequate spectacles which are properly designed for their sight at the age they have reached, they will have difficulty in getting about. This is one of the important points that we have to bear in mind. I have already spoken about cataract sufferers and the tremendous problem involved in providing adequately fitting spectacles.

My main point is that this move on the part of the Government is a fundamental attack on the caring society, to which they allegedly subscribe. Therefore, I am sure that any noble Lord or noble Baroness who has any regard for the caring society, for a society which takes care of its people in their later years, which is one of the fundamental principles to which we subscribe and to which any Christian caring community subscribes, will support the amendment. I hope that the amendment will be put to a Division and that the Government will be defeated—not for any political reason but because of the vital principle to which I have referred: that of caring for the elderly.

Lord Ferrier

I wish to support the amendment. The speech made by the noble Lord, Lord Ennals, highlights the point I made in the debate on Clause 1; namely, that the proposals in the Bill which is before the Committee amount to an impairment of what are described in the Long Title to the Bill as general ophthalmic services. As the noble Lord, Lord Wallace of Coslany, said, this is an attack on services which are covered by the existing legislation of a caring society.

Lord Rugby

Are we talking about cataracts? I understood that cataracts were dealt with by ophthal-mologists, who are fully qualified medical people. The lenses supplied after a cataract operation are standard lenses of fairly high magnification, or of complex magnification. Nevertheless, they are the same for all people who have had cataract operations. I am wondering whether cataracts come under ophthalmic opticians.

Lord Glenarthur

Having listened to the noble Lord, Lord Ennals, I have to say that I fear there may be a basic misconception among those who have spoken to this amendment about pensioners and their glasses: that the ending of general optical service glasses will be a financial disadvantage to them. It is certainly true that many pensioners prefer already to purchase private glasses, or private frames. Among users of general optical service glasses the average subsidy—these figures are important—is around £5 or, to put it another way, about 5p a week over two years. The increase in competition and the ending of general optical service supplied glasses will create an entirely different market situation in which modern, budget-priced glasses will be available to pensioners. Already in London, from qualified opticians, glasses can be obtained at less than the average cost of subsidised general optical service glasses.

There really is no justification for believing that the average pensioner will be penalised by the ending of the GOS supply in the way that the noble Lord, Lord Ennals, suggests. What about the non-average (if that is the right term) pensioner? There will be some who find the price of National Health Service glasses too high, but those on low incomes will continue to obtain their glasses free, or at a reduced price, as the noble Lord, Lord Banks, says. We want to move as quickly as possible to the position where all those on low incomes have the greater choice that free enterprise provides, by giving them cash grants.

There is another kind of non-average pensioner; the pensioner who requires more expensive lenses. This need is not peculiar to pensioners, because some younger people also need expensive lenses. We believe that this group should continue to have access to GOS glasses as the noble Lord, Lord Ennals, would like. However, we shall not continue to subsidise them but will ensure that their lenses are available at a controlled price reflecting the economic cost of providing them. This will in turn reflect the negotiating strength of the department.

The maximum conceivable subsidy is worth about 38p a week and this is hardly an onerous imposition—which I believe was the drift of the remarks made by my noble friend Lord Mottistone. I honestly believe that the fears of that small group are exaggerated and I should like to give them that reassurance.

Overall, we believe that pensioners will be among the major beneficiaries of our policy. They will have a better choice and they will pay reasonable prices. To the extent that financial subsidies are required, they should be directed to those who really do need them. Not all pensioners are poor. To the extent that pensioners needing complicated glasses fear the free market price they might have to pay, we have taken steps to reassure them. In brief, we are confident that the majority will benefit and have taken steps to protect certain minorities.

My noble friend Lord Mottistone suggested a method of saving by stamps. I believe this is possibly better organised by many of the existing provident schemes operating in the health field. I should like to check on my noble friend's suggestion but I believe there are some obstacles to the participation of opticians in some types of schemes. I understand that the General Optical Council advises opticians to avoid selling glasses in association with provident-type arrangements. That objection may not necessarily apply to cash grants made by health savings schemes and I will certainly examine what my noble friend has said.

I believe that the fears which have been expressed are unfounded. Pensioners will benefit from the reduction in costs that will result from this change in policy. I hope that the noble Lord is reassured and that he will not press his amendment.

Lord Ennals

I am most grateful to the noble Lords, Lord Wallace of Coslany, Lord Kilmarnock and Lord Ferrier, for their support, but the Minister does not satisfy me. In answer to the noble Lord, Lord Rugby, the purpose of this amendment would be to ensure that no existing rights are taken away from existing pensioners. That is the purpose of this whole operation. The noble Lord the Minister concentrated on the question of price. He said that the average subsidy was £5. I said that it was between £5 and £10, but let us say that it is £5. Secondly, I wish to make it perfectly clear that there is no intention in this amendment or in my mind to deny people the opportunity of shopping around. If the Minister is right when he says that the price of glasses is to fall (and I do not know whether it will or will not, but certainly it is not true that everyone is satisfied that the price will fall, but only that there is a possibility that it may) then the Government will find themselves paying out virtually nothing.

Although a supposed saving of £17 million is the whole purpose of this operation, the logic of the Minister's remarks is that the alternative arrangement would not cost the Government anything like that figure. If glasses are going to be cheaper on a free market, then people will go to the free market. There has always been that availablility and people have always had that choice. The last thing I want to do is to take away that choice. But, so far as the Minister is concerned, I cannot say that I am satisfied; and, so far as the amendment is concerned, I want to ensure that all pensioners have the same rights as they have at present. I certainly do not intend to withdraw the amendment.

12.5 p.m.

On Question, Whether the said amendment (No. 16) shall be agreed to?

Their Lordships divided: Contents, 49; Not-Contents, 69.

DIVISION NO. 1
CONTENTS
Amherst, L.	Kilbracken, L.
Ardwick, L.	Kilmarnock, L.
Attlee, E.	Leatherland, L.
Banks, L. [Teller]	Lovell-Davies, L.
Bernstein, L.	Maybray-King, L.
Beswick, L.	Molloy, L.
Brookway. L.	Mulley, L.
Carmichael of Kelvingrove, L.	Nicol, B.
Collison, L.	Oram, L.
Cooper of Stockton Heath, L.	Parry, L.
Donaldson of Kingsbridge, L.	Ponsonby of Shulbrede, L. [Teller]
Donnet of Balgay. L.
Dundonald, E.	Prys-Davies, L.
Elwyn-Jones, L.	Rea, L.
Ennals, L.	Robson of Kiddington, B.
Ezra, L.	Sainsbury, L.
Ferrier, L.	Sefton of Garston, L.
Fitt, L.	Stallard, L.
Gallacher, L.	Stamp, L.
Graham of Edmonton. L.	Stoddart of Swindon, L.
Grimond, L.	Strabolgi, L.
Hooson, L.	Taylor of Blackburn, L.
Jeger, B.	Underhill, L.
Jenkins of Putney, L.	Wallace of Coslany, L.
Kaldor, L.	White, B.

NOT-CONTENTS
Ailesbury, M.	Lauderdale, E.
Alport, L.	Lindsey and Abingdon, E.
Ampthill, L.	Long, V. [Teller]
Avon, E.	Lucas of Chilworth, L.
Belstead, L.	Lyell, L.
Bessborough, E.	McFadzean, L.
Boothby, L.	Macleod of Borve, B.
Boyd-Carpenter, L.	Maude of Stratford-upon-Avon, L.
Caithness, E.
Campbell of Croy, L.	Mersey, V.
Cockfield, L.	Monson, L.
Colwyn, L.	Mottistone, L.
Cork and Orrery, E.	Mowbray and Stourton, L.
Cottesloe, L.	Nugent of Guildford, L.
Cox, B.	Porritt, L.
Cromartie, E.	Rankeillour, L.
Cullen of Ashbourne, L.	Reay, L.
Davidson, V.	Renton, L.
De Freyne, L.	Romney, E.
Denham, L.	Rugby, L.
Eccles, V.	St. Davids, V.
Effingham, E.	Saltoun, Ly.
Ellenborough, L.	Sandford, L.
Elton. L.	Sempill, Ly.
Fraser of Kilmorack, L.	Skelmerdale, L.
Gardner of Parkes, B.	Spens, L.
Glenarthur, L.	Swinton, E. [Teller]
Gormanston, V.	Terrington, L.
Greenway, L.	Teviot, L.
Hayter, L.	Teynham, L.
Henley, L.	Trumpington, B.
Home of the Hirsel, L.	Vaux of Harrowden, L.
Hornsby-Smith, B.	Vickers, B.
Kinnaird, L.	Whitelaw, V.
Lane-Fox, B.	Young, B.

Resolved in the negative, and amendment disagreed to accordingly.

12.13 p.m.

Lord Cullen of Ashbourne moved Amendment No. 17 After Clause I, insert the following new clause

("Control of sale of optical appliances. .—(1) The Secretary of State shall by order make provision for the monitoring and control of the sale or supply of optical appliances to the public by persons not being registered medical practitioners or registered opticians. (2) No order to which this section applies shall be made unless a draft of the order has been laid before and approved by resolution of each House of Parliament.").

The noble Lord said: The purpose of this amendment is to give effect to necessary changes following the concern expressed in many quarters that there will be no effective control or monitoring of optical dispensing by unqualified or unregistered sellers. Before I go further, I think that I should perhaps again declare my interest as President of the Federation of Optical Corporate Bodies. I declared this interest on Second Reading, but not on the last occasion, and to avoid doubt I do so once more.

Much of the control that exists is exercised by local authority trading standards departments. I cannot help wondering whether these trading standards departments, which are experiencing financial constraints on their operations, will be in a position to take on any extra burden of complaints, such as inevitably will be engendered by the Bill. This new clause envisages the minimum amount of monitoring and control consistent with safeguarding the public's ability to make the best use of such legal recourse as is available to them. In order to safeguard this position it will be essential to ensure that the unregistered trader keeps a ledger recording, as a minimum, such details of a sale as the date of the sale, the date of the prescription presented to him, the patient's name and address and date of birth, and the prescriber's name and address. From these simple facts their compliance with the law can ge readily checked in the event of any dispute or complaint. They should further be required to keep these entries for a period of, say, three years; which would be one year longer than the validity period of the prescription and allow ample time for consumer complaints to he investigated.

The Secretary of State might like to consider, additionally, a requirement that these people should display a notice advising the public of their inability to dispense prescriptions to children under 16 years of age or to supply contact lenses to anyone.

This new clause does not set out to establish a licensing system or a complicated register for the unqualified; or, indeed, a placing system of any sort. Rather it lays down the barest minimum requirements under which the Government could achieve what they seek; a system of unregistered traders subject to existing consumer controls in a meaningful way. It must be said that the parallel recourse to the registered practitioner offers the patient far greater protection, since record-keeping requirements are extensive both in time scale and in information recorded. Ultimately, the registered practitioners' livelihood can be forfeit in extreme cases—to say nothing of the new powers given under this Bill to the General Optical Council to levy fines of up to £1,000 against registered practitioners who are in breach of their legal obligations.

Needless to say, the unregistered seller will be subject to no such sanctions. The Government tell us that it will be for the public to make a choice; but if they choose unwisely at least they will have some chance of redress if this simple proposition is accepted. I beg to move.

Lord Prys-Davies

I very much wish to support this amendment in the name of the noble Lord, Lord Cullen, and my noble friend Lord Ennals. The Government will be aware of the considerable unease about the possible adverse effects of this legislation and of the risks which are inherent in the position. Therefore, the lack of a reference in the Bill to any monitoring system is worrying.

There are at least three main risks. First, the standard of ophthalmic dispensing will fall. Secondly, there is no effective system of enforcement to ensure that unqualified persons are not acting in breach of this legislation. Thirdly—and this links up with the first amendment this morning—many elderly persons may decide not to seek the help which they need. Those risks are there. The right of appeal to the FPC has gone. That was a great worry expressed on Second Reading. Certainly one can rely on litigation under the terms of the Sale of Goods Act but I see very few people embarking on that expensive and slow-moving legislation. Therefore, in that kind of situation—a new situation to which we are moving—it behoves the Government to monitor the development of the service by the non-registered opticians. As I said, the absence of any reference to monitoring is worrying, and I should have thought that the amendment would deal with the situation. I therefore support it.

Lord Mottistone

I briefly support my noble friend Lord Cullen for the reasons he gave in his excellent introductory speech.

Lord Monson

I oppose this amendment. Its implications are that adults would have to produce a passport or birth certificate before they could buy a pair of glasses, which is patently ridiculous. As to the consumer protection, let us remember that we are in the main talking about simple reading glasses which will not cost more than £20 or £25. Do we want to set up a clumsy bureacracy for that purpose? Surely not.

Lord Glenarthur

I cannot share, or really understand, the desire to monitor and control, with all the bureaucracy which it implies and to which the noble Lord, Lord Monson, refers. Numerous products of all sorts are sold in this country, day in and day out. The belief that glasses are a product requiring elaborate special controls has reached something of a myth over the past few months. We are not talking about explosives or dangerous drugs. As has been said numerous times in the passage of this Bill, badly dispensed glasses cannot do harm to adult eyes.

We have built the main safeguard into the Bill by requiring a recent sight test. It is important to remember that the point of that is to ensure that cases of serious eye disease simply do not go undetected. We do not propose a specific enforcement agency for that. Any public spritied citizen can lay a complaint on this matter, just as he can on numerous other offences. I admit that a citizen determined to go behind that safeguard might be able to find a supplier who is willing to lay himself open to a fine of £ 1,000. But why should a supplier want to take that risk?

Similarly with children; we believe that children should go to registered opticians. We do not see the need for specific enforcement of that requirement. It would require collusion between the parent and the supplier, who would face not only a £1,000 fine but the opprobrium of the public at large and the loss of goodwill of many other potential customers. Furthermore, a parent will have no financial inducement to take such a risk. Children will still get free NHS glasses and later cash grants to meet the full cost of the glasses that they need. Needless to say, we shall ensure that grants for children's glasses will be valid only when the glasses that they obtain are obtained legally.

I believe that that disposes of one aspect of the problem which the amendment was intended to address; that is to say, the absence of a specific enforce-ment agency. The other aspect is more concerned with the quality of the glasses received by consumers. The position of someone buying glasses from an unregistered supplier will be similar to that of someone who patronises an optician as a private customer. In fact, it can be argued that the conditions that we are considering placing upon the unregistered will make the hand of their customers stronger than that of the customers of an optician. The customers of both opticians and the unregistered will have their normal rights under the Sale of Goods Act and the Supply of Goods and Services Act concerning goods being of merchantable quality and fit for their particular purposes, and services being performed with reasonable care and skill. Additionally, the unregistered supplier will be under a statutory obligation to provide glasses which accord with a prescription.

Our orders will also require that the glasses conform to the prescription within the required tolerances in the appropriate British standards for spectacle lenses. The orders which will be laid will require the quality of the glass or plastic used in those lenses to conform to the appropriate British standard also, and the orders will ban frames made from dangerous materials from being sold. Fears of cellulose nitrate (which have not been raised today but which have been raised elsewhere) being supplied from overseas and being sold here are therefore quite ill-founded. We are considering requiring all unregistered sellers to make use of a focimeter—that is, a machine on which lenses can be tested—to ensure that they accord with the prescription. We are considering requiring suppliers to make certain basic facial measurements, particularly the inter-pupillary distance. I hope that this will reassure those who are concerned about proper centration of lenses. For certain more powerful glasses we may add other conditions.

We are intending to consult consumer and other interests on the orders to be laid. They will in any case be subject to parliamentary scrutiny. These provisions will certainly put customers of the unregistered in a stronger position than customers of the registered. It is claimed by some that the latter have redress to the General Optical Council, but this body does not, and cannot, concern itself with individual glasses.

In summary, we have not been convinced by those who argue that glasses are so different that they must be sold only by certain people or, if others are allowed to sell them, they must be supervised by an army of inspectors. As I said, glasses are not dangerous substances. Poor dispensing cannot damage adult eyes. Our approach is to strengthen the hand of the consumer. However, the best safeguard for consumers ever devised is competition, and this is what the provisions on optical services in this Bill are all about. They were rehearsed thoroughly the other day.

The fact is, I think, that there is a great deal more emotion than solid fact behind the proposals which have been advocated by those who have taken part in this debate. Anything to do with sight arouses strong emotions. I can understand that, but we need to look behind the natural reaction and concentrate on the facts. These make it clear that the law on this matter can be safely liberalised, and that is our intention.

Baroness Masham of Ilton

Before the noble Lord sits down, may I ask him whether he is aware that different eyes have different problems? Will that aspect be safeguarded to see that the wrong lens is not put into the wrong side of a pair of glasses?

Lord Glenarthur

I understand the point that the noble Baroness is making; but, again, that is something which will be obvious to the person who wears the glasses.

Baroness Masham of Ilton

It might not be. They might not know.

Lord Glenarthur

If that is the case, I cannot see that that will do any particular damage. I dare say that it is something that will be considered in the orders. But I have to tell the noble Baroness that I am not quite clear in what way, if a lens became swapped around, for example, that it could do any damage to eyes. I should have thought—and I think that this is confirmed by all the experts—that it would become quite apparent to the person wearing the glasses that they were the wrong way round.

Baroness Masham of Ilton

Could damage not he done if a person drove his car into somebody else's car?

Lord Glenarthur

I think that this was something that we covered earlier. I do not think that there is reason to be as concerned as the noble Baroness is about accidents. This was something that we covered when we were last in Committee. I do not believe that her concerns are all that well founded.

Lord Prys-Davies

The Minister has referred to the protection available under the Sale of Goods Act. I made two criticisms of the provisions of that Act: first, that it was slow moving; and, secondly, that it was expensive. The litigant would have to call expert evidence, and that, too, would be expensive. Has the Minister received advice from the department about how long it would take to take proceedings under that Act and what would be the cost? My fear that it is a totally unreal solution to the problem.

Lord Glenarthur

I must confess that I am not an expert on the Sale of Goods Act. That Act and the supply of Goods and Services Act are there. Despite any length of time that they may take, the fact is that those procedures are available to people who wish to complain in the way that the noble Lord suggests they might. I do not think that such problems are quite as strong as the noble Lord fears them to be.

Lord Cullen of Ashbourne

May I thank my noble friend for the very full reply that he has given to the amendment. I should certainly like to study it. I did not say so, hut it was actually a probing amendment to find out what the Government had in mind so far as monitoring the whole thing.

Lord Glenarthur

I am sorry to interrupt my noble friend, but may I just answer the specific point of the noble Lord, Lord Prys-Davies? One thing of which I was not aware is that there are small claims procedures in county courts which are both cheap and quick. I hope that that reassures him on the Sale of Goods Act.

Lord Cullen of Ashbourne

I was saying that it was a probing amendment to see what the Government had in mind. When it comes to the regulations, we shall see what in point of fact they do put down. I am glad that we shall have proper consultation before those regulations are framed. I should like to study very carefully what the noble Lord has said and possibly come back at Report stage if we are not entirely satisfied. However at this moment I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Schedule I [Optical appliances]:

12.30 p.m.

Baroness Robson of Kiddington moved Amend-ment No. 18: Page 30, line 32, at end insert— ("( ) for a person liable to be detained under the Mental Health Act 1983 or received into guardianship under that Act;").

The noble Baroness said: This amendment deals with two groups of people in our society who are particularly unfortunate in that they find it impossible to make arrangements for themselves. You can argue that somebody detained under the Mental Health Act will get free hospital eye service. This may be so; but I also believe, as all do on these Benches, that it is necessary specifically to protect these people and ensure that they will have free spectacles and be one of the groups of people so privileged.

The noble Lord, Lord Glenarthur, has said on various occasions during this debate that in time we shall move towards a voucher system for these people in special situations. It is necessary to ensure that the people detained under the Mental Health Act should, as a result, also be able to take advantage of any voucher system that is introduced.

My reason for wanting to include those received under guardianship is that it is not a very large group of people and I am very concerned that, unless specifically mentioned, they can he forgotten. I believe that we citizens of this country have a special responsibility to safeguard the people that are unable to look after themselves. I beg to move.

Lord Ennals

I should like to support the amendment which has just been moved by the noble Baroness. As things are at present, most psychiatric hospitals have their own arrangements under which visiting ophthalmic opticians or ophthalmic medical practitioners provide an eye testing service for their patients. Certainly in most of these hospitals the eye testing service is supplemented by a dispensing service. It is true to say that virtually 100 per cent. of psychiatric in-patients are supplied with NHS spectacles if they need them and that the hospital pays completely for the supply of those glasses. The law relating to these patients means that they have no control over their own finances once they are detained under the Mental Health Act. It is inconceivable that they should be denied access to a service where price control means that they cannot be exploited. Do the Government intend that the psychiatric hospitals will be tendering for dispensing arrangements? Will such tendering include the new, unregistered sellers of spectacles? If that is to be the case, what guarantees can there be about the accuracy of prescriptions supplied to these patients? Their own judgment of matters such as whether or not their glasses are suitable, can only he suspect.

In answer to an ealier question, the noble Lord the Minister said that people will immediately realise if their lenses are the wrong way round, or something. This is not the case with the people who are inside psychiatric hospitals. There is the possibility of compounding errors and adding to these people's problems. The noble Minister may say that such problems will not affect their eyesight but they will certainly affect their way of life. Though I am not a psychiatric patient, I know from experience, for I suffered from very severe headaches for two years before I discovered that the reason was because my eyes were different from each other. So the possibility of compound errors and adding to these people's problems points clearly to the need to retain existing arrangements. These arrangements have proved inexpensive, accurate and entirely satisfactory both for the hospitals and for the patients. I find it difficult to believe that the Minister could resist this amendment.

Lord Renton

I am not unsympathetic to the broad motive lying behind this amendment. May I take a rather detailed point first. Although the two speeches we have heard referred to those detained under the Mental Health Act, et cetera, the amendment refers to those liable to be detained. That is a different proposition, if I may say so. Of course, we have to bear in mind that those detained in under the Mental Health Act, or received into guardianship, have been subjected to a process of statutory compulsion. However there is a very much larger group—and I acknowledge that it is a very much larger group—of mentally handicapped people who are actually in various types of hospitals, residential homes, and so on—public, voluntary and private—who would come outside this definition but who should nevertheless benefit from what is intended by the definition.

Therefore I find myself in a somewhat mixed up state over this amendment and look forward to receiving a clarification by my noble friend Lord Glenarthur, to which we have become so well accustomed in this Committee.

Lord Glenarthur

I think the first thing I ought to say is that I share with the noble Lord, Lord Ennals and my noble friend a very real concern for those who are mentally ill or detained in any way under the Mental Health Act. As I think both my noble friend and the noble Lord know, it is one of my particular responsibilities. But I have to tell the noble Baroness, Lady Robson, that this amendment is an unnecessary one for some of the reasons which have already been expressed.

Hospital in-patients of all sorts, including psychiatric patients, will continue to get free glasses when this Bill is enacted, and nothing that the noble Lord, Lord Ennals says about not being able to discover that the lenses are wrong applies any more to those who get their glasses free, than it does to those who might have to pay for them. So nothing in the Bill affects their entitlement. Those placed under the guardianship of local authorities do not now get their free glasses on this count. Those under 16 get free glasses. Those over 16 may get them free or at a reduced cost on the grounds of their income. These categories will similarly get a cash grant on income grounds in the future.

Schedule I of the Bill specifically provides for grants on low income grounds. There is no reason to create the additional category which this amendment would do. The fact is that it is not mental handicap, as such, but lack of financial means which creates a need for help with glasses. We have every intention of ensuring that no unsurmountable problem or financial barrier is placed between people of any sort and the glasses which they need. So I hope that with that explanation the noble Baroness will see fit to withdraw the amendment.

Baroness Masham of Ilton

May I just ask the Minister a short question about the cash grant? Is there any way of ensuring that that will be spent on what it is meant to be spent on, such as glasses, or might it be frittered away on something else?

Lord Glenarthur

I am sure it will not be frittered away, and so far as I know the idea is that it should be spent in a way that she wants it to be spent; but if I am wrong I shall let her know as soon as I can.

Lord Kilmarnock

Before he winds up the debate, could I ask the noble Lord for a clarification? I thought he seemed to be implying that the people referred to in this amendment are likely to be covered under paragraph 2A(1) (b), as people whose resources fall to be treated under the regulations as being less than their requirements. But, if that is the case, would he not agree that mental health patients in this category would be people who would be least liable to be aware of their benefit rights and therefore not take them up?

Lord Glenarthur

I am sorry but I did not hear everything that the noble Lord said. I wonder whether he could kindly repeat it?

Lord Kilmarnock

I am sorry; I beg your pardon for not speaking clearly. I said simply that I thought I heard the noble Lord say that the people referred to in this amendment would be liable or likely to be covered under paragraph 2A(1)(b) of this schedule on page 30 of the Bill, which refers to a person whose resources fall to be treated under the regulations as being less than his requirements. In other words, there appears to be a means test there and if you are below the level of the means test then you can get the glasses. My question to the noble Lord is: would he not agree that people who are detained under the Mental Health Act are probably those who are going to be least aware of their rights under paragraph 2A(b) and therefore not likely to make use of them?

Lord Glenarthur

I do not think that that is necessarily true. Those who are detained under the Mental Health Act, for whatever reason, will get their glasses free. They will be in a hospital of one sort or another. They will be looked after by people who have a great deal of experience in these matters, and they will he taken care of. As I understand it, the fears of the noble Lord, Lord Kilmarnock, do not stand on solid ground. But this is an issue that I shall look into. I do not think that he is right. However, if he is, I shall let him know.

Baroness Robson of Kiddington

I thank the noble Lord, Lord Glenarthur, for his explanation of the future for persons detained under the Mental Health Act. I agree that, at the moment, they do receive free service within the hospital. However, in view of what was stated by my noble friend Lord Kilmarnock about these people not being sufficiently capable of looking after their own interests, I would be happy to withdraw the amendment with an assurance from the noble Lord, Lord Glenarthur, which I hope he can give, that the health authorities will be specifically alerted to look after these patients. Can he give that assurance?

Lord Glenarthur

I am sure that I can give the noble Baroness that assurance. It is again an issue that falls into my particular area. I shall therefore take an especial note of what she says and do what I can to ensure that all these conditions are complied with. However, I should not like to be drawn on what the noble Lord, Lord Kilmarnock, said without re-reading and studying that part in great detail. I cannot give an answer without some notice.

Baroness Robson of Kiddington

I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 19 not moved.]

12.43 p.m.

Lord Ennals moved Amendment No. 20: Page 30, line 32, at end insert— ; and ( ) for a person who is registered as disabled, including the blind and the partially sighted.

The noble Lord said: This follows naturally on from the previous amendment we debated. In a sense, it is a probing amendment. I much appreciated the reply given on the previous amendment by the noble Lord, Lord Glenarthur. The noble Lord may be able to give a little more explanation than even this amendment seeks. Paragraph 2A(1)(c) states: for a person of such other description as may be prescribed".

The noble Lord might well have said—I almost expected that he would say—that people who are in hospital, whether detained under the Mental Health Act or in hospital for any reason, psychiatric or otherwise, will be such persons "as may be prescribed". That may be true. I am seeking here to ensure that such other persons "as may be prescribed" will include those who are disabled, blind, or partially sighted. The case is self-evident. It may be argued that someone who is blind does not need glasses. A very high proportion of those who are blind have a small element of sight and, for that reason, need glasses. In that sense, those people and others more legitimately described as partially sighted need this help perhaps more than anyone else.

In replying to my amendment, the Minister may be able to give some further information about a person of such other description as may he prescribed". Presumably, there will be a list of people. There will be groups of people. My anxiety in the amendment is to ensure that the group includes the disabled, the blind and the partially sighted, who should be among the list of those who would be so prescribed. I beg to move.

Lord Renton

I feel that the noble Lord, Lord Ennals, has done a valuable service in putting forward this probing amendment. We are in a slight difficulty—it is not a great one, but it is a familiar one—in that power is given to a Minister to make regulations. We are trusting the Minister to exercise his discretion in a way that pleases all of us. Naturally, those of us with concern for one category or another are anxious that our category should be included.

The noble Lord, Lord Ennals, has singled out the registered disabled. That is a category that we would certainly wish to see included here. In passing, may I say that the expression "disabled" is a very wide expression under statute. It includes the blind and partially sighted. It also includes the mentally handicapped, although it is very unusual for them to be registered as such. This is a rather strange thing which has had certain results in the administration of statutes that one might regret. Having said that. I hope that we can receive undertakings from the Government that the registered disabled, including the blind and the partially sighted, will be included in the benefit of the regulations and that the needs of the registered mentally handicapped and, indeed, of the non-registered mentally handicapped will also be borne in mind.

Baroness Masham of Ilton

I should like to ask the Minister a question following upon what was stated by the noble Lord, Lord Renton, about the registered disabled. How many people who are severely disabled and disabled are not registered? This is a complicated matter. What would happen to those who are not registered? I should like to know more about the register of the disabled. To my knowledge, there is no such thing as a register of disabled people.

Lord Glenarthur

The amendment, as we have heard, is essentially similar to that advocated on behalf of the mentally ill a few minutes ago and extends to the elderly, to the disabled and to those needing complicated glasses. I think that the principle at stake is essentially the same. In brief, the argument is whether financial assistance or subsidies should be given on any other basis than that of financial need. The Government say. "No". Among the registered disabled, of whatever disability, there will be some who are on low incomes and others who are not. We believe that no one should be denied access to the glasses they need on financial grounds. The Bill achieves this objective. The amendment tackles all types of disabled person. Among those who need glasses many will require quite ordinary ones. We believe that these may well cost less in a competitive private market than they do today under the National Health Service. Already some private glasses, from a qualified optician, cost less than the average charge for NHS glasses. Competition, I think, will make this the norm.

Even some of the visually handicapped do not need expensive or complicated glasses to aid their residual sight. My earlier remarks hold good. What of those who need more expensive glasses? The maximum subsidy anyone could theoretically get now from the GOS is £40. Our statistics suggest it is doubtful whether, in any given year, anyone actually needs the particular glasses concerned. Even this loss represents only 38p a week over two years. For someone who needs such glasses, this is a known priority commitment for which they can and should make reasonable and prudent personal provision, just as they do for many other things—fuel, accommodation, clothing and the rest.

It is not as great a financial burden as has been suggested. For those who are in financial need, the provision of grants in place of free or reduced cost GOS glasses is provided for in the schedule. The particular provision to which the noble Lord, Lord Ennals, referred, head (c) is designed for flexibility so that we can help other groups in the future if we feel it necessary. We know that users of expensive lenses have other fears that when the Bill is enacted their glasses will rise disproportionately in cost. They believe that competition will bring down the prices of more routine glasses, but that more specialist ones will go up in price.

At Report stage in another place my right honourable friend the Minister of Health addressed this particular problem. He has promised that from April 1985 those who need these specially expensive lenses will be able to get their glasses through the residual GOS arrangements at a controlled price reflecting to the GOS the full cost of providing them. This will mean that the department will continue to influence the cost elements involved and perhaps achieve a better bargain than these individuals might obtain on their own. This amendment is concerned with the position post-GOS glasses. We believe that by then the market will have settled down and the somewhat exaggerated fears that have been expressed on this particular matter will prove to have been unfounded.

Baroness Jeger

Before the Minister leaves that point, may I ask him something very quickly. He referred to the problem of people needing specially expensive glasses. Can he tell us how special is "special" and how expensive is "expensive"? What kind of sum are we thinking about?

Lord Glenarthur

I am not sure of the technical features of the types of glasses which will be in that particular category. I think I might be right in saying that this will feature in subordinate legislation in the form of the orders which will come out in due course. I really have to leave it to my right honourable friend to carry out the promise which he made at Report stage, that it will not severely disadvantage, or disadvantage in any way, those who need these peculiarly expensive glasses. I hope that reassures the noble Baroness. It is something I can look at, get more details on, and let her know about.

Lord Cullen of Ashbourne

I should like to ask my noble friend whether he is referring to what his right honourable friend mentioned about glasses on which there was a subsidy of £15 or more. Is that the answer to the noble Baroness's question just now as to what are, and what are not, expensive glasses? This seems to be rather moving on to the amendment I was just going to move. If we can get this cleared up now, I shall not have to move it.

Lord Glenarthur

My noble friend is right, and perhaps this will reassure the noble Baroness, too. Possibly it will cover those now subsidised by £15 or more. I say "possibly" advisedly, because no final decision has been reached, but that is the direction in which we are moving. I hope that will satisfy my noble friend.

The amendment is not required to allow grants to such users, should it ever be felt appropriate to make them, because the schedule gives a wide power to make grants to persons, of such other description as may he prescribed". This is the point I covered just now. So the legislative door is by no means closed. But I must re-emphasise that we believe that indiscriminate financial subsidies are inherently a misuse of resources and we do not have in mind grants for this group. We are protecting them while marketing conditions stabilise. We believe that they will be pleasantly surprised when they do. If we are wrong, no doubt many will hammer on our door. The amendment is unnecessary.

The noble Baroness, Lady Masham, asked how many severely disabled people were not registered. Registers are maintained by local social services departments. For reasons of their own, a great number of people do not actually want to register. Our aim is to help not necessarily the disabled, but those who actually need financial assistance. I hope that answers her query. With that explanation, I hope that the noble Lord will not press his amendment.

Lord Banks

The noble Lord says that the Government do not believe in indiscriminate grants. One can understand the point they are making there. But the point that is worrying those of us on this side of the Committee who have been associated with these various amendments is whether the provisions in the Bill for those who happen to be on low income benefits are sufficient to ensure that there will be no economic hardship beyond that. The Government say that there will not be, but we on this side of the Committee feel that there may well he, particularly with regard to old age pensioners and the disabled—those people whose incomes are higher than the level which would bring them into benefit, yet who still are on very low incomes. I have a feeling that at a later stage we shall have to come back again to this whole question in order to be quite certain that, as a result of the Bill, we are not imposing unnecessary economic hardship on people.

Lord Ennals

I agree entirely with the point just made by the noble Lord, Lord Banks. One of the difficulties is that there cannot be an answer to the very proper question put by my noble friend Lady Jeger. One has seen a number of estimates as to how much of an increase there may be in prices. I am not going to go into the details of them. Some of them are very substantial, but they may be exaggerated. Only time will tell. This is the real problem we are facing.

The noble Lord the Minister says that the introduction of competition is going to produce a great fall in the cost of spectacles. That may, or may not, be so. It may he that we shall need to return to this matter not only during the passage of this Bill, but when the Minister comes to fulfil properly head (c), for a person of such other description as may be prescribed". I hope that at the time, whether it is a year or two years afterwards, we shall be able to determine what has been the effect on the price structure and, therefore, the effect on people with particular problems. I hope, too, that we shall be able to return to this question, because the Minister may or may not be right. He will understand that noble Lords on both sides of the Committee are anxious to preserve the position not only of the elderly and the disabled, but also of other groups. I am grateful for some of the assurances given by the Minister. I am not satisfied, but 1 shall not press the amendment at this stage.

Amendment, by leave, withdrawn.

12.57 p.m.

Lord Kilmarnock moved Amendment No. 21: Page 30, line 37, at end insert ("including, in particular, for persons needing complex or high-powered lenses who previously received a subsidy of £15 or more under the provisions of the General Ophthalmic Service.").

The noble Lord said: We have covered some of this ground in the debate on the last amendment, but this one goes a little wider in that it seeks to obtain financial assistance for those who require complex or high-powered lenses, the cost of which, I understand, is liable to double or treble under the present Bill. The amendment seeks to include them with the other categories of those who the Secretary of State is obliged to assist financially.

I hope that at this stage no one will raise the cry of "paternalism" in this case. It seems to me that it is the Secretary of State's patent duty to be paternalistic, or at least avuncular, towards this particular group of people. This seemed to be recognised by the Secretary of State at Second Reading in another place on 20th December last year, when he said, at col. 297: it has been argued that there are those with the very poorest sight who need complicated and more expensive lenses, and I am certainly prepared to consider the evidence on that to see whether they can have continued access to NHS glasses".

I think I heard the noble Lord, Lord Glenarthur, refer to some kind of undertaking of the Secretary of State or of the Government at Report stage. But I am hound to say that I can find nothing in the Bill. My honourable friend Mr. Meadowcroft raised the point on 2nd May 1984 and referred to the Secretary of State's undertaking, which I have already quoted. He said he could find nothing in the Bill that appeared to carry out that promise. If the noble Lord is going to tell us that the people in question are already protected under sub-paragraph (b)—a sub-paragraph to which we have already referred in the last debate and which covers: a person whose resources fall to be treated under the regulations as being less than his requirements"— I must remind him that, in effect, it introduces a means test and that means-tested benefits are notorious for their low take-up.

As I understand it, the qualifying limit for assistance in the case of pensioners is £34.10 plus £2.50, after housing costs, for a single pensioner; and £54.55, plus £2.50, for a married pensioner couple. Anyone even marginally above this extremely low income will, as the Bill is drafted, receive no assistance. For example, a very modest occupational pension would exclude a pensioner from assistance. There is no provision whatever for those whose prescriptions may cost as much as £40 more under the Bill than at present. It seems to me that this cannot possibly be right.

The noble Lord, Lord Glenarthur, in the debate on a previous amendment referred to the fact that some young people have the same problems as pensioners. This amendment takes care of that situation because it would cover all those who have seriously defective sight. It seems to make the case for a category, not by age—that is to say, simply for pensioners—but by need and extent of visual impairment. That, of course, is what the amendment does.

The noble Lord also said that the Government preferred to proceed not by categories of person but on the basis of financial need for any assistance that they were to give. This amendment is drafted on the grounds of financial need.

There is another point that I should like to make before the noble Lord answers the debate. As people get older they need to change their spectacles much more frequently. For example, if someone has an incipient cataract and it is not yet ready or right for operation, he may need to change his glasses at the rate of once a year which, for a complex prescription, is obviously a very considerable drain on somebody in the low income bracket.

So on all those grounds there is a very strong case for this amendment. But what I particularly want to get from the noble Earl who I think is to reply, is what in fact the Secretary of State has done to fulfil his undertaking given at Second Reading. It may be that I have not found it. I could not find anything in the Official Report and I could not find anything in the Bill. I wonder whether the noble Earl can help us? I beg to move.

Lord Renton

The noble Lord, Lord Kilmarnock, has referred to an important point on which we really should try to get an assurance from the Government. To my mind it is unthinkable that a person treated within the hospital eye service and who needs, as the amendment says, "complex or high-powered lenses", and who at present receives a modest subsidy of £ 15, should not continue to receive it. One must hear in mind that, even with that subsidy, those people treated even within the hospital eye service may have to pay a very large sum indeed. I have heard of sums being paid of £ 100 over and above the £15. Therefore, this is of great importance.

I do not say that it needs to be spelled out in the Bill. There are technical problems arising from being too selective. But this is something which could cause great hardship and which could prevent adequate treatment from being given by the provision of proper spectacles within the hospital eye service—and one thinks in particular of post-cataract operations. Of course, in such cases there is a complicated process, because at first the person concerned is merely supplied with spectacles which, in effect, limit vision. Later, when it is possible to consider what the eyes really require, some very powerful lenses are normally fitted, but they may last for only six months, after which time there are provided what it is hoped will be the final lenses—which, incidentally, attract the subsidy.

So this is a matter which requires very special consideration and I hope that we shall receive from my noble friend an undertaking that the Government have the matter in mind and that they will deal with it when it comes to applying the regulations.

Lord Ennals

I should like to support the amendment and, in so doing, I should like to support the generality of the argument which has been extremely well presented by both noble Lords who have spoken. I think that it would he useful to give an example of a particular case and the amount of money about which we may well be talking. I have an example of a 78 year-old woman who now pays £22.35 for NHS distance and reading glasses and who will in future pay a minimum of £80. Let us look at the situation.

The person concerned is a post-cataract case as regards her right eye, but her left eye also needs to be operated on, and she will soon need new glasses. At present her distance glasses cost £11 for the lenses fitted into her own frames, and her reading pair cost £9.30 for the lenses and £2.50 for the frames. In future, as a private patient, she will pay the whole cost of the materials, plus the practitioners dispensing fee, which is now included in the NHS subsidy. Because fitting these thick lens spectacles is more difficult and takes longer than average fitting. I am informed that the fee is likely to be up to £15 for each pair. The cost of her materials had been £52.98. Therefore, her NHS subsidy had been £37. Assuming that the cheap NHS frame—the 524—is still being manufactured, her next bill is likely to be about £80. So we are facing a very substantial increase, and I agree very much with the noble Lord, Lord Renton, that we do need some very clear assurances on this matter and I hope that we shall get them from the Minister.

The Earl of Caithness

As the noble Lord, Lord Kilmarnock, has said, much of the ground has been covered on a previous amendment, but I shall try to answer some of the more specific points that have been raised. It is worth recapping that it is inherent in our approach to Clause 1 and to Schedule 1 that indiscriminate subsidy of the cost of glasses is unneces-sary. Any financial subsidy should be directed towards those who need it. Income is not directly related to optical need. There is no logical justification for subsidising all users of powerful glasses. Noble Lords will be able to think of many people who, while needing somewhat special glasses, are in a position to afford the cost themselves. Where financial need exists it should be recognised and we will help in those circumstances. Financial subsidies should meet financial needs.

Differences in the refracture properties of the eye are only one of the countless physiological differences between people. There are numerous people who lie in the corners of the normal distribution curves for height, weight, size of feet and other such matters. Many people who need outsize clothing or extra large shoes have to pay more for them. If we were starting from scratch today without the weight of past experience in this matter, I do not seriously believe that we would see the indiscriminate subsidising of glasses as a social priority any more than we would propose grants for those needing extra large shoes. I am not being flippant, but mobility is no less important than sight.

Let me turn to cataract patients—a matter referred to in particular by my noble friend Lord Renton. I can confirm to him that in-patients will continue to get free glasses from the hospital. Those hospital out-patients who need complex or expensive lenses will be able to get them from the hospital eye service, as at present, but they will no longer be indiscriminately subsidised.

There are a few hospital out-patients who, following operations, need to have their glasses changed frequently. The HES post-operative patients should continue to be able to have HES prescriptions dispensed outside the hospital for NHS charges—that is, reflecting the actual cost of the transaction—and to benefit from the technical non-tolerance procedure. This would allow cataract patients to have repeated changes of glasses at no extra cost, as now.

Lord Ennals

Before we move from that point, I want to understand it because what the noble Earl is saying is very important. He is saying that there will not be indiscriminate subsidy; that, therefore, there will be discriminate subsidy. Who takes the decision? How is the decision taken as to whether or not there will be a subsidy in a particular case of a person who is an out-patient?

The Earl of Caithness

I can assure the noble Lord that it is the doctor.

Lord Ennals

The hospital doctor?

The Earl of Caithness

The hospital doctor. The noble Lord, Lord Kilmarnock, raised the question of means-testing. Frankly, I believe that means-testing is essentially right because it enables us to focus resources where they are most required. The noble Lord also referred to a comment made by my noble friend the Minister for Health. I can help him in his search for the Answer; he can find it in Hansard of another place of 24th May this year at col. 508. In fact, it is in reply to a Question for Written Answer, which is perhaps why he did not find it in the report of the debate. It would perhaps be useful to read the Answer to the Committee. My right honourable friend said: We have never considered special financial assistance to the users of expensive lenses. We have been considering ways in which we might respond to fears, even though they are often exaggerated, that this group might incur heavy additional expenditure as a result of the proposed changes to the general optical service. I announced our proposals during the debate on the Report stage of the Health and Social Security Bill on 2 May at columns 391–92. We propose to identify certain of the more powerful or complex lenses currently supplied under the GOS. People needing such lenses will be given the option of continuing to have them supplied by the GOS. The charge to the patient will reflect the cost of the lenses and their dispensing as negotiated by the Department. Those on low income will get them free or have part of their charge remitted". I can further tell the noble Lord, Lord Kilmarnock, that the actual implementation of our thoughts on complex lenses will be under orders under Clause 8 of this Bill.

Perhaps I may correct a statement that I made to the noble Lord, Lord Ennals. Although the noble Lord described the subsidy as discriminate, it will be judged on low income grounds as well.

Lord Ennals

I am sorry to press the Minister on this matter, and if he cannot give me an answer now, perhaps he would do so in correspondence. We are talking about patients who, unless they are on supplementary benefits, may have to pay a very substantial sum because of the nature of their eye condition. When the Minister says that the matter will not simply be decided by the doctor and that it will be decided on income grounds, I need to know a little more. Surely part of the discretion will be the nature of the complaint and the amount of cost to which a patient will he subjected, as well as the income of the patient. I do not agree at all with the noble Earl's generalised view about means-testing, but I hope that, as he has corrected what he said about the doctor (I asked whether it was the hospital doctor, and he said, "Yes"), he will, before we reach the Report stage, write to me on this and send copies of the letter to noble Lords who have taken part in this debate, so that we can properly understand just how the decision is taken. This is absolutely crucial.

The Earl of Caithness

Of course I shall write to the noble Lord. It is right and proper that I should do so and I undertake to do so. I can assure him that the Government are equally concerned. I believe that we have it right at the moment, but we are very concerned that those who are on low incomes should not unnecessarily suffer. That is why we are in a position to give financial aid to those who really need it.

1.15 p.m.

Lord Cullen of Ashbourne

I should very much appreciate it if I, too, could have a copy of that letter. I have found myself in rather a muddle during the last two amendments. I do not know whether my concentration wandered, but on the previous amendment I understood my noble friend Lord Glenarthur to indicate that people with lenses with a £15 subsidy or more could get the benefit of the General Optical Service. I have always assumed that that meant that they would still receive the £15 subsidy. However, as far as I can understand it, under the Bill those people will have the benefit of the General Optical Service but without the subsidy. That will not be much use. They might as well go into the private market. Therefore, I find myself in rather of a muddle.

I shall certainly read extremely carefully what my noble friends on the Front Bench have said on these last two amendments, but I think it is almost a certainty that we shall have to return to this matter at the next stage.

Lord Wallace of Coslany

Did the noble Earl mean what he said when he said that people who receive hospital treatment as out-patients will continue to receive help? But what happens afterwards? The noble Earl must remember that we are dealing with people who, in point of fact, have an extreme medical need. Therefore, under the arguments that the noble Earl has advanced, they will be worse off financially than people with less serious eyesight troubles. To put it mildly, I think that that is diabolical.

The Earl of Caithness

I thought that I covered the point about out-patients. If the noble Lord, Lord Wallace, reads what I have said, I think that he should be satisfied. If not, I am sure that he will draw the matter to our attention again. I can confirm to my noble friend Lord Cullen of Ashbourne that the £15 subsidy will not be available.

Lord Ennals

It will not be available?

The Earl of Caithness

It will not be available. I do not want to repeat what my noble friend Lord Glenarthur said on the previous amendment about our remaining thoughts. In view of what I have said, I hope that the noble Lord, Lord Kilmarnock, will withdraw his amendment.

Lord Renton

Speaking for myself, I am to a great extent reassured by what my noble friend Lord Caithness has said. But I hope that he will not take it amiss if I also say that we shall want to study very carefully what he has said, because this is not a straightforward matter. Therefore, while thanking him very much, in order to make quite sure I think that we should leave the matter open until the Report stage.

The Earl of Caithness

Of course I do not take it amiss. I am sure that my noble friend will, with his usual diligence, study my reply.

Lord Kilmarnock

I am grateful to all noble Lords who have taken part in this very useful debate. The noble Lord, Lord Renton, shared my anxieties but felt that the remedies do not need to be spelt out in the Bill. I am not entirely certain that I agree with him on that. I spoke about the constant changes of pre-cataract glasses, which might take place once a year, but I forgot to mention the point the noble Lord made about post-cataract glasses, which are likely to need changing even more frequently until the right prescription is reached. It seems to me that there has been sympathy for this amendment to all sides of your Lordships' Committee.

The noble Earl says that the Government are not in favour of what he calls indiscriminate subsidies, but this would not he an indiscriminate subsidy because it would he directed to people with special needs. The noble Earl referred to the continuation of the hospital eye service and the benefits that are derived from it, but he did not help us very much on what happens when one comes out of hospital and perhaps one has to change glasses after three or six months. He did not advance any suggestions as to how those people might be helped.

The noble Earl referred to the safety net in the schedule—people whose means are below the poverty line. But, as I tried to explain on an earlier amendment, many people will fall through the means-tested safety net. It is a well-known fact that not everybody claims the means-tested benefits to which he is entitled. I do not feel that the safety net has a sufficiently small mesh, if I may put it that way.

The noble Lord, Lord Cullen, said that he thought, quite rightly, that to leave the General Optical Service in position without any subsidies, or the £15 subsidy, would be equivalent to destroying it. That is a perfectly good point.

The noble Earl referred me to the department's answer on 24th May, which I must confess I have not read. I certainly shall read it. Although the noble Earl read it to us, I should like to look at it again. He also referred to orders under Clause 8 and said that any help in this direction will be provided by orders made under Clause 8.

The Earl of Caithness

It was Clause 28.

Lord Kilmarnock

I beg the noble Earl's pardon. Clause 8 simply refers to borrowing powers: it does not state what the money is to be borrowed for.

We have had a detailed debate on points of considerable concern to all sides of the Committee. It is only right and proper to read the debate very carefully and to decide whether the assurances or semi-assurances that we have had from the noble Earl are sufficient. My instinct at this stage is that they are not sufficient. I cannot honestly see why, if the Government have these intentions towards these people, they should not be spelt out in the Bill rather than left to be brought forward under Clause 28.

Lord Ennals

Before the noble Lord sits down, I wonder whether he would agree with me—I am addressing the Government more than I am addressing him—that the question of financial need is much affected by the additional costs one may have to pay for spectacles and other services. If a person is not at supplementary benefit level but is expected to pay £40 more for spectacles and may require two sets in one year, that affects financial need.

Lord Kilmarnock

I thank the noble Lord for his intervention. I entirely agree with him, because that goes back to a point he made earlier, about the standard of assessment. If it is merely to be the needs-based standard of assessment on the very low threshold written into the schedule, we say that that is inadequate because, as the noble Lord, Lord Ennals, implies, anyone slightly above that with a small occupational pension on top of the old-age pension immediately loses the whole of any subsidies that that person might expect to receive, hence the poverty trap situation.

It seems to me that the noble Earl has tried to be helpful, but my instinct is that he has not helped us enough. The Government will have to spell this matter out in greater detail and give firmer assurances at the next stage of the Bill. I should like the noble Earl to say that he will perhaps come forward at Report stage with a Government amendment to allay our worries. The noble Lord, Lord Cullen, made the same pont: if the Government do not come forward with an amendment which allays our concern, we shall come back at Report stage. I beg leave to withdraw the amendment.

The Earl of Caithness

I do not think the Government will come forward with an amendment. We shall certainly read very carefully what the noble Lord has said, but we think that we have it right.

Lord Kilmarnock

Then I assure the noble Earl that he will find another amendment at Report stage.

Amendment, by leave, withdrawn.

[Amendments Nos. 22 and 23 had been withdrawn from the Marshalled List.]

On Question. Whether Schedule 1 shall stand part of the Bill?:

Lord Renton

I am sorry to take up time, but I feel that we should ask the Government to consider the drafting of just one small phrase which arises on paragraph 3, in the newly-written paragraph 2A, of the schedule on page 30. Under the head (b) it reads: a person whose resources fall to be treated under the regulations as being less than his requirements". I must confess that when I first read that I could not understand what it meant. In such cases one has the benefit of the Notes on Clauses. I naturally turned to that document, and I found the beautifully compendious phrase: those assessed as having financial need". That is as plain as can be; so perhaps my noble friend would ask the draftsman just to look at this. I think it could be a little more clearly and shortly worded.

Lord Glenarthur

I am well aware of my noble friend's particular interest in drafting. I must say that I, too, find the words used by draftsmen are more often than not extremely tortuous. I shall have a look at it to see whether it can be changed.

Schedule 1 agreed to.

Clause 2 agreed to.

Lord Cullen of Ashbourne moved Amendment No. 24: Before Clause 3, insert the following new clause:

("Companies Committee. . For subsection (2) of section 18 of the Opticians Act 1958 there shall be substituted the following: (2) The Companies Committee shall be constituted in accordance with rules made by the Council, but the rules shall secure that the Committee includes a majority of persons representing the interests of bodies corporate whether carrying on business as ophthalmic opticians or dispensing opticians.".").

The noble Lord said: It may be for the convenience of the Committee if I speak also to Amendment No. 27. After Clause 3, insert the following new clause:

("Amendment to Schedule to 1958 Act. . The following sub-paragraph shall be inserted after paragraph 1 (f) of the Schedule to the Opticians Act 1958: (g) one person nominated by the Federation of Optical Corporate Bodies.".").

I was in two minds whether to move these two amendments, but I think it would be as well to get them on the record. I also have one or two things to say to correct the remarks previously made on the General Optical Council.

There is an overwhelming case for one corporate body representative on the General Optical Council to be nominated by the Federation of Optical Corporate Bodies. That is the purpose of Amendment No. 27. However, whether or not the Government accept that, I do not believe that anyone could quarrel with the proposition that the corporate bodies should have a majority of members on the companies committee which was set up under Section 18 of the Opticians Act 1958 and which was intended to ensure that the views of the corporate bodies were made known to the council. The Act laid a duty upon the GOC to set up such a committee, to which they must refer for advice on all matters relating to bodies corporate, other than disciplinary matters.

That sounds fine in in principle, but in practice the members of the companies committee who have a corporate body knowledge are at present heavily outnumbered on the committee, which is composed of eight members of the council who may have no corporate body experience and five additional members appointed from outside the council made up of three persons representing ophthalmic companies and two persons representing dispensing companies. The present chairman of the companies committee is a lay person.

Since the whole purpose and intention of Parliament in providing for a statutory companies committee was to ensure that the corporate body viewpoint was adequately made known to the council of the GOC, there seems to be an overwhelmingly reasonable case for saying that the majority of people on the companies committee should represent the views and interests of corporate bodies. The fact is that the corporate bodies represented by the federation are now responsible for the provision of nearly half the optical services in this country, yet they have been denied any representation on the GOC itself and have been in a minority on the companies committee.

I also want to refer to something said by the noble Lord, Lord Rugby, in the Second Reading debate about the General Optical Council. The noble Lord said that out of the 26 members—he is quite right, there are 26 members-22 were opticians and at least 13, maybe more, represented corporate bodies. I can only say that nothing could be further from the truth.

At the end of last year the GOC consisted of these 26 persons, and they comprised the following groups: seven persons, of whom two were doctors and five were laymen, nominated by the Privy Council; five persons elected by registered ophthalmic opticians; three persons elected by registered dispensing opticians; five persons nominated by the optical examining bodies; one person nominated jointly by the ophthalmic training institutions; four registered medical practitioners nominated by the Faculty of Ophthalmologists and one layman nominated by the Secretary of State for Northern Ireland. That, to sum up, is 10 ophthalmic opticians or their representatives, four dispensing opticians or their representatives, six doctors and six lay members. The noble Lord also in that same Second Reading debate considerably exaggerated the number of retail outlets by Dollond and Aitchison which is closer to 450 than to 750. I hope that the Government will see fit to accept these two amendments. I beg to move.

Lord Rugby

I would apologise if I got those figures slightly wrong. I think that to most of us the General Optical Council is a sort of secret society and we do not really know what goes on inside it. As regards Dollond and Aitchison, as we all know, it is now virtually in the hands of a very large tobacco consortium and I myself feel that it is rather contrary to the whole spirit of the Act, as laid down originally by the Crook Report, that these corporate bodies should exist at all. It was stated at the time that they would not exist and we were given many assurances after that that they would not exist. The fact is that they now occupy a very dominant role and are very highly commercial.

I am very glad to note that the Government are now going to open up the General Optical Council and that a much better representation of the public interest is now going to manifest itself within that body. But, at the same time, I should like to apologise to the noble Lord for having got those figures wrong.

Lord Mottistone

My Lords, it saddens me to have to disagree with my noble friend Lord Cullen, in particular in relation to Amendment No. 24. On Amendment No. 27, I do not have a particular feeling one way or the other. I think that it is not altogether right to single out one particular official body and not to include a composite, balancing amount from, for instance, the Association of Optical Practitioners, who, as I have told your Lordships, give me advice on this point. I think that it is probably wrong and I find myself remarkably in sympathy with what the noble Lord, Lord Rugby, had to say. Perhaps I have said quite enough for the time being.

1.33 p.m.

The Earl of Caithness

May I speak to both of these amendments? The first amendment would alter the constitution of the Companies Committee of the GOC to give corporate bodies majority representation. The second Amendment, No. 27, would change the constitution of the General Optical Council to include a representative of the Federation of Optical Corporation Bodies, thus altering the GOC constitution. I do not believe that it is appropriate for Parliament to amend the constitution of the GOC in this Bill. The Schedule to the Opticians Act 1958 allows the Privy Council by order and after consultation with the GOC itself and other bodies or persons to alter the membership and qualifications of members of the GOC to reflect changes in circumstances. Such orders are made in the form of statutory instruments and can be annulled by resolution of either House of Parliament.

Noble Lords will be interested to hear that a comprehensive review was launched in 1978. Evidence was taken from all relevant interests including the federation. The review could hardly be accused of excessive haste. It was not until December 1983 that the Privy Council made the required orders to give effect to the changes arising from the review. The Privy Council, having heard all points of view, were not persuaded to give a seat at the GOC to the federation. This was no doubt a source of disappointment to the federation.

They and others had, however, been given every opportunity to state their case. If any noble Lord felt that a great injustice had been perpetrated then it was open to him to persuade this House to pray against the Privy Council order. This is the means which Parliament has provided to allow the actions of the Privy Council in this matter to be subjected to scrutiny. No such steps were taken.

Turning to Amendment No. 24, I have similar objections to altering the internal constitution of the GOC's committees via this Bill as I have to altering the constitution of the GOC itself. The Companies Committee is provided for in the 1958 Act. The Privy Council have agreed rules governing its current constitution. The Committee comprises 13 members of which 5 are outside members nominated by organisations affiliated to the federation.

I mentioned earlier a review of the GOC's constitution. Following that review I know that the Privy Council Office wrote to the GOC asking for their views on relations between the Companies Committee and the GOC as a whole. I believe the GOC is giving this matter careful thought. It is up to them to agree what changes, if any, are necessary. As this proven system has not failed to date, we believe that it would be quite wrong to amend the Opticians Act 1958 in the way proposed by my noble friend. I would also add that I agree with what my noble friend Lord Mottistone said on his particular point of criticism on Amendment No. 24. I hope therefore that my noble friend might seek permission to withdraw these amendments.

Lord Cullen of Ashbourne

I am grateful to my noble friend for making the Government's views crystal clear. It does not particularly surprise me, but I am glad to haw it on the record. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Mottistone moved Amendment No. 25: Page 5, line 18, leave out from ("the") to ("registers") in line 23.

The noble Lord said: With the permission of the Committee, I should like to move this amendment and at the same time to speak to Amendment No. 26. Amendment No. 26: Page 5, line 39, leave out from ("of") to ("the") in line 43.

These amendments are related to the same subject. The purpose of the amendments is to prevent the title of "optician" from being used, on its own or in conbination with any other word, by any person or by any corporate body if not registered in one of the registers of the General Optical Council. The Government have gone some way towards protecting the title of "optician" and, in a rather convoluted way, subsections (2) and (3) of Clause 3, using a double negative, provide some protection; but it is not good enough.

The object of these amendments to both of those subsections is to try to make things clearer. There is a possibility that, under the Bill as worded, the unregistered suppliers of optical appliances could make extensive use of a title such as "unregistered optician". It is possible that, even with the title prefixed in this way, the public could be misled into thinking that they were using the services of a person who was qualified as an optician but not actually registered as such. The distinction between registered and unregistered is one which is of immense importance, but it is not a distinction which is likely to be readily perceived by the public.

A further possibility, without adequate protection of the title "optician" and its restriction to registered practitioners, is that there might be a greater incentive for unregistered sellers of spectacles to take and use bogus or spurious qualifications which would enable them to describe themselves as, for example, "Qualified Optician (Unregistered)". One even might find them abbreviating that to "Qualified Optician (U)". This sort of use of the title (which, as we read it, the Bill does not at present protect) in my opinion will downgrade the true value of the title "optician" on which the public should be able to continue to rely.

I hope very much that my noble friend the Minister will be sympathetic to these amendments, and in the event that he does not like the specific way we are proposing them perhaps he might accept the principle behind them and help us to arrive at a conclusion which provides proper protection for the, at present, professional title of "optician".

Lord Rugby

I have before me two pages of qualifications which are required to register as an optician. There are altogether 28 different types of letter that you can have after your name in order to come into that register. I feel that this is really overcomplicating the issue. I cannot help being reminded of the statement that when things really get too complicated they tend to become insignificant simply due to their complication. If we are going to have the title of "optician", surely only one type of requirement is necessary and not 28 in order to satisfy the public that that man is qualified.

1.41 p.m.

Lord Glenarthur

I am afraid that I cannot meet my noble friend on the matter of principle to which he referred just now because in formulating this clause the Government were intent on striking a balance between two objectives. The first objective, which my noble friend and the Government clearly share, is to ensure that the public have an informed choice between the registered or enrolled optician and alternative retailers. We believe this is achieved by the continuation of the registers and lists maintained by the GOC and by preventing anyone from implying that they are on those registers or lists when they are not. Our other objective is to allow people who sell glasses to use the historically accepted word for that occupation, which is the term "optician".

It would be a little strange, in a Bill giving effect to the Government's policy of opening up to unregistered people the ability to practise what the man in the street rightly recognises as an optician, to provide that they may only do so if they do not use the only description by which such a business is generally known. That would be to replace one monopoly by another and impose an extreme and unwarranted competitive disadvantage.

What the Bill does is to create a position, corresponding to what has long been the case for doctors, in which practice is open to both registered and unregistered persons although there are some things which the registered may do but the unregistered may not. There is no law prohibiting an unregistered person from practising medicine but he must not do so in a way which misleads the public into believing him to be registered under the Medical Act or recognised by law as a medical practitioner. Registered medical practitioners have no monopoly of the title "doctor" but others must not use it to convey that they are qualified in a way that they are not. If John Smith, with a Ph.D. for his botanical studies, decides to practise as a herbalist he will be prosecuted if he puts on his front door a brass plate inscribed "Dr. John Smith./Consulting hours 10–12.30 and 2.30–5". He would he unlikely to be prosecuted and be convicted if he put "Dr. John Smith./Herbalist/ Consulting hours 10–12.30 and 2.30–5".

The position is similar in the case of dentists. The practice of dentistry is open both to registered dentists and registered medical practitioners and therefore both, but they alone, may use the title of dentist or dental surgeon. However, even a doctor who practises dentistry may not use any description which implies that he is a registered dentist if he is not one.

Under Section 22(1) of the Opticians Act 1958 it is already an offence for a person to use a title indicating that he is registered, either generally or in a particular register, if he is not; or to describe himself in a way which falsely implies that he is registered.

Those who framed the 1958 Act did not choose to go further and outlaw the use of the term "optician". They saw no necessity to do so. We have however recognised that circumstances have changed. Since 1958 there has been no one other than registered opticians legally selling glasses. Thus the public have not had to distinguish between the registered and others. We therefore propose extending protection of the title "optician" to a considerable extent. We have proposed that use of this term carries the implication that the user is a registered or enrolled optician. We have however included a defence against prosecution. We propose that a prosecution shall fail if the word optician is used in circumstances where it would be unreasonable for registration or enrolment to be implied. This is surely a reasonable middle course.

I hope my noble friend will accept that it is. I cannot really believe that it is a danger to the public if someone describes himself not as an "optician" but as an "unregistered optician" or an "unqualified optician", in the way which my noble friend says. Similar methods of protection have, as I have explained, served well in the case of doctors and dentists.

I think we have to keep a measure of perspective in these matters and acknowledge some ability and common sense on the part of the public to discriminate between the qualified person and the rest. Many responsible professions have no protection for their titles at all. I believe accountancy and even teaching are examples. I believe that we have gone as far as we need and that this amendment would serve no good purpose. I hope with that I have been able to reassure my noble friend.

Lord Cullen of Ashbourne

I think my noble friend Lord Mottistone has put his finger on an extremely interesting point. My noble friend Lord Glenarthur has given a long and full reply at which we shall all have to look very carefully. I do not know how my noble friend will feel about this, but I think it is something that we must look into extremely carefully.

Lord Mottistone

I wish to make one small point. I think that my noble friend inadvertently misquoted me because he talked as though I said that somebody might describe himself as an "unqualified optician". I do not say that. I said he might describe himself as a "qualified optician (unregistered)". I never suggested that he would describe himself as an "unqualified optician".

Lord Glenarthur

I am sorry if I misrepresented my noble friend; I had no intention of doing so. What I meant was what my noble friend has just said.

Lord Mottistone

I thank my noble friend Lord Cullen. My view is the same as his. I am not at all sure that I am happy with what my noble friend the Minister has said, but he said a great deal and for that I am grateful. I shall look very carefully to see what it is and see whether it is good enough. I must confess that I find myself, although I have heard this before, slightly alarmed that people can practise medicine without being qualified. I am not sure that that ought not to be tightened up, particularly these days when people are damaging themselves with drugs from all sorts of directions. I know that that is irrelevant, but I would have thought that that needs tightening up rather this needing loosening.

As to what the noble Lord, Lord Rugby, said about 28 different types of qualification, I find that extraordinarily hard to believe, but I will look into that together with what I might call "qualified and registered people" who perhaps might have a greater knowledge of it than the noble Lord, Lord Rugby. Having said all that, we will look with immense care at what has been said. At this point I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 26 not moved.]

Clause 3 agreed to.

[Amendment No. 27 not moved.]

Clause 4 agreed to.

Lord Banks had given notice- of his intention to move Amendment No. 28: After Clause 4, insert the following new clause:

("Concessions for registered partially sighted people and for old age pensioners

Partially Sighted People and old age pensioners. The following sub-paragraph shall he inserted after paragraph 2, sub-paragraph (1), of Schedule 12 to the and National Health Service Act 1977: (1 A) It shall be the duty of the Secretary of State to provide by regulations for payments to be made by him or by any authority established under this Act to meet, or to contribute towards, the cost incurred (whether by way of charge under this Act or otherwise) for the supply of optical appliances for which a prescription has been given in consequence of a testing of sight under this Act—

1. (a) for any person who is on the blind or partially sighted register; or
2. (b) who is an old age pensioner.".").

The noble Lord said: In view of the fact that we have discussed the position of registered and partially sighted people under Amendment No. 20, and old-age pensioners under Amendment No. 16, I do not propose to move this amendment at this stage of the Bill.

[Amendment No. 28 not moved.]

Schedule 2 agreed to.

Clause 5 [Family Practitioner Committees]:

Lord Ennals moved Amendment No. 29: Page 7, line 21, at end insert— ("( ) It shall be the duty of all Family Practitioner Committees to co-operate with District Health Authorities in promoting health education in their areas.")

The noble Lord said: At this stage in the Committee's debate we move on to an entirely different but extremely important subject of the future of the family practitioner committees. I believe it may be for the convenience of the Committee if in moving this amendment I speak to Amendment Nos. 30, 31 and 32.

Amendment No. 30: Page 7, line 21, at end insert— ("( ) It shall be the duty of each Family Practitioner Committee to establish, run and monitor a deputising service for general medical practitioners in their area, the service to be financed by those practitioners using the service and may where a Family Practitioner Committee considers it appropriate be provided in conjunction with one or more other Family Practitioner Committees.")

Amendment No. 31: Page 7, line 21, at end insert— ("( ) It shall be the duty of each Family Practitioner Committee to establish, run and monitor a call and recall system for screening all female persons of the appropriate age group in their area for breast cancer and cervical cancer.")

Amendment No. 32: Page 7, line 21, at end insert— ("( ) All aspects of the work of Family Practitioner Committees shall be within the jurisdiction of the Health Service Commissioner.")

Clearly these amendments are putting the cart before the horse, because your Lordships will have noted also Amendment No. 34:

Amendment No. 34: Leave out Clause 5 and insert the following new Clause—

("Family Practitioner Services

—(1) Subject to subsection (2) below, section 10 of the National Health Service Act 1977 is hereby repealed.

(2) The following section shall be substituted for section 15 of the National Health Service Act 1977— 15. It is the duty of each District Health Authority in accordance with regulations—

1. (a) to make arrangements in pursuance of this Act for the provision of general medical services, general dental services, general ophthalmic services and pharmaceutical services for their locality, and
2. (b) to perform such other functions relating to those services as may be prescribed".

(3) All Family Practitioner Committees shall cease to exist on the appointed day.

(4) All functions which immediately before the appointed day were functions exercisable by a Family Practitioner Committee shall be conferred upon the District Health Authority or jointly upon those District Health Authorities which established that Family Practitioner Committee.

(5) Wherever in the National Health Service Act 1977 as amended by the Health Services Act 1980 and in other enactments, orders and regulations the functions of a Family Practitioner Committee are prescribed, those references shall from the appointed day be read as references to the functions of a District Health Authority.

(6) It shall be the responsibility of the District Health Authority in pursuance of its responsibilities under section 15 of the National Health Service Act 1977 to establish a Primary Care Committee which shall include persons nominated by the Local Dental Committee for that locality, the Local Optical Committee for that locality, the Local Pharmaceutical Committee for that locality and such other persons as the Secretary of State shall prescribe in regulations.

(7) Schedule 3 of this act shall have effect.")

There I am making very much more radical proposals which indicate quite clearly that I do not support in any way the Government's intention to establish what have been called "free standing family practitioner committees" separate from the rest of the National Health Service. I made this very clear on Second Reading, and my reasons for opposing this are quite simple: I will not go into them in any great detail. One is that I believe we have always, since the National Health Service was created, failed effectively to secure an integrated National Health Service and it was impossible to negotiate—even going back to the days of Nye Bevan—a satisfactory situation in which the independent contractors providing primary health care facilities were brought in as part of the National Health Service.

It seems to me that in the reorganisation that was carried out in 1982 we took the family practitioner committees a stage further away—and this takes them further away still—from being part of the National Health Service. I believe that constant reorganisation is extremely damaging to the National Health Service. I thought that the 1972 reorganisation, carried out in 1974, had catastrophic effects upon the service. I did not, when Secretary of State, promptly seek to put them into the position that I thought they should be, because you have to let people operate a system that is working. You have to let them make the best of it. I would say that now about the existing situation of family practitioner committees. To make further changes now, and to make the committees free standing is a bad move.

The second argument I would use is that I believe it is our task, as a result of the 1982 reorganisation, to strengthen the role of district health authorities. That is why, under Amendment No. 34, I make a number of proposals as to how family practitioner committees and their services could be integrated with the district health authority.

If I should fail in my attempt under Amendment No. 34, which is a radical amendment—it has not yet been moved and if I were to press that to a vote at this moment I am not certain whether I would win or lose, but I would not be over-confident—then I am extremely anxious that what is to be done, as proposed by the Government, should be adequate and should take into consideration the role of district health committees, and that a number of tasks that are not specifically set out should be set out. Perhaps I could quote from the Minister of Health, Mr. Kenneth Clarke, when he was speaking in the other place (col. 455) on the 2nd May. He said then: … once we have taken on powers to appoint the FPCs"—

I intervene to say that these powers I strongly oppose, and opposed on Second Reading— and have given them the independent status they desire"—

Of course they desire it, but whether it is in the interests of the service is another matter— we must lift their performance generally and give them a more positive role to play.

That is all right: I agree with that. He went on to say further in the same column: First, they must develop positive policies for the promotion of the family doctor, pharmaceutical dispensing and dental and optical services in the locality. Secondly, they must be properly accountable to the Ministers. Parliament and—equally important—to the general public for those policies and the way in which they carry them out. Thirdly, they must collaborate closely with district health authorities responsible for the hospital and community services so that the planning and financing of the National Health Service may be considered as a whole. In these four amendments I have sought to do what I thought the Minister intended to do, which was to give them a more positive role and to lift their performance, as he suggested in his speech from which I have quoted.

Amendment No. 29 refers to health education. I think all of us who are interested in health believe that we do not do enough on health education, though there have been improvements. And health education, if it starts anywhere, starts with the primary health care team and is, or should be, one of the main responsibilities of the family practitioner committees—of course, in co-operation, as I say in my amendment, with the district health authorities in promoting health education in their own areas. I think that should be quite clearly written into the Bill.

There are a whole variety of ways in which they should co-operate with the health authorities, whether we are talking about the labelling of drugs and pharmaceutical products, about the problem of drug abuse or the problem of smoking, which was debated to great effect in this Chamber just a few days ago, whether we are talking about education on the dangers of the abuse of drinking, poisons, and so on—the whole variety of issues on promoting health education, although I do not suggest that my listing of them is anything more than just scratching at the surface.

When we come to Amendment No. 30, we are dealing with monitoring the deputising service for general medical practitioners in their areas. This is of course a very controversial question; but I believe there needs to be some body which monitors deputising services where they are found to be necessary. The monitoring of deputising services at present, as I think most people would agree, is inadequate. One could argue that there is a conflict between the profit motive of the private deputising services and good patient care. One could argue that where there is a general practice with three, four or five partners, no deputising service is necessary. But we know very often that if there is a single doctor or a doctor and one assistant, some form of deputising may be necessary, if a 24-hour service is to be provided; and certainly it should be properly monitored.

When we come to Amendment No. 31, we are looking at running and monitoring a recall system for screening all female persons of the appropriate age groups in their area for breast cancer and cervical cancer. That is extremely important. These types of cancers are particularly susceptible to treatment if they are caught early enough. If those two terrible afflictions are diagnosed early enough by a screening programme, in nine cases out of 10 things could be put right and lives could be saved.

The arrangements at present are extremely hit and miss, and the Government, having abandoned the cervical cancer recall system (in which they have saved a number of jobs) certainly have not gone very far in promoting this. Perhaps the Minister will be able to reassure me on that. But it does seem to me that this should be written into the Bill as one of the responsibilities of the family practitioner committees—again, as I say, on the assumption that my Amendment No. 34 is not successful. We are talking about a very large number of people—at least 2,000 women a year die of cancer of the cervix—and we cannot let the matter rest until a proper screening system is established. I believe the job can best be done by family practitioner committees.

The fourth of these amendments being taken together deals with the simpler point that the work of family practitioner committees should come under the general jurisdiction of the Health Service Commissioner. This would be one way of enabling patients to be satisfied that they have an effective way of dealing with complaints. One does not want to encourage patients to complain, but the health service ombudsman has done a very good job. His job should be extended to the role of the family practitioner committees, and if that is to be done, we need to write it into legislation.

So what I am seeking to do here—again, I have to add, if I fail in my principal purpose with Amendment No. 34—is to ensure that the family practitioner committees have a major job to do, that they do it effectively in co-operation with district health authorities, and that they face up to the immediate problems, such as cervical cancer, to which I refer in one of the amendments. I beg to move.

Baroness Robson of Kiddington

I should very much like to support this amendment because, if we end up with the Bill as it is, we shall certainly need an amendment of this kind to put in the Bill what will be the duties of the family practitioner committees. This is therefore desperately important.

I am particularly interested in Amendment No. 31. Having been involved in the health service, I have all my life tried to achieve a proper screening system for all female persons, particularly for cervical cancer. Amendment No. 31 refers to "the appropriate age group"—and the noble Lord, Lord Ennals, has already referred to the 2,000 women who die unnecessarily from cancer, because of the lack of screening within the NHS—which is 35 years of age, unless it has changed in the last two months. But the medical profession will tell you that this is no longer the relevant age group, and that the age should be lowered enormously, probably because—although we do not know—the sexual life of the nation has changed. As a result, the screening should start at a much younger age.

I believe, with the noble Lord, Lord Ennals, that the right place for this screening to take place is with a family practitioner. He should be the referral point, and it is desperately important, if we have a freestanding FPC, that these amendments should be written into the statute when it is published. I also agree with the noble Lord 100 per cent. about the family practitioner committees being within the jurisdiction of the health service commissioner. I support the amendment.

Lord Rea

I should also like to support my noble friend's amendment. These amendments emphasise in statutory form the need for close co-operation between the newly formed free-standing family practitioner committees, should Amendment No. 34 not be carried. I fully agree with the noble Baroness, Lady Robson, about Amendment No. 31 and cervical screening. However, I should like to talk briefly about Amendment No. 29 and preventive medicine in the form of health education. This very much involves the seconding of personnel from the district health authorities to the family practitioner committees, whether they be health education officers or, as more often happens, nursing personnel—and probably in greater numbers. It would be of considerable help if this could be written into the Bill, rather than for it to be left to the stated wish of the department for co-operation to occur between the FPCs and the DHAs. I realise that there has been a helpful working party on this aspect, but it would strengthen the recommendations of that working party if these amendments could be written into the Bill. Even if the Government do not accept these in toto, I hope that they will pay considerable attention to this discussion.

Lord Glenarthur

1 take it from what the noble Lord, Lord Ennals, said earlier that he proposes to deal entirely separately with Amendment No. 34. So if that is the case, what I propose to do is to give my answer to Amendments Nos. 29, 30, 31 and 32, and come back to Amendment No. 34 after he has spoken to it, and in doing so I shall comment on each of those amendments.

On the first one, the Government share the view which the noble Lord, Lord Rea, and others have expressed about the major importance of promoting good health and we agree that FPCs should be concerned with health promoting activity. But we do not accept that it would be right to impose upon FPCs a specific duty to co-operate with district health authorities in promoting health education. There is already a wide range of matters on which co-operation between FPCs and DHAs will be crucial, and the Bill already requires FPCs to collaborate with health and local authorities by amending Section 22 of the National Health Service Act 1977 to that effect. This will, of course, apply to health education. The report of the joint working group on collaboration between FPCs and DHAs, which was published on 26th April, stated that, collaboration arrangements should be used to co-ordinate family practitioners' health promotion efforts with those of the DHAs. I support that view.

If I may now turn to deputising services, to which the noble Lord, Lord Ennals, particularly drew attention, I would point out that one of the fundamental principles of the doctor's contract is that he is responsible for ensuring for his patients the provision of all necessary and appropriate personal medical services of the type usually provided by general medical services. If he chooses not to do so personally, he remains responsible for all acts and omissions of any doctor acting as his deputy, unless that doctor is on the medical list of the same family practitioner committee.

We see no role for the family practitioner committee in offering deputising arrangements to family doctors with whom it is in contract. There is already a number of efficient and well-organised commercial services operating in this field, as well as a variety of co-operative and rota arrangements. There are, of course, some FPC areas—I believe 13—where no deputising services operate because it would be uneconomic for them to do so. I am sure the noble Lord will accept that rota arrangements are the solution there. We would not wish the family, practitioner committees to shoulder the financial burden, which could be considerable, that providing a deputising service would involve.

On the question of screening, to which in particular the noble Baroness, Lady Robson of Kiddington, referred, a substantial part of the cervical screening programme is operated by the DHAs and not by the family practitioner service. In addition, the DHAs are responsible for the laboratory services, which are of course an integral part, and a necessary part, of the whole screening programme. In these circumstances, it would not be appropriate for responsibility for the screening programme to pass to the family practitioner committees.

Baroness Robson of Kiddington

We are asking for the recall system to be the responsibility of the family practitioner committees.

2.10 p.m.

Lord Glenarthur

The national recall system was not so effective as the noble Baroness and the noble Lord, Lord Ennals, have made it out to he. That is why it was stopped and that is why we are setting up new arrangements. New ages for women to be screened are also proposed. The noble Baroness may be aware of them. The recall scheme, as the noble Baroness knows, is no longer centrally organised. Responsibility for it has passed to the local district health authorities, most of which have schemes running or in an advanced state of planning. The reason for this, as I have said, is that the national scheme was not so effective as it should have been. While many use FPCs on an agency basis, and will no doubt continue to do so, it is for the DHA to determine the most appropriate local recall arrangements. There is nothing to prevent a health authority from developing its own recall system if it is felt to be a local priority and the resources for it are available.

At present there is no national breast cancer screening programme, as there is insufficient evidence to be certain that mass screening is effective in reducing deaths from breast cancer. However, the department is funding a large-scale programme to evaluate breast cancer screening, and until the results of the trials are available the Government are unable to make a decision on a future screening programme. However, the noble Baroness will be aware that we recommend that all women should regularly examine their own breasts. Leaflets on breast self-examination are widely available from the Health Education Council and the Women's National Cancer Control Campaign.

Lastly, I shall deal with the matter of the Health Service Commissioner's jurisdiction. Under the terms of the National Health Service Act 1977. the commissioner can look at the actions of family practitioner committees, as he can look at the actions of other health bodies, but he is precluded from looking at matters where a complaint can be referred to a tribunal. He is also debarred from looking at personnel and contractual matters, as he is with other bodies, but he can look at the informal procedures used by FPCs to resolve difficulties between patients and practitioners where the patient does not want to refer the matter to a service committee; and he has also looked at the administrative action taken by the FPC prior to the formal complaints procedure being implemented.

It is only where a complainant decides that he wishes his complaint to be dealt with under the formal procedures that the Health Service Commissioner is excluded. The eventual decision of the Secretary of State, either on the recommendations of the FPC, or on an appeal, is not subject to the jurisdiction of the Health Service Commissioner. We have to strike a balance between the need adequately to investigate complaints and the need for decisions of tribunals, subject to their appeal systems, to be final. The procedures under the National Health Service (Service Committee and Tribunal) Regulations already fall under the jurisdiction of the Council on Tribunals, on which the Health Service Commissioner its. If he, or any other member, sees a need to change procedures, we shall listen carefully to the council's advice, but, just as with the courts and other tribunals, we should not cut across the work of the service committees with an investigatory, ombudsman type of system.

A further, perhaps unintended, effect of this new clause would be to override, in respect of family practitioner committees alone, the general provisions in the National Health Service Act 1977 limiting the jurisdiction of the Health Service Commissioner in, for example, contractual and personnel matters. We have always seen the role of the Health Service Commissioner as being to protect the interests of the patient in his relations with the National Health Service, rather than those of a member of staff in the National Health Service and his employing authority, for which there are quite separate arrangements.

Given the service committee and tribunal regulations on the one hand and the ability of the HSC to become involved in formal complaints proceedings which are not subject to these regulations, I can see no justification for disturbing the present arrangements. I am aware that we shall return more generally to this matter when we debate Amendment No. 34 and other amendments, but I hope that I have explained to the noble Lord, Lord Ennals, why we see our new arrangements as being practical and sensible. If that has been made clear to him, I hope he will withdraw his amendment.

Lord Prys-Davies

I am particularly interested in the Minister's reply to Amendment No. 32. The FPC will be a constituent part of the NHS. It should follow that we should have one universal complaints procedure which will apply throughout the NHS in every part of the country; to every constituent part of the NHS, and to every complaint which arises within the NHS—whether it arises in the surgery, in the health center, or in the hospital.

The Minister has given a very detailed reply and I am sure we shall want to read his reply very carefully. I am just wondering whether he can tell the House today, or at some later stage, to what extent patients have filed complaints with the Health Service Commissioner in respect of the treatment they have received from general practitioners. How many such complaints have they made? What have been the commissioner's findings? Our basic point is that there should be a universal complaints system which applies throughout the country, to every authority, and to every level in those authorities.

Lord Glenarthur

I cannot give the noble Lord the figures for which he asks now, but perhaps I may find them out and then let him know them. Before I sit down, perhaps I may refer to a point raised by the noble Baroness, Lady Robson, concerning cervical screening, because it is important that I should clarify what I said.

The noble Baroness may be aware that advice has recently changed. Women asking for contraceptive advice can at any age have a smear. When a woman first requests a smear, she must be given one; and thereafter at the ages of 20, 25 and 30. She then enters the priority scheme at age 35. This arrangement does represent a change and I am sure that the noble Baroness will welcome it.

Lord Rea

I should like to make a few remarks about Amendments Nos. 30 and 31. Amendment No. 31 concerns screening, and it is now fairly well recognised that the best result comes from screening procedures being provided through general practitioner services. Women are more inclined to respond to a call to have a cervical smear taken—or any other procedure that may be thought suitable, and particular blood pressure checks—if the request comes from their general practitioner. Also, the general practitioner may well make such tests in the course of his normal patient consultations.

Another reason why the recall system should he the responsibility of Family Practitioner Committees is that they are increasingly having their lists computerised. It will be much easier for the FPCs to get hold of people than it will be for a rather more remote DHA. It is very appropriate that the responsibility for screening should be handed to the FPCs, who will have the tools to do it. The effectiveness of requests made through the FPCs will be greater.

Amendment No. 30 deals with the deputising system. Recently, this has been a controversial issue. Why has it been a controversial issue? Obviously, because it has not been adequate and has not been serving the needs of patients. This amendment will not cost the Government anything, because the doctors who use the system will have to pay for it themselves. At the same time, the control, supervision and recruitment of the doctors who will serve in the deputising service will be under the scrutiny and control of the FPCs, which will be a duly appointed body with responsibilities in this area to look after the health of the patients of the practioners concerned.

2.20 p.m.

Lord Glenarthur

I recognise the important role which general practitioners have in regard to the screening of women in the way which the noble Lord describes. However, as I said earlier the district health authorities have, in many cases, quite advanced recall schemes going ahead, and they also have responsibility for the laboratory service. I am more than satisfied—I have seen some of these schemes being prepared or in action—that they work perfectly well, so I do not share the noble Lord's view that screening should be passed to the FPCs.

I have nothing to add to the noble Lords's further point on deputising services. My right honourable friend the Minister for Health made an announcement on this and said that he believes that good deputising services are an essential feature of our family doctor service and they are providing an excellent standard of care for most patiensts when they are used. He went on to say that the system of control and preventing excessive use of them has not been as good as it might across the whole country and the time has come to revise our arrangments to bring our services in line with the best. The noble Lord may not be satisfied with that, but nevertheless it is the view that we hold and that we shall continue to hold . I hope that that answers his two points.

Lord Kilmarnock

Before the noble Lord winds up the debate on the question of the deputising services, is not the argument that the noble Lord has just advanced equally an argument for accepting Amendment No. 30? At one point the noble Lord said that the commercial services were already working well. Is it not the case that the Minister recently had to issue new guidelines because he was so concerned about their malfunction? He was trying to arrive, through his new committees, at a system of better monitoring of these services. The noble Lord, Lord Ennals, has now provided him with a very handy amendment which will do precisely that and I wonder why the Minister does not accept it.

Lord Glenarthur

I am—

Lord Ennals

Is the Minister about to make a concession?

Lord Glenarthur

I hate to disappoint the noble Lord but I am not going to make a concession. The important thing is that the deputising services, as they have been arranged and as they have been examined by my right honourable friend the Minister for Health, are given a chance to work. I cannot suggest that it would be right for me to accept Amendment No. 30 in any way. My right honourable friend has made strenuous efforts to make sure that the deputising services do improve and they must be given the chance to work.

Lord Ennals

I am, of course, grateful to the Minister for what he has said and for dealing with each of these four amendments. I should like to make a general comment. I have been involved with legislation in the other place, as well as here, for very many years. I find it disturbing that there has not been at any stage of the Bill, as I understand it, an occasion when the Minister has agreed to take something back, think again and return on Report with something that we have convinced him of. Whether it is that all the wisdom lies with the Minister or his right honourable friend and those with whom he collaborates, or whether it is the ineffectiveness of all those who have put forward amendments. I do not know. However, I find it a disappointing method of legislating when the Minister, with all his charm, knowledge and good arguments says "No" to every amendment put forward.

I accept that there are some amendments to which there are arguments of principle and I would not expect the Minister to agree to those, but there are others where I should have thought he would say, "Right, we would like to look at this again". In Amendment No. 29 we refer to co-operating with district health authorities in promoting health education in their areas. I do not believe that most family practitioner committees now are anywhere near active enough in health education.

Lord Rea

My noble friend can say that again!

Lord Ennals

I shall say it again. It is absolutely clear that health education is one of the most important tasks. We are running not just a sickness service; we are seeking to run a health service. One reason why it is constantly argued that it would be nonsense to reduce the number of doctors, community nurses, and the rest, is that it is at the primary health care level where health education is so important.

It is so important, and I think the Minister said that he agreed that it should be the responsibility of the family practitioner committee. As I say in the amendment, the family practitioner committee should co-operate with the district health authority. It is not intended that it should take away its responsibility. Therefore, why, in heaven's name, is it not sensible to put that in the Bill? If it is part of statute law that that is one of the things that the family practitioner committee should do, it will enable the Minister to give advice to supplement what the law says. I am extremely disappointed that the Minister stone-walls on this, instead of coming forward with a willingness to accept the principle and to see whether, in case the wording in my amendment is wrong, there is another way of doing it.

I would say something similar about deputising services. The noble Lord, Lord Kilmarnock, took the words out of my mouth. Of course there is concern about deputising services. As the noble Lord said, the Minister himself has recently issued guidance. That has been a subject of tremendous controversy. I could understand it if the Minister said that he did not like the idea of establishing the fact that family practitioner committees should run the services, but it seems to me that this is the level at which a deputising service should be monitored. Why does he not say that a separate service, established and run by family practitioner committees, is going too far, but they should at least have a monitoring responsibility? If they do not, who does? I think that the noble Lord wishes to say something, and so I shall sit down and let him say it. If he wants to say something, it must be good.

Lord Campbell of Croy

Hear, hear!

Lord Ennals

Perhaps I am too kind.

Lord Graham of Edmonton

My noble friend can say that again.

Lord Ennals

I shall say that again, too! The general practitioner is of course responsible, but the family practitioner committee is responsible for all the contractors who are providing services, including the general practitioners. I shall now sit down so that the Minister can give us his good news.

Lord Glenarthur

The good news that I am going to give the noble Lord is that the changes proposed by the Bill will take the accountability for looking after deputising services rather further. Ministers will have responsibility for monitoring the standards of deputising services. The inclusion of lay members in the committees responsible has been widely welcomed by those who commented on the original proposals.

Lord Ennals

It has not been widely welcomed by me, and I am the one who is proposing the amendment. I believe that the Bill goes much too far in centralising powers with the Minister. One complaint that I made on Second Reading, which was echoed by several noble Lords from different parts of the House, was that over 2,000 people are to be appointed to the new family practitioner committees by the Secretary of State. I believe that this is all part of the system of excessive centralisation, which is not good. Of course, the Minister did not give me any good news. I knew that the Bill made provision for monitoring to be done centrally, but I do not believe that one can effectively monitor centrally a deputising service that may work for only two or three practices. It can be done only at the level of the family practitioner committee. The idea of going up to the kind of level of the Secretary of State or the new general manager who will be appointed under the Griffiths recommendations and the thought of how he could carry out any such responsibility make the mind boggle.

This takes me on to Amendment No. 31. I was most grateful to my noble friend Lord Rea for what he had to say about the relationship between the patient and the general practitioner. We have the finest GP service of any country in the world. One of the great glories of our National Health Service is the role of GPs. Most of them are willing to put themselves at the disposal of their patients to the nth degree. One cannot generalise, but that applies to most. Most general practitioners visit when necessary, though again one cannot generalise. Their role is extremely important. That is because of the personal relationship that exists between the GPs and their patients.

I absolutely agree with my noble friend Lord Rea, who argued that the GP is the best person to work a recall system: he knows the patient and the patient is much more likely to come back and see the GP than he is to go into a clinic, hospital outpatient department, or whatever it may be.

I am sorry that, on each of these points that I have pressed, the noble Lord has given nothing at all. I am sure we shall have to discuss this again at Report stage. It would make it very much easier, in view of the feeling that obviously exists in the Committee, if the noble Lord would go some way to meet us. I say "us" because there are three noble Lords who have their names to this, quite apart from others who have supported it.

I am not going to press it to a Division, but I have no doubt that we must return to this at Report stage. I hope the noble Minister will think very carefully, between now and then, about whether or not the principles of the amendments that have been proposed can be incorporated in the Bill when it comes before us on Report.

Amendment, by leave, withdrawn.

[Amendments Nos. 30, 31 and 32 not moved.]

2.33 p.m.

Baroness Robson of Kiddington moved Amendment No. 33: Page 8, line 2, leave out ("1985") and insert ("1986").

The noble Baroness said: I should say first that my noble friends and I are moving this amendment irrespective of whether we believe basically in the benefits of a free-standing FPC. We are moving it with quite another concern in mind. I myself have been involved in the health service since prior to 1974. I was first appointed chairman in the first week of June, 1974. By the end of August or the first week in September all my area chairmen had been appointed. By the end of September or the beginning of October, all the members of those authorities had been appointed.

That gave those authorities a full six months to exist in shadow form, to appoint their senior officers and to set up their management structures. So when they became responsible for what they were appointed to do on 1st April, they were ready to go. Even that time-scale was very tight, and that related to only about 90 authorities—a much smaller number than that we are dealing with now.

Since then, even if ony partially because of the problems that exist in finding people who have the time to spare to take on the responsibilities that are offered, appointments have taken much longer, and it really began to get very bad prior to the 1982 reorganisation. I went to see the Secretary of State, in June 1981, in order to tell him that, for personal reasons, I should have to resign on 1st January 1982. When the time of my resignation became relevant, no successor had yet been appointed. In the region of which I was chairman, during 1982 there was one district in which the chairman had not been appointed a month before the date of reorganisation. This is not a criticism of what goes on in the department, but it is enlightening to realise the number of appointments that have to be made every year because of the changeover of personnel in the various authorities. Some people retire because of age; some retire because their appointment has come up for renewal and the Secretary of State, in his wisdom, decides to change the appointment.

I have also been chairman of a board of governors. On many occasions, when the time has come for re-appointment of my fellow members of the board some have not known whether they were to be re-appointed up to about a fortnight before the vital date. It is a lot to ask of people who give of their free time to keep themselves available on the off-chance that they might be re-appointed. When they are appointed, they should have enough free time to enable them to carry out the job to which they have been appointed. I am just explaining some of the difficulties that occur when these appointments are made.

We are now going to add another 2,000, and some people say 3,000. I have not added up because we do not yet know exactly the number of FPCs. We are to have another lot of appointments, and this has to be done very quickly. It has to be done in consultation with professional bodies, voluntary organisations and local authorities, which can all put in their nominations. We are approaching the holiday period. These things will not happen until some time in the autumn. At that time, the appointments will have to be made.

There is then the problem that arises over the cut-off date of 1st April 1985. What is happening about the staff of these new authorities? Are senior staff again to be expected to continue on an ad hoc basis until such time as they might be properly appointed to their new jobs? How are they going to set about creating a management structure for the FPCs? I intend to say much more about that on the Question, Whether the clause shall stand part? All these things should be done before the alteration to the structure is made. That is why I appeal to the Government to make the date April 1986 instead of April 1985.

Because the NHS is involved, the Government and the authorities will also have to go in for lengthy negotiations with the Whitley Councils over whether the administrator of the FPC is the same as the administrator of the DHA or where he fits into the scale. If we are to alter the NHS yet again, let us give ourselves time to do it properly. I beg to move.

Lord Ennals

I rise simply to say that I agree with every word of the noble Baroness, Lady Robson. Her wisdom confirms my own reason for having reappointed her as chairman of the regional health authority at the time she accepted it. It was a great pity that she had to leave when she did. She was an outstanding chairman of the authority. The noble Baroness speaks with great experience; I speak only with the mere experience of a former Secretary of State. With the number of appointments that I had to make, I can say that it was a monumental task.

Of course, it is possible to say it is not the Secretary of State making the nominations; it is the Civil Service. One can take that attitude; and I believe that that is what will happen if everything has to be done not later than 1st April 1985. Is the Minister really going to tell me that between now and 1st April 1985 the Secretary of State himself, with all the problems that he has to face and with Griffiths round his neck—well, he tied it round his own neck—and with Griffiths about to be implemented, he really will be able to make these changes? If he says to me that he really will be able to do it, then I would be deeply suspicious of the way in which he will do it.

I do not believe that changes ought to be made with such rapidity because of the effect upon the people involved. All of them are committed in one way or another to the health service, whether they are lay people, professional people, or what-have-you, and to constantly rush them into situations of change like this is grossly unfair and leads to inefficiency and incompetence. I support very strongly the amendment proposed by the noble Baroness.

Lord Kilmarnock

I think the noble Baroness, Lady Robson, and the noble Lord. Lord Ennals, have said it all. There are only two further points that I should like to add. The noble Baroness, Lady Robson, has talked about the inevitable and natural delays in finding people for all these new jobs—and finding the right people, which perhaps is even more important.

There are two other considerations. One is that, as I understand it, the Government have announced for July a Green Paper to review the whole issue of primary health care, and this could reopen the whole question. Quite apart from that, we are also still expecting the removal of the wraps on the Binder Hamlyn report, a report of a distinguished firm of accountants. which is going to throw some light on the question of management costs in the FPCs.

What conceivable reason can there be for rushing ahead with legislation before these reports have been published, properly digested and properly debated? It is simply another instance of the Government rushing hastily into legislation without looking at all the facts and all the possible suggestions and improvements that there could be to their proposals. They do it again and again, and the result is simply going to he bad legislation which is not going to work. I strongly support the amendment.

Lord Glenarthur

The noble Baroness herself described the effect of this amendment, but I have to tell her that such an extension is unnecessary since administratively it will be perfectly practicable to bring these new bodies into operation by April of next year. The appointments exercise is certainly a formidable one, but it is one which we already have in hand. We shall consult very widely when looking for names for new members; but, of course, in order to preserve continuity and expertise there is likely to be a substantial number of reappointments of those who are serving at present and are willing to continue to do so

Existing administrative staff of FPCs will be transferred to the new authorities on 1st April 1985 in their existing grades and with their existing administrative structure. We must remember that these committees already exist. They have done so since the inception of the National Health Service, and the chief aspect of this change is the securing of direct accountability to Ministers, which I referred to earlier. So in that respect the new FCPs will inherit the management structure of the exiting family practitioner committees. As I said, the appointments exercise will commence within the next few weeks, and shadow authorities will be appointed in January of next year.

At Second Reading of this Bill, in answer to the noble Lord, Lord Ennals, I said that Binder Hamlyn will be published with, or at the same time as, the Green Paper. The fact is that if we were to go beyond the date which we propose it would be necessary, because of the very strong reasons for making such a change at the beginning of a financial year, to delay until 1st April 1986 the implementation of Clause 5. This would be a wholly unacceptable delay to all those concerned with the provision and administration of the family practitioner services.

It is the case that approximately one-third of DHA members are due to be considered for appointment in 1985, but, of itself, this is not a sufficient ground to justify postponing the implementation of our proposals. Health authority nominations, as important as they clearly are, will provide only 13 per cent. of FPC members, and although there is advantage in nominees being DHA members, it is not a requirement that they should be so. I have explained the reason why this amendment is inappropriate and I hope that as I have answered some of the points that the noble Baroness raised, she will not press her amendment.

Baroness Robson of Kiddington

I thank the noble Lord for his reply, but I do not find it convincing by any means. First, there is the implication that the staff of the FPCs will be just transferred as they are. If that is so, and the duties of the FPCs are not going to change at all, then why do we not keep the present structure? If they are to be the same staff in any case, they will not be unhappy whether they are paid by the DHA or by the FPC if we wait until 1986, but at least we would have enough time to think about what we are doing, and for once in the NHS we would do things properly and would not rush into them. However, in the circumstances I do not intend to press my amendment at this stage, but I shall certainly consider what to do at the Report stage. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Ennals had given notice of his intention to move Amendment No. 34:

[Printed earlier.]

The noble Lord said: I never intentionally waste time—my time or anyone else's. Having heard the Minister's reply to what I thought were most reasonable amendments—namely, Amendments Nos. 29 to 32, and Amendment No. 33 which stands in the name of the noble Baroness—I would be wasting my time if I were to set out the arguments as regards the present amendment.

I put this amendment on the Marshalled List because it expresses the view that is held by myself and by my noble friends on these Benches. We would like to see the integration of the family practitioner service within the National Health Service. However, I am not going to move the amendment because if I were now to do so, the noble Lord would then make a speech which I could easily write myself. It would not satisfy the noble Lord and it would not satisfy me. It may be best that we use our time in debating the Question, Whether Clause 5 shall stand part of the Bill.

[Amendment No. 34 not moved.]

On Question, Whether Clause 5 shall stand part of the Bill?

Baroness Robson of Kiddington

I said that I would reserve some of my comments to this point on our agenda. Two very conflicting views have been expressed by your Lordships during the Committee stage of this Bill. One view has been 100 per cent. in favour of the independence of the FPCs, and the other has been in favour of integration within the main line of the NHS. I wish to appeal to your Lordships' Committee to remain with the status quo.

On Second Reading many noble Lords, including the noble Lord, Lord Pitt, claimed that DHAs are influenced by the hospital sector because that sector accounts for the great bulk of their expenditure. Let me tell your Lordships, as an ex-chairman in the NHS, that of course the hospital sector takes the greatet bulk of expenditure; but none of us on the authorities is not fully aware of the fact that the best way in which to reduce hospital expenditure is to improve the primary care service. I agree with noble Lords who have said that primary health care can be the most effective sector of the NHS. I said "can be" and not "is". The emphasis is on "can be" and it is my contention that that can only happen when the whole range of services is supplied by one authority in a district. That is why, if the noble Lord, Lord Ennals had moved his amendment I would have supported it, although I know from experience that the noble Lord did not have much chance of success. After all, many of us in the health service have argued this point ever since 1948. However, if even at this moment in time we cannot have the ideal, let us at least not destroy what is slowly, but slowly, becoming an integrated service.

The NHS has been subject to too many reorganisations in the recent past. The 1974 one was far from ideal, but at least it brought the community services within the orbit of the NHS. At the time the tier system seemed impossible and fairly expensive as well as not responsive enough to local needs. But it was just about to begin to work when the 1982 reorganisation was introduced. I am quite happy openly to admit that I prefer the pattern of 1982.

However, since then we have had Griffiths, and do not let anyone tell you that Griffiths is not a form of reorganisation. I know that it has not yet been introduced, but the circulars have been sent out and I have seen some of them. Now we have this Bill establishing FPCs as free-standing, autonomous bodies, thus moving yet a step further away from real integration. Arguments were also put forward on Second Reading which implied that until the administrators of FPCs were on a level with administrators of DHAs and their funding was separated from that of the DHAs, effective planning would not be possible, presumably implying that the FPCs were in some way subordinate and therefore not able to make their point of view felt. I do not believe that for one minute.

As it stands, the funding of the family practitioner service is open-ended and the only funding to the FPC provided by the DHA is the administrative costs of the FPC. One may think that that is a very slight connection, and one would be right. However, it creates at least some in-built communication between the FPCs and the DHAs, even at officer level. It also ensures that there is some promotion structure open to administrative employees in the FPCs.

On the financial side, I should like to express a view that the likelihood of increased administrative costs is enormous. The noble Earl, Lord Caithness, was kind enough to send me the working party report on collaboration between FPCs and DHAs and how it can be achieved. The implications really horrify me. I realise that if we separate the two authorities, a document of that kind on how the co-operation will work would be necessary. But we cannot possibly claim that the family practitioner committees could conform with that amount of co-operation, with perhaps four or five district health authorities, with cross-over membership, with staff meetings coinciding, with the creation of sub-committees of the FPCs for general purposes and planning, which all have to be staffed, and with primary health-care teams and local joint committees, which they already have but which they will also need at unit level.

For all that the FPCs need administrative back-up. In the past, that kind of administrative back-up was provided by the DHAs. I do not believe that it will be anything but a very expensive exercise which will further divide the authorities that are supposed to provide a unified primary health-care system.

The report to which I have just referred concludes with the following words: The achievement of these goals in the future depends on the ability and willingness of DHAs and FPCs to work together as partners". There is no clear-cut statement in that report on the division of responsibility, and in this plan I can see massive opportunities for putting the blame for shortfalls in the service on the other side.

I am not as ambitious as the noble Lord, Lord Ennals, in the present climate. Nor am I convinced, as many noble Lords in this Chamber seem to be, that three authorities are more likely to co-operate amicably and effectively than are two authorities, including one fairly independent wing. I therefore plead with the Government to leave things as they are and to allow the authorities as presently constituted to continue their co-operation towards a fully-integrated primary care service.

2.56 p.m.

Lord Glenarthur

As the noble Baroness will be aware, it is the object of this provision to simplify and strengthen the administrative arrangements for the provision of family practitioner services. The noble Baroness has set out her views quite clearly and I hope that the Committee will bear with me if I set out mine, equally clear, but, I fear, at slightly greater length. The present arrangments were made in 1974 with the best of intentions. It was hoped that the administrative links with DHAs would create opportunities for bringing hospital, family practitioner and other community services together within an integrated health service. However, it has become increasingly apparent that the administrative dependence of FPC son district health authorities has caused problems of delegation and accountability and has led to the creation of an unnecessarily complicated bureaucracy. The result has not been in the interests of either good management or the effective provision of primary health care, about which many of your Lordships have spoken. I am bound to say that I share the views that they expressed about the importance of primary health care.

But in the light of experience we have come to the conclusion that new arrangements are required. We do not favour the so-called integration option of merging FPCs with DHAs. The independent contractor status of practitioners is an important factor in the successful development of the services they provide and it is because of this special status that we need a separate body with particular experience and skills developed over the years which are suited to the complex business of administering these contracts. We need also a firm focus for the family practitioner services as part of the wider system of primary care. On average, some 10 per cent. of a health district's expenditure is on those community health services for which it is responsible. A family practitioner committee's expenditure is solely on the family practitioner services to which it devotes 100 per cent. of its time. We see the new FPCs as an important part of the strategy effecting a shift in the balance of provision from secondary to primary health care, working, as they must, in close harmony with the district health authorities.

There are three main strands to Clause 5 and the associated Schedule 3. First, we want to clarify lines of responsibility and strengthen accountability. The present arrangements are muddled and they divorce accountability for internal FPC administration, for which FPCs answer to DHAs, from accountability for the administration of family practitioner services, for which they are responsible to the Secretary of State. Obviously the two functions cannot be separated in practice and the new arrangements recognise that accountability for both should be to Ministers. The provision in Schedule 3 for the Secretary of State to appoint the chairman and other members of the committee will secure the line of direct responsibility together with the powers of direction as to the exercise of functions which we are taking in paragraph 2 of that schedule.

This accountability will be reinforced by regular performance reviews forming part of a continuing dialogue between the department and the FPCs about their performance. Both members and officers will be encouraged to examine their functions and their roles critically.

Secondly, we are aiming for greater efficiency. We expect the new structure to be more efficient as well as more effective because having complete responsibility for one's own management functions brings with it its own disciplines. Cash limits will continue to apply to these administrative functions and FPCs will be expected to contribute their share of savings in NHS management costs generally. There will be both internal and external audits (the latter to be undertaken by the department) and there will be the further safeguard of the involvement of the National Audit Office.

The third strand reflects our determination to promote and improve collaboration, and a distinct and much clearer role for FPCs should enable them to play a constructive part with district health authorities in the planning and delivery of primary health care. This will be reinforced by cross-membership between them. Provision is also made for FPC membership of joint consultative committees, and that is a key step in cementing the relationships between the family practitioner services and the community services as a whole.

Finally, we recently published the report of a joint working party which established and identified key areas for collaboration and proposed guidelines. Its recommendations should prove a sound basis for the discharge of the statutory duty placed on health authorities and family practitioners by the new Bill to co-operate with one another in order to secure and advance the health and welfare of the people of England and Wales.

I hope your Lordships' Committee will recognise that the new arrangements in the Bill for FPCs offer a sound basis for effective administration and for improved efficiency and collaboration in achieving a better balance of care. Those must be objectives which we all share. The noble Baroness, Lady Robson, expressed her concern over what she regards as the fragmentation of primary care services, but I have to tell her that I think her view is ill-founded. Since 1974 it has been the duty of, first, area and, now, district health authorities to estabish family practitioner committees to administer the arrangements made for the provision of the family practitioner services. Yet in practice the committees function as separate bodies, and. understandably so, because of the highly specialised procedures involved in the administration of services provided by independent practitioners.

The districts have little day-to-day involvement with the family practitioner services. Their major, almost overwhelming, preoccupation is with the great health care institutions which they must keep running. The proportion of their hospital and community health budget which they spend on the community is some 10 per cent.—a very small amount. This point regarding the hospital orientation of health authorities and the priority accorded to the community health services was also raised by the noble Baroness at Second Reading. She suggested that our expenditure comparison was invalid, in that it failed to take account of sums spent by DHAs on family practitioner services, but the point of comparison is between elements of expenditure over which DHAs have control and between which they can accept priorities. The family practitioner services are in effect administered by FPCs rather than DHAs who act as paymasters, and expenditure on them is, as the noble Baroness knows, demand-led. It is not determined by the policy choices of the district health authorities.

We maintain that the hospital orientation of district health authorities and the specialist nature of the family practitioner services together warrant the administration of the latter by a separate authority. Such a body will facilitate the development of primary health care in collaboration with health and local services, while integration with DHAs would run the risk of the family practitioner services being overshadowed by the other responsibilities of those authorities.

For those reasons I think it important that the provisions in Clause 5 stand. If the noble Baroness presses her case to a Division on the Question whether the clause shall stand part of the Bill, I must ask your Lordships to support what I and my noble friends contend is a perfectly proper intention.

Lord Prys-Davies

The noble Lord the Minister has galloped through that brief. We really need time to consider its contents. It seems to me that first of all he is acknowledging that the Government are not contending that the GP services have suffered under the existing system. He is, it seems, content to acknowledge that they have not suffered, and I should have thought it necessary to leave well alone. Then the Minister acknowledges that the aim of the Bill is to ensure budgetary and manpower control. He is convincing on that point. So far as I know, this is the first time I have heard specific reference to cash limiting the service to the expected savings on the FPC service, but I am sure that that is the principal aim of Clause 5. That will have grave implications for the FPS which has been geared to meet the oncoming demand.

But the Government are not convincing when they claim that the present system has led to fragmentation. The system was fragmented from its birth because of the failure to integrate the FPCs with the DHAs. I accept that the noble Baroness does not advocate a closer integration necessarily with the DHAs, but we do so. We say that the basic flaw was the failure in 1973 to integrate the FPCs with the DHAs. The Government are also unconvincing when they claim that the system has led to inefficiencies. We have not been given evidence of the inefficiencies. If the Government are building their case on inefficiencies there ought to be evidence. But we do have evidence that in Scotland and in Northern Ireland the FPCs have been successfully integrated with the DHAs.

At Second Reading the Minister, the noble Earl, Lord Caithness, sought to draw a distinction between Scotland and England, but he did not extend this to include Wales. He maintained (in the Official Report of 21st May, at column 85) that the situation in England was very different from that in Scotland and that the Scottish solution could not be applied to the English scene. He went on to say: However, the situation in England, with its much larger number of patients and practitioners and generally higher population densities than Scotland, is different and admits to a solution that we have adopted". If we are applying those criteria—the number of patients and practitioners and population densities—then the Scottish solution could be fully applied to the Welsh situation. I conclude by saying that we on this side of the House consider that integration has tremendous potential and that we ought to persevere in order to bring it to fruition.

Lord Kilmarnock

Before the noble Lord, Lord Ennals, explains his interest in the new clause, I wish to ask him if he can help me understand the case that he is making for the separate existence and upgrading of the FPCs. In the debate on his Amendments Nos. 29 to 32 the noble Lord, Lord Ennals, proposed a number of areas in which the FPCs might properly take responsibility. I think he mentioned health education as one, and breast screening for cancer as another—a point also made by the noble Lord. Lord Rea. This would be a proper sphere of activity for the family practitioner committee. Various suggestions of this sort were made. They were all turned down as being irrelevant to the family practitioner committee. This then raises in my rather simple mind the question: what is the object of upgrading the FPC if it is not going to have any additional responsibilities or functions?

That of course brings one to the point made by the noble Lord, Lord Prys-Davies. He has suggested, and he must be right in suggesting, that this is largely or mainly a cost-cutting exercise directed at budgetary control of the FPCs and possibly paving the way for whatever recommendations may come out of the Binder Hamlyn report when and if it is published. I return to the main object because the noble Lord has talked about primary care and the Government have said that they do not propose to shift any other forms of community care from the hospitals to the family practitioner committees. Therefore, we must assume that the sphere of activity is to remain very much as it is at present, but with a considerably beefed-up top management structure.

At present the FPCs are able to make use of the expertise of health authorities in regard to organising finance, personnel, supplies, and so on. But when they become independent authorities in their own right, it is to be expected that with their newly independent status they will establish their own departments. So we shall then have not one department doing these things, but two departments.

I find it quite extraordinary to embark on a cost-cutting exercise, which is what I expect this is, and at the same time to increase the bureaucracy needed to administer it. That seems to be a total contradiction in terms. Not only is there likely to be an increase in the bureaucratic cost of the FPCs, but also a substantial increase in the management time required within the noble Lord's own department if there is to be any realistic opportunity to supervise and review the working of the FPCs on a regular basis, since the noble Lord has said he expects them to be accountable, through the department, to the Secretary of State.

On all these grounds, I cannot see what is the object of the exercise and, like my noble friend Lady Robson, I cannot see how it can possibly be any cheaper. Although we are sympathetic to the clause that is to be moved by the noble Lord, Lord Ennals, we recognise that in fact we are landed with the separation of the FPCs, but certainly we see absolutely no case for taking their separate identity any further.

3.13 p.m.

Lord Ennals

I shall be very brief, since I agree with so many of the comments that have been made by the noble Lord and the noble Baroness, Lady Robson. My noble friend Lord Prys-Davies referred to budgetary and manpower control. I simply do not understand how this Bill can be put through Parliament—I would say "forced through", if no change is made to it—with the Binder Hamlyn report sitting on the Minister's desk. Time and time again I have asked for the report to be published so that we may all know what are its recommendations. Why it should be kept secret when it deals with the central issues that are contained in this clause of the Bill? The Minister told us a couple of days ago that it would be published at the same time as the Green Paper, which we expect to be in July. In heaven's name why is it not published now, when we are debating this Bill? I really do not understand this. I am sorry if I am raising my voice, but I get a little angry when taxpayers' money has been spent on an important study which is involved with cash limiting, a number of aspects of how private contractors will operate, the way in which family practitioner committees will operate, manpower control, and so on. Yet we are denied the right to see it. That is my first point.

Secondly, I shall not belabour it, but this constant chopping and changing within the National Health Service is, I am sure, a fatal mistake. Always the Government have said that it will lead to greater efficiency and financial savings. Hardly ever does it lead to greater efficiency. I say that because I did not introduce any reorganisation during my period of office. Hardly ever does it lead to greater efficiency. Rarely does it lead to savings in bureaucracy. Usually the estimates as to what will be the financial savings turn out to be false. Sir Gerard Vaughan said at one time that the 1982 reorganisation was going to save £30 million. It never did. It did not save any money at all.

Thirdly, contrary to what the Minister says, I fear that the decision will lead to a greater degree of centralisation of district health authorities in regard to the hospital service. What is important is that the relationship between family practitioner committees and district health authorities has pulled them towards the community. Their free-standing nature will pull them towards the community. Their free-standing nature will pull them back again towards a hospital orientation, and, with great respect to him, the Minister's argument on that did not seem to make any sense at

Fourthly, I wonder whether he can say what his honourable friend Mr. Kenneth Clarke, the Minister, meant when he said: Once we have taken on powers to appoint the FPCs directly and have given them the independent status they desire, we must lift their performance generally and give them a more positive role to play". What is the "more positive role to play" that is to be given to them?

Finally, I want simply to repeat what the noble Baroness, Lady Robson, said. For heaven's sake, leave things as they are. I know that I had an amendment down, which I did not move, which had to do with moving towards integration, but at this stage I say: leave things as they are. Do not do another reorganisation, particularly at a time when the Griffiths reorganisation is about to be implemented.

Lord Glenarthur

I ought to respond to some of the points that have been raised from the Benches opposite. The noble Lord, Lord Kilmarnock—I see that he is not in his place at the moment—said that he still did not understand exactly what was the purpose that lay behind the introduction of this clause. I explained in some detail earlier exactly what the purpose was, and I think that the noble Lord ought to study what I said, as I am sure he will. I should like to quote from one recommendation which was made by th Joint Working Group on Collaboration between FPCs and DHAs relating to health promotion. That specifically states at paragraph 31: We recommend that a collaboration arrangement should be used to co-ordinate family practitioners' health promotion efforts with those of the DHA, and that FPCs and LRCs should encourage them by collating information about particular health problems locally, making proposals for initiatives for health education and prevention, helping to plan campaigns and assisting in securing family practitioners' participation. So that goes some way towards explaining that point.

he noble Lord, Lord Ennals—not for the first time—raised the question of Binder Hamlyn, and he will be aware of the answers that I have given him on many occasions. The report is concerned with the financial control of the family practitioner services. There are, however, a number of other major issues which need to be considered in relation to the development of primary care over the next decade.

The central problem is how to ensure the proper development of the family practitioner services to meet changing needs, consistent both with our overall health strategy, including greater concentration on prevention and care in the community, which we all accept, and our commitment to achieve the best value for money. There is a need for the Government to take a long-term look at this area. Our intention, therefore, is to publish the Green Paper to stimulate an informed debate among the professions and the public about future primary health care needs. I reinforce what I said before, though it does not seem to do any good if I do. We expect to publish the report at the same time as the Green Paper, because it must be considered in the wider context of the future development of primary health care.

The noble Lord, Lord Kilmarnock, raised a point about the administration functions of FPCs. The fact is that there will be many functions, such as pay-roll and internal audit, which they may well choose to contract out—quite possibly to DHAs if they can offer the best tender. We do not expect there to be any unnecessary duplication of administrative services between FPCs and DHAs. As to the noble Lord, Lord Prys-Davies, and his comments about cash limits, the fact is that cash limiting applies only to the administrative expenditure of FPCs and not to expenditure on the family practitioner services. Administrative costs are already cash limited.

I do not want to prolong the debate, but I ought to draw one point out about Scotland, because the noble Lord referred to Wales and to the fact that there is a connection between the two. The fact is that the so-called integration of FPCs in Scotland represents the shadow rather than the substance. In one health board, for example, the primary care adminstrator is located in a building some 18 miles away from the rest of the health board. He is responsible only for the administration of the family practitioner services and takes no part in the planning and provision of the other community health services, such as nursing. The view is taken that the family practitioner services cannot be absorbed into general administration because of the specialist knowledge required to deal with independent practitioners, but there seems to be an equal reluctance to absorb the administration of other primary health care services into the administration of the family practitioner services.

I cannot resist the challenge which the noble Lord, Lord Ennals, virtually threw at me about what the Government have achieved so far as greater efficiency in the health service is concerned. A number of steps have been taken, and the noble Lord is well aware of them. One tier of administration has been abolished. Ministerial reviews of performance were begun in February 1982. I know, from having been involved in them, just how effective they are. Performance indicators have been introduced for the first time. Improved manpower use has been encouraged. I am sorry that the noble Lord did not feel able to say that he had done anything to improve the efficiency of the National Health Service when he was in office.

Lord Ennals

I did not say that, and the noble Lord knows that I did not say that. I said that I did not impose upon the National Health Service a reorganisation, or a series of reorganisations.

Lord Glenarthur

If I misrepresented the noble Lord, I apologise for doing so, but the fact is that he did not take many of the steps which we have now taken. Competitive tendering is one. The Griffiths Inquiry is another. There has also been the Korner Inquiry and the Rayner Scrutiny of the National Health Service. These all point to greater efficiency. None of us can sit back and say that the system is perfect and does not require improvement, because the noble Lord knows as well as I do that the NHS is a bottomless pit into which one could pour almost the entire GNP, and still people would not be satisfied with it. This is why it is essential that all aspects of the National Health Service should receive very careful scrutiny to achieve the best possible value for money.

Baroness Masham of Ilton

The Minister has said that the new administration will lead to greater efficiency, but will it not also be at greater cost? Has that been worked out?

Lord Glenarthur

No, it will not be at greater cost. The whole point is that we are trying to achieve greater efficiency and greater value for the money that is spent. That applies to the family practitioner committees as well as to the other arrangements.

Baroness Masham of Ilton

Is it not going to be very expensive?

Lord Glenarthur

Is the noble Baroness referring to Griffiths?

Baroness Masham of Ilton: Yes.

Lord Glenarthur

Griffiths is not going to be expensive. We ought not to debate Griffiths now, because it is an entirely different subject. The important point is that accountability and responsibility for managing the National Health Service has not featured so prominently in the past as it ought to do in the future.

Clause 5 agreed to.

Schedule 3 [Family Practitioner Committees]:

Lord Prys-Davies moved Amendment No. 34ZA: Page 40, line 22, at end insert— ("( ) after subsection (1) there shall he inserted: ( ) The Family Practitioner Committee and its officers shall furnish a District Health Authority if its locality is wholly or partly included in its district with all such information relating to its functions as the District Health Authority may reasonably require in order to secure and advance health facilities in the district. ( ) The Public Bodies (Admission to Meetings) Act 1960 shall apply to any meeting of the Family Practitioner Committee.".").

The noble Lord said: The next two amendments are probing amendments. The first paragraph of Amend-ment No. 34ZA deals with collaboration. Under the earlier legislation, the question of co-operation between the family practitioner committees and the DHAs did not arise, as the FPC was a committee of the DHA administering services on behalf of the AHA. However, as the FPC will now be separated from the DHA and will be a separate source of authority, we believe that a duty ought to he placed on the FPC to co-operate with the DHA. However, earlier today the Minister referred to a duty to co-operate which has been incorporated in the Bill. We should need to refer to that clause to see whether the FPC would be under a duty to furnish the DHA with such information as the DHA might reasonably require. If that is so, then obviously one would not press this amendment further.

The second part of the amendment seeks confirmation that the Public Bodies (Admission to Meetings) Act 1960 will apply to FPCs, because they will have a responsibility and accountability to the Secretary of State but also to the people who live in their area. We want confirmation that the press will be allowed to attend meetings of FPCs and to report their proceedings. This is really a probing amendment. I beg to move.

Lord Glenarthur

I have listened carefully to what the noble Lord. Lord Prys-Davies, has said. Although the Government endorse wholeheartedly the intentions of both parts of this amendment, I have to tell the noble Lord that it is in our view unnecessary. Schedule 3(3) to the Bill amends Section 22 to the National Health Service Act 1977 so as to require health authorities and FPCs to co-operate with one another in order to secure and advance the health and welfare of the people of England and Wales. Such co-operation would certainly involve a two-way traffic of necessary information between the two authorities.

The report of the joint working group on collabo-ration has been issued to both DHAs and FPCs, and it provides the necessary framework for the exchange of information. This is a matter to which we shall attach particular importance when reviewing the performance of authorities.

So far as the Public Bodies (Admission to Meetings) Act 1960 is concerned, the Government have already taken the necessary steps to secure its application to FPCs. Paragraph 7 of Schedule 9 to the Health and Social Services and Social Security Adjudications Act 1983 did in fact bring the executive functions of FPCs within its scope. A circular was issued to all committees in August of last year indicating that community health councils would be entitled to send one of their members to meetings of FPCs as an observer with the right to speak but not to vote. The CHC observer may be asked to withdraw when confidential matters are discussed—for example, in respect of some service committee proceedings—but otherwise may attend all meetings of the FPC. Given that assurance. I hope the noble Lord will see fit to withdraw the amendment.

Lord Prys-Davies

I am grateful to the noble Lord the Minister for his response and explanation. As to the second part of the amendment, the noble Lord's comments are acceptable—but we shall need to read carefully his remarks in respect of the first part. Meanwhile, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

3.28 p.m.

Lord Ennals moved Amendment No. 34A: Page 43, line 27, after ("chairman") insert (", who").

The noble Lord said: I hope that this will be not only a brief amendment but also one that the Minister will be able to accept. I believe that the majority of the present chairmen of family practitioner committees are laymen. I want to ensure that all of them are laymen and not members of any of the contracting professions. The chairman of an FPC inevitably has to keep the peace. He has to ensure co-operation.M

If one looks at the list on page 43 showing membership of the family practitioner committee—which numbers 30 in all—one sees that it would be perfectly possible for the medical profession (for which I have great respect) to form the majority if, under various headings, with decisions taken by various people, they were to be nominated to represent health authorities or other bodies under the various categories.

I myself feel convinced that it is in the best interests of harmony—and this has been found so by district family practitioner committees—that there should be lay chairman. Since the chairmen will in future be appointed by the Secretary of State, I want to ensure that he will appoint laymen as chairmen of the FPCs. I beg to move.

The Earl of Caithness

I am sorry to disappoint the noble Lord, Lord Ennals, but this is not something we would wish to see because it is our guiding principle that we should have the best man or woman for the job. However, I can assure him that we shall look for a measure of lay and professional balance in chairmanship throughout the country as a whole and, in the first round of appointments, to the need for a degree of continuity of experience. I hope that the noble Lord will see that it is necessary to follow the lines that we propose and that he will feel able to withdraw his amendment.

Lord Ennals

Can the Minister tell me—if not now perhaps later—how many chairmen at present are laymen and how many are members of a profession? I do not expect the noble Earl to tell me now, but I would be grateful for the information before Report.

The Earl of Caithness

Is this for existing or future chairmen?

Lord Ennals

It is for existing chairmen. I do not expect the noble Earl to answer now and my action would not be dependent on his reply. I shall not press the amendment to a Division. I raised the matter because I think it is very important. It is not just a matter of choosing the best person. It is important, as I have argued, to have a layman and I hope the views that have been expressed will be conveyed to the Secretary of State who has the task of making the appointments.

Lord Prys-Davies

; I support my noble friend Lord Ennals because at least half of the members will be representatives of the skilled groups. They will represent the point of view of their particular interest. Within those skilled groups the dominating section will be the medical profession. If the medical group can carry the support of the other skilled groups they will control the workings of the FPCs. That is why there is a strong feeling—I have been approached about it—that in those circumstances the chairman should not come from a skilled group. He should not be a representative of a skilled group and should he seen to represent the community for which the service exists. This is almost a piece of syndicalism, as it is. The chairman ought to have an unbiased approach and he able to offer judgment and qualities of leadership. I reinforce the point made by my noble friend Lord Ennals.

Amendment, by leave, withdrawn.

[Amendment No. 34B not moved.]

Lord Prys-Davies moved Amendment No. 34C: Page 43, line 46, at end insert— ("( ) I shall be a community nurse appointed from persons nominated by a body representative of community nurses employed in that locality; ( ) I shall he a health visitor appointed from persons nominated by a body representative of health visitors employed in that locality; ( ) 3 shall he appointed from persons who are members of voluntary organisations whose primary interest is health care and having knowledge and experience of health care facilities in that locality;").

The noble Lord said: Every important skilled group is reflected in the membership of the FPCs apart from the community nurses and the health visitors. Who knows better then the community nurse and the health visitor how well the primary health service is reaching out into the community? Are they not likely, given their experience, to have special skills to offer to the FPCs? If the structure excludes representation of those two skills, it can be said that it is a wrong model. After all, the essence of the health service lies in the transaction between the doctor, the nurse and the patient. Just as one feels that the role of the nurse and the health visitor has been overlooked so too has the role of the patient, who is very much a manager of the NHS, or the organisations which represent the patient, been overlooked.

The thrust of this amendment is that the community nurse, the health visitor and voluntary organisations with a special interest in health care also ought to be represented on the FPC. The formula is probably not correct, but the principle is that there should be representation for the skill groups and for the patients and their representatives.

Lord Kilmarnock

I should like to say from these Benches that we certainly support the spirit of the amendment moved by the noble Lord, Lord Prys-Davies, but we have one or two reservations. As the noble Earl will be aware, I shall later be proposing an amendment along the same lines which refers simply to nurses. The noble Lord, Lord Prys-Davies, wants to go a bit further; he wants to have two nurses rather than one nurse. I think probably that the noble Baroness, Lady Cox, will be able to comment on this with greater expertise; but I understand that there is a technical difficulty in the way in which he has phrased his requirements for a community nurse and a health visitor. No doubt she will speak with greater expertise about that.

I think that the point about representation from voluntary organisations is a good one, and it is something that we should consider. But I do not feel that these categories should all be lumped together in the way of this amendment. Of course the noble Lord is asking for five new members, or for the replacement of the five existing members, or possibly for the Secretary of State to use the seven places in his gift for the five persons who are proposed in the amendment. I am not quite clear as to how that is supposed to work. We think that the spirit of the amendment is in the right direction, but I should like to suggest to the noble Lord that we should get together to have a think about this before the next stage of the Bill.

Baroness Cox

May I briefly say that I welcome very warmly indeed the spirit and intention of the amendment and particularly the objective of ensuring representation of the community nursing services? However, I have been advised by the Royal College of Nursing that the present wording could cause some difficulties in terms of the practicalities involved. I do not wish to take your Lordships' time now, unless you would wish me to do so. I believe that those difficulties could be avoided by the rather simpler wording of Amendment No. 36. It might also he preferable to consider the merits of membership of professional organisations separately from those of voluntary organisations. I conclude by reiterating my appreciation of and support for the objectives of this amendment but saying that I must record some reservations on its detailed wording.

The Earl of Caithness

I think that we all have much sympathy with the view of the noble Lords, Lord Prys-Davies and Lord Ennals, and indeed the noble Lord, Lord Kilmarnock and my noble friend Lady Cox, on the spirit of the amendment and that those involved in community nursing and voluntary service within the community should be adequately represented on FPCs. We have given an assurance that we shall ensure by administrative action that community nursing is represented. Our proposal is that these committees should have 31 members, and there are 98 of them in England and Wales. As we discussed earlier, this already represents a formidable appointments exercise, and we shall draw heavily on those people in the locality with a spirit of public service.

I am rather surprised that the noble Lord, Lord Ennals, put his name to this amendment, because at Second Reading he said that it was going to be a formidable job and that 3,000 people were perhaps quite enough. He now wants to create another 500 appointments. We shall shortly be consulting, on the widest possible basis, for names of people to be put forward to take up what I believe will be a challenging new task. All the professional nursing bodies and all those voluntary organisations active in the community will be invited to make nominations. I believe that is the best way to secure the outcome which the noble Lord, Lord Prys-Davies and the noble Lord, Lord Ennals, require. On that basis, 1 ask them to withdraw this amendment.

Lord Ennals

I rise only to defend myself in the belief that when attacked, defend. I object to this very large number of appointments but if it is going to be done I want to make quite certain that the nursing profession is included.

Lord Prys-Davies

I am grateful to the noble Lord, Lord Kilmarnock, and to the noble Baroness, Lady Cox, for their support of the principle which I tried to express in this amendment. I accept that it is very imperfectly worded and 1 will take it back and have consultations.

Amendment, by leave, withdrawn.

Lord Kilmarnock moved amendment No. 35: Page 44, line 9, at end insert ("and the Secretary of State shall so arrange these appointments as to ensure that at least one person nominated by each district health authority entititled to make nominations in respect of sub-paragraph (g) above is appointed to the Committee.").

The noble Lord said: This amendment also refers to the composition of the family practitioner committees. It is written into the schedule at the moment, as indeed was the case previously, that four members should be appointed from persons nominated by the district health authorities, any part of whose district is in the locality of the family practitioner committee. We know that as a result of previous reorganistions there is no necessary co-terminosity between the FPCs and the health authorities and that in some cases areas of more than four health authorities fall within the boundaries of the family practitioner committee.

Of course, this can lead to the obvious unfairness that some district health authorities may not be able to secure direct statutory representation as of right on the Committee. So this amendment is a very simple one. It simply requires the Secretary of State, out of the seven freewheeling appointments that he holds in his hand, in the case of there being more than four health authorities to be represented, to use one of those places for the health authority which has not secured representation under subparagraph (g). That seems to me to be a very simple matter and a very proper use of the Secretay of State's power. I hope that the Government will be able to accept it. I beg to move.

The Earl of Caithness

It is certainly our intention to ensure that where any FPC has within its locality more than four districts, all will be represented on the Committee. This arises only in five cases and it is our intention that these should be dealt with by enlarging the membership of the FPC under paragraph (7)(1) of this schedule rather than by using one of the Secretary of State's seven appointments. In doing so, we will of course maintain the balance on the committee between the contractors and non-contractors. I hope that this covers the worry that the noble Lord, Lord Kilmarnock, has and that he will withdraw the amendment.

Lord Kilmarnock

I am grateful to the noble Earl for that. That is helpful. As he rightly says, it only occurs in a small number of cases. I think we will be satisfied with that and accept the noble Lord's word that this is the way that it will be done. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Kilmarnock moved Amendment No. 36: Page 44, line 9, at end insert "and one of them shall he a nurse qualified in either district nursing or health visiting.").

The noble Lord said: With this amendment we come hack to the question of nursing representation, which was the subject or part of one of the subjects of the amendment moved by the noble Lord. Lord Prys-Davies. It was this amendment to which the noble Baroness. Lady Cox, referred when she said that the Royal College of Nursing on balance preferred this rather more simple amendment.

This is an important amendment. It is a more substantial point than that of the last amendment. It is that out of the seven members in the Secretary of State's gift under subparagraph (h) he would be required to appoint one person who shall be either a nurse or a nurse qualified in either district nursing or health visiting. I understand—and it is a very reasonable ambition with which we can all sympathise—that the Royal College of Nursing feels strongly that even though it was opposed to the separation of the family practitioner committees in the context of their becoming independent authorities, it is critical to make sure that nursing is assured a place on these committees. I underline the word "assured". It is perfectly possible for nurses to be appointed either under the four places accorded to district health authorities or the remaining seven places in the Secretary of State's gill. But there is no guarantee of that in the Bill as drafted.

As we know, the nurses are the largest of the health professions. They fought a long battle to establish their nurse member places on health authorities. It would seem reasonable, if the Government are now determined to upgrade the family practitioner committees to the status of health authorities, that nurses should also secure some representation there. All the other main health care disciplines associated with primary health care have been accorded specific places under Part II of Schedule 3. It is therefore the opinion of the college, my opinion and the opinion of my noble friends on these Benches that nursing should also he accorded a place.

There is a further point. The Government have said that they do not intend to shift the community health service significantly in the direction of family practitioner committees. We shall have to see how that works out. It is, however, at present the case, according to the best estimate that I have been able to obtain, that there are something like 5,000 nurses working in the GP sector of the health service as practice nurses. It is not just a question of designing a place for nurses who may be needed in the future: there is already a considerable amount of valuable nurse activity in this field.

I raised this point on Second Reading, and the noble Earl was kind enough to write to me. I have sought his permission to quote from his letter. In that letter, dated 6th June, he says: Secondly.

after answering another question, you sought an assurance that a nurse member will be appointed to each FPC. This is our firm intention".

Those are his words. We do not consider, however," that specific provision need be made in the Bill but rather that it should he secured by administrative action. I hope that you will feel able to accept this undertaking".

We do not doubt the noble Earl' intention. But the Government have alluded during debate today to their intention to take administrative action in a number of fields. However, this has been coupled with an unwillingness to write it into the legislation. If the noble Earl is so definite as he was in his letter to me, and if it is the Government's firm intention to make these nurse appointments, I cannot see why we should not have it on the face of the Bill. Exactly the same argument can be made for all the other groups represented on the FPC. The Government can say that they intend to see that there is representation for these groups and that it is therefore unnecessary to write it into the Bill.

On all those grounds, I should like to ask the noble Earl to reconsider the Government's position and to take what I feel is the proper and sensible course of writing into the Bill the provision for representation by one nurse on family practitioner committees. I beg to move.

Baroness Cox

Before speaking to this amendment, may I say that I welcome and support legislation designed to increase efficiency and accountability in the provision of health care, and particularly to promote measures designed to enhance the quality of primary health care. Therefore, in so far as this Bill will achieve those objectives, it has my support. However, I hope that this amendment will be considered sympathetically. It is necessary on grounds of consistency and efficiency.

The arguments relating to consistency are of two kinds. First, it is anomalous and professionally unacceptable that present provisions specify the other major health care professions but exclude nursing. The nursing profession accounts for the largest number of staff in the primary health care services. With all the implications that this carries for resources, it is anomalous that this category of membership is missing.

But that anomaly is even more strange in view of the recognition which has already been accorded to the nursing profession in their statutory membership in both regional and district health authorities. Surely that membership needs to be paralleled by statutory membership on the FPCs if legislation is not going to appear inconsistent and arbitrary.

But far more fundamental to the question of anomaly is the problem of the exclusion of nurses from membership of FPCs, because of the implications of that exclusion for sound and efficient planning and policy making. The growing emphasis on community care is reflected in quicker discharge of patients from hospital and an attempt to move patients from long-stay institutions into the community. A major responsibility for the care of such patients falls on the community nursing services, and therefore it is the height of folly not to ensure nurse representatives on these bodies, which are concerned directly with primary health care.

I am aware—indeed, we have just heard it again—that the Government have said it is not their intention to exclude nurses from the FPCs, and also that opportunity exists implicitly for their inclusion, for example, in the category covered in paragraph 3(h). However, this is not satisfactory. If the Government do have a sincere intention to include nurse representatives, surely it must be better law to make that explicit rather than implicit, because however sincere that intention may be there is always a real danger that over time subsequent Governments may not heed it. Therefore, I believe that there is no substitute for ensuring that the membership of FPCs explicitly includes a nurse qualified in either district nursing or health visiting. This is surely an uncontroversial amendment, and I sincerely hope that it will be incorporated.

Lord Ennals

Very briefly, I wish to support entirely this amendment. I agree that it is a better amendment than the one my noble friend and I had tabled. I do not see that there is any logic in saying there should be an optician, this number of dentists and this number of doctors, but not saying that there will be one nurse. It seems to me to be absolutely obvious. An assurance given by a Minister that the Government will do that does not necessarily carry the conviction of a future Minister: I have argued this on many issues. If it is the Government's firm intention that there should be a nurse representative on the family practitioner committee then the best thing to do is put it in the Bill. I cannot see any possible argument against it.

3.53 p.m.

The Earl of Caithness

We accept that community nurses should play a part in administrating the family practitioner services and that this should be underpinned by the appointment of such a nurse to each FPC. This has always been our intention, but it is something that we shall secure by administrative action, as I have confirmed in a letter to the noble Lord, Lord Kilmarnock.

We do not feel that a statutory requirement is necessary for the Secretary of State to appoint from among his seven nominees. We would hope that a number of the nurses—perhaps all of them—would be nominated by DHAs under paragraph 6(1)(g) of this part of Schedule 3. Surely they are as well placed as anyone to put forward suitable names. Therefore, I would ask the noble Lord not to press his amendment but to seek leave to withdraw it. because he has the Government's very firm assurance that his intention will be secured administratively.

Lord Ennals

Before he sits down. I should like to ask the noble Earl, what is the logic of this? I really do not understand it. It may be that there will be nominations of nurses, hut it may be that there will not. There may be nominations of doctors, dentists or opticians. Of course, they are open to make those other nominations. But if it is thought that the community nurse should be there, in the same way that it is important that there should be representation of the other professions, it should be included in the Bill. With deep respect to the noble Earl, he has not given any reason at all why it should not be in the schedule.

Baroness Robson of Kiddington

May I also ask the noble Earl why, then, it is important to have it specified that nurses should be part of the DHAs if they do not have to be part of FPCs? I do not see the logic.

The Earl of Caithness

The present arrangements ensure representation of the independent contractors to the committees, who provide the family practitioner services. These we have carried forward into the new legislation. Home nurses and health visitors are employed by the DHAs, as are other health care professionals, such as physiotherapists, occupational therapists, and speech therapists. We hope that they will all be represented on FPCs, but we do not intend to write them into the Bill.

Lord Ennals

Why not?

The Earl of Caithness

For exactly the reasons that I have given. Under those circumstances, I hope that the noble Lord, Lord Kilmarnock, will withdraw his amendment.

Lord Prys-Davies

The noble Earl the Minister is really withdrawing from his first position. His first position was that they will become members of the committee by administrative action. But he now says that he hopes that they will become members of the committee.

Lord Kilmarnock

I must confess that I am disappointed. As the noble Baroness. Lady Cox, said, this is a supremely uncontroversial amendment—perhaps the most uncontroversial that has been moved so far in the whole of this Committee stage. As the noble Lord, Lord Ennals, has pointed out, we do not doubt the noble Earl's intentions, but we do not know who will occupy the noble Earl's seat in a year or two, and whether we can rely on future Ministers to the extent that we can rely upon the noble Earl. That is the purpose of writing things into Bills. We do not doubt the noble Earl's good intentions, but we do not know the intentions of those who will follow him. That is the whole point of statutory provisions.

The noble Earl suggested that it would be very likely that in the DHA quota nurses would emerge on the FPC, but it is quite probable that the DHA may have other professional interests that it would prefer to have represented. So there certainly is no guarantee under that category.

The point has been made about the Government's whole approach to care in the community and the general shift of people out of hospitals into the community. For that to work it must almost certainly be accompanied by a shift of nursing in that direction, too. That will inevitably mean greater nurse involvement with the FPCs. So it seems to me that we have simply won the argument. There cannot he any doubt about it.

Lord Ennals

I am certain that the noble Lord would not want to have a Division at this stage, but this is a crucial issue. Would the noble Lord be satisfied if the noble Earl, Lord Caithness, were to say that he would take the matter away and consider it with his right honourable friend before we come to the Report stage?

The Earl of Caithness

I may perhaps intervene at this stage. Without any commitment, let me say that I shall of course take the matter away and have a look at it.

Lord Kilmarnock

I thank the noble Earl. I am grateful to the noble Lord. Lord Ennals, for his intervention and to the noble Earl for that crumb of comfort. However, I hope that that crumb of comfort will become a little more like a proper cookie before we reach the next stage of the Bill.

I must tell the noble Earl that it is quite obvious that there is general support for this amendment from all sides of the Committee. Naturally, I shall not divide the Committee at this time on a Friday afternoon. I have already discovered that there are 13 Tories in the Library and none of my noble friends, and so obviously a Division would be counter-productive. But I must remind the noble Earl that ahead are later stages of the Bill when we may hope to have a fuller Chamber. I am sure that a fuller Chamber will be just as sympathetic to this amendment as a thin Chamber has been this afternoon. So I really must suggest that before the next stage of the Bill the noble Earl comes forward with something a little more substantial than the crumb that he has offered us—in other words, with a Government amendment. If not, we shall certainly revert to an amendment of our own, and I think that we would carry it. Meanwhile. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Colwyn moved Amendment No. 37: Page 44, line 34, at end insert— ("( ) If a Local Dental Committee so require, the Secretary of State shall appoint from among dental practitioners nominated by the Committee under sub-paragraph (3)(b) above a dental practitioner to be the deputy of any such practitioner appointed from among persons nominated by them under sub-paragraph (3)(b) above.").

The noble Lord said: At this stage in the afternoon I promise to be as brief as I can. In moving Amendment No. 37, I should like to speak at the same time to Amendment No. 38.

Amendment No. 38: Page 44, line 34, at end insert— ("( ) If a local Pharmaceutical Committee so require, the Secretary of State shall appoint from among pharmacists nominated by the Committee under sub-paragraph (3)(c) above a pharmacist to be the deputy of either pharmacist appointed from among persons nominated by them under sub-paragraph (3)(c) above.").

During the Second Reading debate I mentioned one or two arguments as regards the first of the amendments which stand in my name. The additional sub-paragraph would give the three dentist representatives on the FPCs the backup of one deputy member; that is, one deputy for the three full members together, not one deputy each.

Before 1 briefly explain my reasons—and here I declare my interest as a dentist—for thinking that such a provision would improve the Bill and the effectiveness of FPCs, may I explain my second amendment? This is an exactly parallel provision but for pharmacists, so again there would be one deputy pharmacist member for, in this case, two full pharmacist members.

Therefore, taking Schedule 3 as a whole, we would have deputy member provisions for each of the minority contractor groups on the FPC. Looking at page 44 of the Bill, sub-paragraph (6) gives the ophthalmic medical practitioner a deputy. This would then be followed by my two new sub-paragraphs, (7) and (8), which would give deputies to the ophthalmic optician and the dispensing optician members of FPCs. Sub-paragraph (9) explains that: A deputy may, while the member for whom he is deputy is absent from any meeting of the relevant Family Practitioner Committee, act as a member of that Committee in the place of the absent member".

Perhaps I may explain briefly why I think that deputy members are necessary for the minority contractor professions on a FPC by looking at the case for the additional dental representation first. I have to say—and I remind your Lordships that I am speaking as a dentist—that I think the number of full dental members on an FPC is inadequate. I have here some pages from the 1984–85 Supply Estimates. On page 20 the cost of the family practitioner services in England is shown. I see that there are 25,000 general medical practitioners in a general medical service estimated to cost £927 million in 1984–85. There are then 14,000 general dental practitioners in a general dental service costing the Government £458 million, and the patients another £173 million in dental charges, making a total cost of £631 million.

From these figures it can be seen that there are approximately twice as many general medical practitioners as general dental practitioners and that the general medical service costs just about twice as much as the general dental service, or about 50 per cent. as much if we include the dental charges paid to the NHS by patients directly, as I think we should. So if dentists have three representatives on an FPC, as they do, then we might expect doctors to have five or six, if representation is to be in relation to manning levels or costs. In fact, they have seven scats on the FPCs and far outnumber the other professional groups. In my view this uneven level of representation is of vital importance.

At the moment, FPCs do not pay, and executive councils before them have not paid, enough attention to dental matters. I said this during the Second Reading debate, and I emphasise it again this afternoon. Most FPCs will do the routine functions of listing dentists, deducting superannuation payments and investigating complaints, but they will not generally take much intelligent interest in the local dental services, as to whether they are adequate or could be improved, or whether groups such as the housebound, the elderly or the handicapped are getting the sort of dental services they need.

I believe that this failing must, in part, be due to the level of dental representation on FPCs. But I have to be realistic. The professional composition of FPCs shown on page 43 in paragraph 6 of Part II of Schedule 3 will not be changed at this late stage of the Bill. There would have to be lengthy consultations with all the professions to bring about any change. So I am trying to improve the situation with what I hope will be seen as relatively uncontroversial amendments to give the two under-represented minority groups on FPCs the back-up of one deputy each.

In conclusion, and to summarise, FPCs should be paying more attention to dental matters, and this needs proper dental representation. Dental members of FPCs have particular problems attending meetings, which are invariably held during the day, which will involve them in having to be away from their practices, where overheads still have to be paid. The FPC job for dentists will be growing, with dentists having to he involved not just in full committee meetings but also in various sub-committee activities. There will be a great deal of pressure on just three members which one deputy could help to relieve, and 1 do not believe that this would damage the continuity of approach to any significant extent.

Finally, there is a special problem for the two pharmacist members of the FPC: not overheads, this time, but a statutory requirement that a pharmacist cannot leave his premises. I know that pharmacists are concerned about the difficulty that this creates for FPC members and I have taken the liberty of raising it this afternoon, not only because it is a valid argument in itself but, taking the two amendments together, the Bill would then treat all the minority professions in the same way, giving them one deputy member each. I hope that your Lordships will be able to support these amendments. They are a means of strengthening the contribution which the minority professions can make to FPC deliberations and can ensure that FPCs look more broadly at health planning and not just at its medical aspects.

Lord Ennals

Perhaps I may support this in one sentence only. There is no logic at all in having some professions that can have deputies and others that cannot. It is quite clear from my consultation with both the dentists and the pharmacists that they feel strongly about this. I cannot think that there could be an argument against it.

The Earl of Caithness

My noble friend's amendment seeks to break the long-established principle which has been adopted in respect of deputies—that is, that where there is a single representative for a profession there should be provision for a deputy. It would be unrealistic to expect that such a member would be able to attend every meeting and, thus in his absence, his group would be unrepresented. This does not apply to dentists and pharmacists, who have three and two members respectively. We consider that to extend the appointment of deputies to groups on the committee with more than one member would have undesirable results so far as continuity of experience is concerned. If these amendments were carried, it would open up the possibility of requests for deputy members for the health and local authorities who have four members each and even for the doctors who have eight members. This could result in eight deputies eligible to attend meetings, or over a quarter of the entire membership. We do not think that it would be desirable to create such a floating body of members, with the threat it would present to consistent policy-making from one meeting to the next.

My noble friend argued persuasively that dental representation of FPCs is inadequate. His amendment would provide for a deputy for dentists and pharmacists on the committees rather than an increase in their representation, but we would not accept that representation of the contractor professions on FPCs should be related either to expenditure rationally on the services they provide or to the number of contractors. These are variables which will fluctuate over time. The number of dental and pharmaceutical members has remained constant since 1946, and our objective in this legislation has been to avoid controversial changes in the balance among the professional groupings. However—and here perhaps is some comfort to my noble friend—in due course when dispensing opticians cease to be represented on FPCs it is likely that we shall fill the resulting contractor vacancy by rotation among the remaining professions. This will lead to an intermittent increase in dental and pharmaceutical representation. I hope that my noble friend will see tit to withdraw.

Lord Colwyn

I am grateful for my noble friend's reply. This is a subject that has been brought up many times in the last few months by the British Dental Association and myself. I shall read carefully what he has said this evening, and hope that his assurances that careful consideration has been given to this subject are justified. If so, I shall be very happy to look at it and decide what to do in the future. With the reservation of possibly coming hack at a later stage, I beg to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 38 not moved.]

Lord Denham

I think this is probably as far as we can usefully go today. I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.

House adjourned at ten minutes past four o'clock.