HL Deb 02 December 1986 vol 482 cc788-810

8.28 p.m.

Baroness Turner of Camden rose to ask Her Majesty's Government whether they will comment on the difference in pay between speech therapists in the National Health Service and other graduate professions in the National Health Service.

The noble Baroness said: My Lords, I rise to put to your Lordships the Unstarred Question standing in my name on the Order Paper. In so doing I must declare my interests. Speech therapists are members of the union ASTMS of which I am assistant general secretary. However, I am not speaking today simply to make a salary plea for a section of membership. I quite appreciate that your Lordships' House is not a suitable forum for salary negotiation. I am emboldened to speak to your Lordships on this subject because I have been impressed since I have been in the House with the concern that is frequently expressed for the welfare of the disadvantaged and the disabled. It is on the subject of speech therapy as a profession and its rewards that I wish to speak. It is my belief that too little is known about it.

Speech therapy for speech disorders began in this country in about 1906, when classes for children with speech problems were developed in Manchester. Other cities followed suit. The original pioneers of the profession were ladies of independent means who worked for an honorarium to establish the foundations of the discipline. They trained recruits of a high academic standard. University entrance qualifications have been required for at least 22 years.

Academically, speech therapy has never been an easy option. It involves a wide range of academic subjects, including advanced neurology, normal and abnormal psychology, phonetics and linguistics, the whole field of speech and language pathology and a wide range of medical and surgical specialities, with heavy clinical commitments during training. The profession is now all-graduate entry. I have here the outline syllabus published by the University of Newcastle on Tyne for a B.Sc. (Honours) Degree in Speech and Psychology, obtained through a four-year course, and the B.Sc. (Honours) Degree in Speech similarly obtained through a four-year course leading to a recognised professional qualification. This is a fairly tough course to undertake.

The profession has always been poised between medicine and education. There is of course a strong teaching element. However, there has been uncertainty about precisely where the profession fits in. There was an examination of the situation by a committee chaired by Professor Quirk, which reported in 1972. The Quirk Report still provides a valuable insight into the profession and the problems it faced then and indeed still faces.

The foreword to the report, which was signed by Margaret Thatcher, Keith Joseph, Gordon Campbell and Peter Thomas, says: Although disorders of speech and language may not be as obvious as physical disabilities, they nevertheless cause great distress to large numbers of people. They hinder some of the most fundamental human activities—making wants known, expressing ideas and getting to know other people. Those engaged in the treatment of these disorders are therefore performing an essential service and making an important contribution to human happiness.". The foreword expresses thanks to Professor Quirk and his committee for the helpful account of the nature and uses of speech therapy and the emergence of the profession and for its rigorous analysis of the problems.

As I have said, it is a valuable source of information as to what speech therapy actually is and the qualities required successfully to undertake it. Not only are these qualifications academic. As one school concerned with the training of speech therapists put it to the Quirk Committee: One of the main interests of this work lies in the fact that every case has to be assessed as an individual problem, because the personality of the individual can affect the results of treatment. For this reason, students [of speech therapy] should have a stable, well-balanced personality themselves, as well as a sympathetic and understanding attitude towards others. This work calls for patience, initiative and imagination: to the prospective student these qualities are as important as the necessary academic ability.".

When one considers what the work actually entails, it is clear why these qualities are required. Speech therapists are involved in the treatment of a wide range of communication problems in childhood, including specific language disorders, delayed language development, articulation disorders, stammering and disorders associated with cerebral palsy, with emotional disturbance, with hearing loss and with mental subnormality.

As far as adults are concerned, patients include those with an acquired reading and writing problem as the result of a stroke or head injury. Indeed, speech therapists helped many young men wounded during the Second World War who had to face speech difficulties as a result of head injuries. Stammering is also a condition where speech therapists have been of great help. Here there have been some very famous clients, including His Majesty George VI.

There are voice disorders, hearing loss and mental illness, as well as mental subnormality to be dealt with as far as adult patients are concerned. Anyone who has seen, as I have, a formerly articulate person who has suffered from a stroke struggling to make himself understood, or parents of a child with learning difficulties because of problems of communication, can have no doubt at all of the value of the work that speech therapists do and of the need for it.

It is an almost entirely female profession. When the Quirk Report was published, 99 per cent. of the profession was female. I gather it is almost the same today. I think the figure is 98 per cent. It may well be that the history of the profession and its purely female, caring character has been responsible for its lack of status and the low level of pay which has been a feature for a long time and which no doubt contributes to the shortage of qualified speech therapists at the present time.

It is an undoubted fact that the service is inadequate to meet present needs. A recent report by Dr. Pam Enderby and Dr. Robin Philipp, extracts of which appeared in the British Journal of Disorders of Communication, makes this very clear. They say: The study of the literature supports a widely held view that the true incidence and prevalence of speech and language disorders is much higher than previously estimated. The data that have been gathered are deficient in many respects but suggest a revised estimate for the size of the speech and handicapped population in the United Kingdom as follows: Severe communication disorders (that is, people with little or no spontaneous speech) 800,000 persons; Moderate communication disorders (speech and language is noticeably disordered) 1.5 million persons".

They suggest that these estimates of the size of the speech and language handicapped population in the United Kingdom could well be conservative, because there are some groups of people who suffer from speech and language disorder which have not been included. Nevertheless, the estimates strongly suggest that the speech impaired population quoted in the Quirk Report, which at that time was 324,180, is a considerable under-estimate. It is clear from a report produced by VOCAL, (Voluntary Organisations Communication and Language—a voluntary organisation concerned with these problems) that there is an unfulfilled need. The VOCAL report is critical of the restructuring of the National Health Service in 1982 which VOCAL claims produced a serious setback for the profession because of the loss of Area Speech Therapy Management, which had existed until that time.

The report which VOCAL produced is the result of a questionnaire sent to speech therapists who are members of the College of Speech Therapists. The overall impression is of an overloaded, understaffed service struggling against ignorance and apathy. Speech therapists are well aware that they are not reaching all who need their services but are equally well aware that they could not cope with the volume of work if all the patients were referred to them.

The VOCAL report says that it did not seek views in the questionnaire regarding salaries and levels of grading. It says that this was a deliberate omission because the report it was seeking to make was primarily concerned with patient care. Nevertheless, VOCAL concludes that: It appears that little progress has been made in recognising and rewarding the important role of speech therapy in health care. It is deplorable that a graduate profession highly trained in all aspects of human communication should be accorded such low priority in staffing, accommodation and clerical back-up.

There has been, and still is, great dissatisfaction with pay levels. Perhaps I may quote some examples drawn from the salary structure at present operative (the date is with effect from 1st April 1986). A speech therapist who is a graduate, gets at point of entry £6,096 per annum. At point 04 in the scale (four stages on) the salary is £7,056 per annum. These are speech therapists with what is known as a "relevant degree". A senior speech therapist can attain the princely salary of £7,368 per annum rising to £8,676 per annum. A senior at the next level commences at £8,676 and rises to £9,720. Your Lordships will be aware of many professions and other occupations in which far less social commitment is required where the salary and the rewards are very much greater than that.

It is not surprising that with rewards at this level there is a shortage of people willing to undertake this necessary work. A survey conducted by the College of Speech Therapists in 1986 showed that, of 130 recent vacancies for speech therapists remaining unfulfilled for more than three months, 20 per cent. were vacant because of low pay. It is all very well to be socially motivated, to enter a caring profession, but bills nevertheless have to be paid. The profession is out of line with other graduate professions in the health service—for example, clinical psychologists—to the tune of several thousand pounds per annum.

As I have already said, speech therapists themselves, who are almost entirely women, believe that there is an element of sex discrimination here. They believe that if this were not a female profession it would be more highly valued. So, they decided to test out our equal value legislation and three of them recently took test cases to an industrial tribunal. However, they failed. They could not even get to the point of having their cases considered in substance with an independent expert undertaking an evaluation, because the industrial tribunal has accepted the argument of the employing health authorities that because salary scales are approved by Regulation 3 of the National Health Service Remuneration and Conditions of Service Regulations 1974, the health authorities concerned have no power to vary the salaries paid, even though they may be discriminatory. I have no doubt that the speech therapists concerned will pursue this further. However, if the Government would themselves look again at the profession and its rewards, or lack of them, an expensive trek through the courts on the matter of equal value could be avoided.

It is surely necessary to do something. Every so often newspapers carry stories which highlight the desperation of parents who cannot get speech therapy for children who need it. There was the case of Mr. and Mrs. Wallace, who went to the High Court to try to force a local education authority to provide speech therapy for their nine-year-old boy, who had profound difficulties in learning to speak. They failed in their action. There was the case of the Wilson family, which was referred to in a recent story in the Sunday Times, who were in despair when a school language unit was closed, but who fortunately were able to secure the support of VOCAL, the voluntary organisation to which I have already referred, and the unit was reopened. Incidentally, VOCAL has a great deal of information available about unfulfilled need, based on the material that it has collected.

I therefore appeal for this important but undervalued profession to be given the necessary support and for the Government to ensure that badly needed services are extended and made available to the large numbers—young and old—who need them. On behalf of these kindly, gentle women, who are most unmilitant, I appeal for support.

8.41 p.m.

Earl Attlee

My Lords, when I was a child I could have done with the services of a speech therapist. This morning I could have done with the services of a computer therapist. I wrote the speech on my computer and I crossed the "t"s and dotted the "i"s. Then, after polishing the priceless prose, I pressed the wrong button and lost the lot. I had to start again from scratch.

I should like to begin by congratulating the noble Baroness, Lady Turner of Camden, on putting down this Question, which is, I think, very important. I am only sorry that there are not more noble Lords present on both sides of the House.

I speak with a personal interest. In my maiden speech in your Lordships' House, I mentioned the fact that one afternoon I was talking to a very pleasant lady in the London Press Club. After some time she asked me whether I stammered as a child. I admitted that I had. That was over 50 years ago. I was rather puzzled as to how she knew this. She explained to me that she was a speech therapist. I wondered whether she knew I stammered because there was a certain hesitation in my voice and because there were certain words that I consciously avoided. To be honest, one of those words is "therapist." One cannot very well speak on this subject without using that word. I wondered also whether it was because I speak slowly. This lady had more than just a keen ear. She had spent four years training to become a speech therapist.

The noble Baroness has mentioned some of the attributes that are required. I must admit that some I did not know until the noble Baroness mentioned them. Four years' training is a long time. When you have your degree and are a qualified speech therapist, what have you got? You have a job that pays less money than if you had spent three months or possibly six months learning to be a shorthand typist. That is disgraceful.

Therefore, is it any wonder that we have a shortage of speech therapists today? Who do they treat? Obviously, they treat the old. The noble Baroness mentioned those who have had a stroke and who have to be taught to speak again. Speech therapists also teach the young. I should like to give one small illustration. In my new family there is a young son. Let us call him Sid, because that seems to be quite a popular name these days. At the age of nine, Sid had a lisp and, being concerned, his mother went to his school and was told "What do you want? Expert advice? You want a speech therapist? No, you will give the boy a complex". How could the boy have a complex when he knew he lisped. However, the school said "No". By the time the boy was 13 years old his lisp was well developed and he went to another school. Little boys being what little boys are, they teased him. His mother told the school that she was worried about Sid and his lisp. The school said, "We quite agree. What Sid needs is to see a speech therapist." And he did. At the end of the period of speech therapy, his mother was told, "What a pity we did not have him at the age of nine because we could have cured his lisp in six weeks rather than the six months that it took". One cannot really blame the first school. How many of your Lordships know about the training of speech therapists, what they can do and what they do? If we do not know and if the general public do not know, then, sure as hell, local authorities do not know. That is a great shame.

In the broad spectrum of these medical matters—noble Lords can hear how technical I am getting—everyone knows what physiotherapists do. If you have aches or pains or something wrong with your neck, they do the right thing and you are cured. However, with a speech disorder—a great many people have a speech disorder—if you are lucky and you are caught young enough, you will go to a speech therapist, and the disorder will be put right.

As a young lad, I stammered because I was left-handed. There were attempts to make me write with my right hand. But there was no way that I could do so. Left-handed people always notice other people who are left-handed. The noble Baroness the Minister is left-handed and the Government Whip who was sitting in the Chamber a few minutes ago is also left-handed. Unlike me, I do not think that the noble Baroness the Minister has a stammer. Possibly, unlike me, she is also not dyslexic. Whenever I can I mention the fact that I am dyslexic, because it helps those who are dyslexic to know that just because they are dyslexic does not mean that they cannot stand up and speak in public.

The noble Baroness, Lady Turner of Camden, kindly sent me a leaflet produced by the ASTMS, the union to which the speech therapists belong. It contains a foreword by Clive Jenkins, the general secretary and, as she was then, Muriel Turner, the assistant general secretary. It is a short leaflet. It is a good one. I would recommend it to your Lordships. I would recommend it to local authorities, and I would recommend it to those members of the DHSS who have responsibility for the payment of salaries and for the numbers of qualified speech therapists who are employed. If your Lordships, myself and everyone else knew more about what speech therapists do, perhaps we should start to get somewhere in respect of having sufficient numbers and paying them the money to which they are entitled.

8.51 p.m.

The Earl of Halsbury

My Lords, before addressing your Lordships this evening, I have an interest to declare. I am in mid-term of my second term of office as the elected president of the College of Speech Therapists. I am therefore deeply grateful to the noble Baroness, Lady Turner of Camden, for having raised this subject at all in your Lordships' House this evening, and equally grateful for the extremely distinguished presentation that she has made of her subject. It really renders it quite unnecessary for me to say any more about speech therapy than she already has. Instead, I am going to draw on my own experience to advise your Lordships about where the difficulties lie.

Some 16 years ago the total mess in which successive governments had landed the salary structure of the National Health Service was deposited in my lap by the Prime Minister and the Secretary of State of the day, and I was asked to make of it what I could, starting as chairman of the review body for doctors' and dentists' salaries. To that was added a few years later a departmental committee of inquiry—with a different committee of which I was chairman so that I was the common factor to both—for the salary structure of nurses and midwives in the National Health Service.

Then a third branch fell into rebellion and I was landed with another departmental committee of inquiry into the salary structure of what were sometimes called the paramedicals and sometimes called the PSMs—an acronym which stands for "professions supplementary to medicine"—together with the speech therapists, who were not at that time classified as paramedicals or PSMs. After five years of struggle, I brought a rational scheme of salary differentials into the National Health Service which was accepted by the government of the day, but the great problem, having got this scheme of differentials, was where to level peg the centre of gravity of this system with the centre of gravity of other professions.

After a lot of discussion with my colleagues—and if I sometimes speak in the first person singular I hope you will understand that this is not out of any egotism on my part; it is just a habit of speech—I and my colleagues finally agreed to level peg the ward sister in a hospital with the police sergeant in the police force at the station level. That is the station sergeant in the police force. That was, I think, really the least sexist piece of level pegging there ever was. It gave universal satisfaction. No one in the police force complained that the nurses, midwives and paramedicals were paid too much, and no one in their professions complained that they were paid too little.

As a result of this exercise I came to the conclusion that the mess from which I had rescued the system would recur within a decade unless the Secretary of State accepted my private recommendation—this was not a public recommendation—to render my function permanent by having a review body for these other bodies. This was because my analysis led me to the conclusion that the Whitley Council procedure was invalid outside the Civil Service.

It is extremely important to realise that in the Civil Service the Treasury is the employer, and in the Whitley Councils the employees, or their representatives, can meet the employer in a bargaining match. But the moment you try to apply that to the National Health Service you find that the National Health Service is in fact a man of straw. It has no money of its own other than the money that the Treasury give it. The Treasury is ever willing to play hide and seek, and to put a third party between it and whoever seeks to get money out of it who will say impassively and with great regret, "Unfortunately, the Treasury won't agree to it'.

I do not want to say anything ungallant about the Treasury. I have always maintained that probably they are the most brilliant collection of double firsts dedicated to the national interest that you could find if you searched the world for them. I think that that is unarguable. Whether in some contexts they possess an ounce of common sense between the lot of them is arguable, but I shall not argue it this evening because in other contexts they undoubtedly work on a basis of common sense.

They are dedicated to the proposition that Her Majesty's Government should spend less. They are the only body of people in the country dedicated to this proposition. Everybody else wants Her Majesty's Government to spend more, provided they spend it on somebody's pet thing. The Treasury do not care what you do not spend money on, as long as you do not spend it, and that is their maxim. Quite frankly, without them we should all be bankrupt.

The speech therapists are now excluded from the review body system, which, eight years after I had brought order out of chaos, collapsed into chaos again, and the Secretary of State of that day then had to institute the type of review body for nurses, midwives, paramedicals and so on that I had recommended earlier. That has now been going for a few years. All they ever ask for is, "Back to the Halsbury scale" so I did them well in the past, and that is probably why the Treasury thought that I was too expensive, and they would not accept my recommendation that I be made a permanency of some kind or other.

The speech therapists stood ouside this arrangement. Why? It would be easy for the noble Baroness to say, "Well, they are the victims of their own decision. The reason they don't get properly paid is that they are looked after by Whitley Councils and not by review bodies". But, my Lords, self exclusion from the review bodies that exist is deliberate because they feel themselves to have more in common with other bodies such as medical psychologists than they have with physiotherapists or radiotherapists, who work under supervision from doctors. Speech therapists are not the subject of reference from doctors. They practise on their own. They are their own kind of profession and they want their own kind of review body.

Twelve years ago I liberated them from two situations, both of which were intolerable and one of which has been referred to by the noble Baroness, Lady Turner of Camden. The first was that pay scales were linked to the number of subordinates controlled. Speech therapists do not control large numbers of subordinates. They are much more like counsel learned in the law who practise on their own at the Bar and whose remuneration depends upon their reputation and their skill. At most they may have a junior; and a speech therapist may have at most an assistant. From that prison I liberated them by saying, "There is no connection, or there should be no connection, in some professions between your salary and the number of people you control, where those professions do not control large numbers of people".

The second situation from which I liberated them was that they were imprisoned in far too low a salary structure because of it. It seems to me the ultimate in reductio ad absurdum that a person should be paid less in the profession for which he or she has been trained than he can earn in some semi-skilled profession outside it. That is absolute nonsense from beginning to end. This was the point made by the noble Baroness and to which I believe your Lordships will agree.

The essence of false economy is to spend good money on training experienced people and then have half of them desert the profession for which they have been trained because they are being underpaid. It is a totally false economy. You end by training twice the number of people that you need in order to have perhaps not quite the number of people that you want.

That will conclude what I want to say to your Lordships this evening, because I have tried to place before you what amounted to five years of my life dedicated as a voluntary public service to this subject to enable your Lordships to understand exactly why this situation has recurred and will recur until a proper review body is appointed for the speech therapists equally with the medical psychologists and with one or two other professions in a similar group who do not work under medical supervision, who do their own diagnostics and have their own means of therapy.

I must tell your Lordships that it is a wonderful experience to sit at the side of a speech therapist watching her taking down in international phonetic shorthand the utterances of somebody who, from a speech point of view, is handicapped and then turning back her notes of last week to compare the performance of last week with their performance of this week in order to evaluate the progress that is being made. When you actually do this and talk to them, you will realise what very highly skilled, dedicated people they are. It was always my friendship with them and my insistence on taking the most general, rather than the narrowest, view of the profession that persuaded the speech therapists to extend their interests a little wider than they were originally—from such subjects as stammering and so on, or recovery from strokes, into such associated subjects as dyslexia, which they now take under their wing to a very large extent, which are so important in the educational field.

The speech therapists and the medical psychologists are a different kind of person altogether from the physiotherapists and the radiotherapists; they are a different kind of person from the doctors and the surgeons; they are imprisoned in the Whitley Council system (as they ought not to be) and they badly need a review body to look after them. Although, as the noble Baroness has said in introducing this subject, it is quite right that this is not the forum in which to discuss finance, pay, individual salaries and that sort of thing, it is a very right and proper forum to discuss the structure whereby these matters are evaluated and settled. On that note, I think I may conclude what I have to say.

9.4 p.m.

Lord Lovell-Davis

My Lords, the subject of this debate, framed as a deceptively simple-sounding Question to the Government, is not only important of itself—to speech therapists, those who have embarked with some understandable trepidation on the qualifying course and to many thousands of our population who will desperately need speech therapy to live or to regain a full life—it is also important in that it raises the question of the support or lack of support the Government give to services, other than crisis-intervention services, which a constantly reorganised and increasingly restricted National Health Service is attempting to provide.

A very wide audience outside your Lordships' House will appreciate the initiative taken by my noble friend Lady Turner in asking the Government to state their position on a distressing, not to say dangerous, anomaly which affects the quality of so many lives.

I hope that what the Minister says in her response to this Question will at least give us some cause for hope—if only that the Government are aware of the seriousness of the problem, of the strength of the "equal value" claim and the need to remedy the present situation.

My Lords, it is desperately serious. In the limited community of your Lordships' House, in the 12 years I have been here, we have witnessed many sad instances of lively and articulate colleagues suddenly and tragically transformed by the effects of cerebral haemorrhage or stroke. Many of us have personal acquaintance of people, even young or in early middle-age, whose whole happiness and ability to function in society has depended upon their being able to regain their speech following a stroke. As has been said, the need for speech therapy goes far beyond the victims of stroke. Thousands of children are born with, for one reason or another, speech defects which, unless remedied, will effectively wreck their lives, causing misery and the frustration of any hope of their leading a full and useful life.

It is quite astonishing to me, as it is to the noble Earl, Lord Attlee, that we have come to the position in which it would be hard to find a recently-qualified typist for the £5,000 or £6,000 a year which is all a graduate speech therapist, after several years of intensive study and practical work—an essential part of the training process—can expect to earn on present scales of pay. Is it any wonder that many give up the struggle, either during training or even having qualified, when the reward for so much work and dedication, often having to pinch and scrape to survive as a student, is an income on which one can barely live? Where is the incentive to train for or stay in the profession, vitally necessary though it be, when all that is likely to happen at the end of the day is that your interest and dedication will be exploited and you will be grossly underpaid? As a one-time member of a district health authority, a trustee of a hospital's academic centre and someone still deeply involved in the health service and community care, I know of potential recipients of that derisory £6,000 a year who, in the process of achieving their aim of becoming speech therapists, have acquired academic qualifications up to an MA degree before earning their qualification as a speech therapist—because speech therapy is, of course, a graduate entry profession.

As result of all that effort, and provided you can keep body and soul together in the process, what can you look forward to as the financial crown of your career? It is from £10,556 to £13,770 as a district speech therapist, as against the comparable professional qualification of top grade clinical psychologists of from £18,000 to £24,000. That is a difference at the top grades of £10,000 a year.

Obviously, if the Government set up and maintain such ludicrously inappropriate pay scales and disregard any reasonable claim for improvement, they will get what they deserve, or at least they will get what the country neither needs nor deserves—that is, qualified people dropping out of the profession altogether, or going into the private sector where they can devote their talents to curing lisps rather than post-stroke defect, or they will go abroad and take one of the posts regularly advertised in publications in this country, at starting salaries in excess of the equivalent of £25,000 a year. It is a rotten choice to be confronted with when, as a qualified speech therapist, you recognise only too well that the real and desperate need for your skills lies within the National Health Service.

There is of course an aspect of this problem which does not help towards its solution. It is pretty clear to anyone who looks at the situation carefully that we are into the old "equal pay" bind. Most speech therapists, as my noble friend Lady Turner has pointed out, are women. Therefore any authority seeking an escape route from facing social need, because it costs money, can dismiss speech therapy as a second income profession. This is the argument, which I rather hoped was by now wholly discredited, which says that women get married and have children and their husbands can support them; and so we can deal with the problem on a second income basis. My Lords, what outrageous nonsense, 10 years after the Sex Discrimination Act became law!

It seems to me that the case is so clearly made that I need not go over it in great detail. The answer is obvious, and I believe it has been clearly made by the Association of Scientific, Technical and Managerial Staffs who, although they were not responsible for prompting me to intervene in this debate, have done much to draw attention to the plight of speech therapists. The union is to be applauded for so forcefully taking up the case of this small but socially very important sector of its overall membership.

At the risk of offending the susceptibilities of those whose interest I am trying to promote, I have to say that in contrast to the Association of Scientific, Technical and Managerial Staffs, the professional body, the College of Speech Therapists, seemed to me—until tonight at least—to have chosen to maintain a discreet silence on the subject of pay. I hope the college are not deliberately adopting a low profile—and the contribution made by the noble Earl, Lord Halsbury, encourages me to believe they are not—for it is disappointing when one comes across a professional body which distances itself from problems such as this because of a misguided fear of political involvement, as though to say anything in the political arena is implicitly to make a commitment to one party or another, which of course is not the case.

I hope—though I have to admit without great expectations—that in replying to the Question raised by my noble friend, the Government, through the Minister and her officials, will not simply resort to bombarding us with statistics. In recent years we have had a surfeit of bland and often misleadng figures to divert attention from what everyone really acknowledges to be problems fundamental to our society. I should like to think, in the interests of a vitally important profession and of those who now need, and in the future will probably increasingly need, its expert help, that this debate will draw from the Government a real expression of concern and commitment—and, what is more important, some practical demonstration of sincerity. The profession has more than a legitimate claim: it has an irrefutable case. It is within the Government's power to concede this claim. They should do so.

9.13 p.m.

Lord Hooson

My Lords, I have an interest to declare in that my elder daughter is a speech therapist of five years' standing and she certainly would not have forgiven her father if he had not taken part in this debate. But I am also very happy to do so because, over the years when she was an undergraduate and since, I have had occasion to meet speech therapists and students of speech therapy at different stages of their development—and not only from this country but from other countries—who have stayed with us.

I must say that I have always been tremendously impressed by them as a body, by how gentle they are, by the great sense of social devotion that they have. They are a body of people in a small, relatively new profession and they need a great deal of help. I should have thought they were the last people on this earth who were likely to prove a militant body, and they are among those who render dedicated service to the community.

The noble Lord, Lord Lovell-Davis, at the outset of his speech expressed the belief that a large number of people outside this House would be grateful to the noble Baroness, Lady Turner of Camden, for raising this debate. I wish I could share that belief. I think the noble Baroness is to be greatly congratulated on raising this debate and on the way in which she has framed her Question. But I think one of the problems of the speech therapist is that so few people in this country appreciate what speech therapy is about. There is a great deal of ignorance about it.

The noble Lord was correct in saying that people who have experience of speech therapists—those who have a relative who has had a stroke, those who have had handicapped children, those who have had any kind of contact with children with speech defects and have seen the speech therapist at work—will have very great appreciation of their work. On the other hand, the vast majority of people in this country have not had need of the service of a speech therapist. Unlike a doctor or a nurse, the vast majority of people in this country do not know what speech therapy is about. They are unaware of what speech therapists do, of their substantial skills, of their expertise and of the great range of their responsibilities.

Already reference has been made to the fact that the speech therapist, by the nature of her profession—and, after all, we are talking of a profession with 98 per cent. female members—has to work on her own. From the moment that speech therapists qualify, they are on their own, without direct day-to-day supervision, and they bear a very heavy responsibility. They have to diagnose, to counsel and to treat all kinds of conditions. The range of their patients is great, from the child who the parents learn is having difficulty in expressing himself or herself in communication, to the man or woman who has been highly articulate but suddenly has a stroke; the range of responsibilities is very great.

Then there is the width of their duties, the articulation problems which affect a number of people in their intelligibility and effectiveness of speech. There are the language disorders which affect the use and understanding not only of the spoken word but these days of the written word as well. There are voice disorders which affect audibility and the effectiveness of communication. There are all the problems that are involved with people who have had operations on their throat, the larynx and so on, who must have restored to them the means of communication. There are the fluency disorders such as stammering when the continuity of speech is interrupted. Every aspect of these very wide problems has to be assessed, evaluated and treated by the speech therapists. Therefore, with the greatest respect, I do not think that the average citizen has any idea of the breadth of the duties of speech therapists.

I remember that when my daughter was studying speech therapy a cousin of my wife, who is a distinguished orthopaedic consultant surgeon, was staying with us. She happened to look at my daughter's books on the medical aspects of the throat and so on that speech therapists were learning, and her view was that they studied them in far more detail than any GP would need to do in order to qualify. It is a more limited sphere that speech therapists have to study, but that surgeon's view was that she would not like to have to do it, and she had no idea until she saw the books and the notes that speech therapists had to study these matters in such depth.

Today we have the ludicrous position that fully qualified speech therapists, who have entered a university course which is very trying and difficult because they need high academic qualifications, who have to work on their own when they are qualified and who have very heavy responsibilities, are paid less than somebody else who has completed a three-month secretarial typing course. It is a national disgrace and we are taking advantage of them. Everyone knows that that is true.

I not only congratulate the noble Baroness on bringing this matter before the House, but I also congratulate her on the way she has framed her question. As the noble Earl, Lord Halsbury, rightly pointed out, we are an unsuitable body as such to go into the details of precisely what relative pay should be. What we need and press for is an adequate review body. The beauty of the way in which the noble Baroness has framed her question is that it invites the Government, in the form this evening of the noble Baroness, Lady Trumpington, to comment on the difference in pay between speech therapists in the National Health Service and that of other graduate professions. We therefore look to the Government, who surely have a responsibility towards this group of dedicated graduates, to express their view on the matters which have been drawn to their attention this evening.

9.22 p.m.

Lord Rochester

My Lords, like other noble Lords who have spoken in this short debate, I am most grateful to the noble Baroness, Lady Turner of Camden, for having asked this Question and for the way in which she has done so. Our discussion seems clearly to have demonstrated that the National Health Service is facing a serious and growing shortage of speech therapists. Perhaps your Lordships will allow me to take this opportunity to say how, in terms of overall pay policy, the situation might perhaps be improved.

I join with my noble friend Lord Hooson and also with the noble Earl, Lord Halsbury, in saying that in the short term the best way forward may be to arrange for speech therapists to be included, along with doctors, nurses and dentists, among those whose pay and conditions are determined by review bodies set up for that purpose. I also join them in expressing the hope that the noble Baroness, Lady Trumpington, when she comes to reply, will have something constructive to say to us on that point.

There is a further basic problem from which I think we cannot escape; namely, that the Government at present have no pay policy other than exhortation for the private sector and arbitrarily set cash limits for the public sector. All past experience shows that one great difficulty in the public services is that when matters relating to the pay and conditions of a particular group—such as teachers—are examined in isolation, attention is concentrated on the problem from the viewpoint of the group concerned rather than from that of others affected by it. That, surely, leads to the conclusion that there is a need to establish procedures for pay determination which in the longer term might apply to the public services generally.

As I understand it, there are within these services at least five major groupings: the health service, the Civil Service, education, the police and the armed forces. Similarly, there are at least three different kinds of employer: central government, local authorities and what might be called "quangos". Provisions for pay determination therefore need to be sufficiently flexible to take account of the different circumstances affecting each of these groups.

I do not for a moment underestimate the difficulties of working out practicable procedures along these lines. But that is no reason for inaction. In my view, arrangements should be such as to ensure that the relevant trade unions continue to play a part in pay negotiations. The application of the raw principle of market forces is surely not enough. We cannot merely seek to recruit and retain a sufficient number of staff for a particular public service at a given point in time. Many people in the National Health Service—speech therapists are a good example—need training, experience and expertise that can be acquired only over a period of years. That necessitates provision for career development and for a progressive salary structure.

It is surely inefficient and contrary to the public interest that such people should move in and out of the health service in accordance with fluctuations in their pay and conditions relative, it may be, to those in the private sector. There is also a need for staff—even such dedicated staff as speech therapists—to be thoroughly well motivated. That means that they need to feel that they are being dealt with fairly. Under these conditions there is surely no escape from ensuring that, in the public services, pay is broadly comparable with that available for similar work in the private sector.

A number of consequential requirements arise, none of which can be satisfied easily. This is not the occasion, I realise, to do more than merely mention some of them. I refer to the need for a generally acceptable means of collecting and assessing relevant data; the need to take account of factors such as fringe benefits, pension arrangements and security of employment; and the need to ensure that comparability is applied within a particular pay structure in a way which makes internal sense in the public service concerned. In return, society, which has to foot the bill, is entitled to receive a service comparable with that available in the private sector.

This might perhaps be achieved through some kind of efficiency audit on which, again, it is not possible to elaborate now. But in all this, the essential point is that it is surely unreasonable for the Government to argue that the taxpayer can afford only a certain level of pay increase in the public services unless they are prepared to introduce a pay policy that is applicable to public and private sectors alike.

Finally, I suggest, not for the first time, that provision needs to be made for the settlement of disputes by a third party in the event of negotiations resulting in a failure to agree. At this late hour I shall not weary your Lordships by rehearsing once more the precise form that such an arbitrating body might take, nor the procedure under which its findings could be overturned only by parliamentary resolution. But it is only if treatment of the kind that I have sought to advocate is accorded to those employed in the public services that they will feel they are being rewarded fairly.

I recognise that, at first sight, all this may seem a little remote from the specific plight of speech therapists. But, in my view, their situation cannot be divorced from the larger question of overall pay policy and structure. It is when that question is resolved that the pay of speech therapists will fall into place.

9.30 p.m.

Lord Ennals

My Lords, as others have done, I want first to thank most sincerely my noble friend Lady Turner of Camden for raising this very important issue and for the admirable and clear way in which she has done so. She has attracted a significant number of your Lordships to the debate who have in one way or another a great deal of experience on this subject. I am thinking of the noble Earl, Lord Attlee, who, clearly from his lucidity and the way in which he always speaks, has benefited from the skills of the speech therapists.

I think of the noble Earl, Lord Halsbury, as the great liberator. There are many people in the health service who look back with gratitude to the work he did over the years to which he made reference. The speech therapists are very fortunate to have him as their president.

I want to move on to pay tribute to the speech therapists themselves. As with almost every profession, theirs is a changing one. I must add that I am not uninfluenced by the fact that two of my close relatives are also practising speech therapists. They are very proud of it and I am proud of them. Moreover, I shall not conceal the fact that my membership of ASTMS, which represents most of their interests, prejudices me in their favour.

The importance of their work is increasingly recognised by the public and by the professions, not only because it has become an all-graduate profession—important though that is—but on account of the very wide range of skills and experience required. As the noble Earl, Lord Halsbury, said, they are not like professions—he said "supplementary" but I prefer "complementary"—to medicine. They are not working under medical instruction. They are highly skilled, and highly trained.

A speech therapist is responsible for the acceptance of cases and for the planning and determination of treatment, having regard to inter-disciplinary consultation and co-operation. This places a high level of responsibility on a speech therapist, particularly on the newly qualified therapist who is in the main working alone, without direct day-to-day supervision. As the noble Earl said, it is quite different from the newly qualified physiotherapist who will probably be working in a large hospital department where patients may be allocated on a daily basis and where he or she is constantly under supervision and able to take advice.

My noble friend Lady Turner and the noble Lord, Lord Hooson, went through some of the speech therapists' major responsibilities, and I do not need to do so. Every aspect of the problems with which they are faced must be assessed and evaluated. That involves the use of test procedures which the speech therapist is trained to administer. Careful and detailed assessment is needed before an appropriate treatment can be planned and carried out.

Thus the speech therapist is completely autonomous in the clinical sense. This accountability is not unlike the level of responsibility borne by members of the medical profession. The speech therapist alone has the expertise to assess, diagnose and treat disorders of communication in children and in adults—sometimes the very elderly and the very young, and sometimes the disabled. Speech therapists are specialists and consultants in the field. As such they do not receive direction or guidance from other professional associates. Of course where the speech therapists suspect that other disorders may be present they will freely consult other professional colleagues.

From the start the speech therapists go alone into schools, day centres, adult training centres and homes. They tackle consultants, give talks and demonstrations, including career guidance talks. They give lectures to doctors, nurses, medical students, physiotherapists, teachers, and so on. Each one is an expert in his or her own field and should be seen as such. With that pattern, which is clear to all of us, one has to ask why speech therapists are so badly paid. It is not as if it has always been so—which was a point made by the noble Earl, Lord Halsbury—and it went on after the noble Earl ceased to have those responsibilities.

If we look at the year 1979, in which I have a particular interest, in some instances the salary of speech therapists was similar and in some instances better than people in a range of other comparable professions in the National Health Service; yet by 1986 speech therapists have become by far the least well paid, in spite of the fact that during the same period the level of qualification—and I think the level of performance—improved enormously. We now recognise entry to the profession as being through a three or four year degree course. Many therapists have gained further qualifications including an MSc or a PhD. They are highly qualified people. One asks how it happens that they are so badly paid.

The noble Baroness, Lady Turner, gave some figures which were very alarming indeed. It is ludicrous that these people at the end of a four-year course will receive not much more than £6,000 a year, and one wonders how the profession is able to attract people. It can only be by deep commitment, and I say to the Minister that the National Health Service can no longer rely upon deep commitment. People need to be paid for the job and if the best people are to come into vital professions such as this we have to pay them what they deserve.

Let us look at the teachers, who after industrial action achieved an increase of 16 per cent., and compare them with the speech therapists who would never withdraw their labour from their patients but who have had to accept a 6 per cent. increase. In fact, over 20 per cent. will be necessary to retain the pay status that speech therapists enjoyed in 1979. One asks what action the Government will take. What effect do the Government think that these appalling conditions of pay will have on recruitment? One has to recognise that the demand for speech therapists is increasing greatly and there is a shortage in this profession.

The speech therapist's caseload would be daunting enough if she had only patients with stroke and head injuries to treat. Conservative estimates give a combined figure of between 20,000 to 25,000 new cases per annum in Britain requiring speech therapy following strokes and head injuries. Yet this small, predominantly female profession also treats communication disorders arising from cancers of the head and neck, brain tumours, Parkinson's disease, multiple sclerosis, motor neurone disease, cerebral palsy, cleft palate, hearing loss, etc. The list is a very long one. The Government will have to face up to this problem.

Perhaps I may raise just one final issue, which was touched on by the noble Baroness, Lady Turner. A few days ago in the courts the parents of a nine year-old boy who had profound speech difficulties failed in the High Court to oblige a local education authority to pay for the speech therapy that he needed. First, I do not understand how this could be so. Lord Justice May, sitting with Mr. Justice McCowan, said that he had the "greatest sympathy" for the family but local education authorities were not responsible for providing such therapy. That seems to me to be quite wrong. After all, children with other disabilities are taught by the education authority.

The judge went on to say: Its provision should be a matter for the district health authority through the National Health Service". Of course the decision had been awaited with great anxiety by parents all over the country who have children in need of speech therapy. It was clear that when they went to the National Health Service it could only offer a very much smaller service than was known to be needed by the child. The area health authority had agreed to provide three daily sessions but it said that lack of funds prevented it from providing more.

I do not understand why speech therapy is not an educational responsibility for a child of school age in the same way that it is a health responsibility for children and adults of a greater age. If this is so, why is there a lack of funds to prevent the child having the necessary therapy?

The debate is about pay. It is in the interests of all speech therapists that we are speaking today, not just the present speech therapists but the speech therapists who will be coming into a noble and skilled profession—or not coming into a noble and skilled profession, because I say to the Minister that unless the situation is improved and improved quickly, in a few years' time we shall find the same shortage of speech therapists (I speak as president of the College of Occupational Therapy) as we are now finding of occupational therapists. We shall find that skilled people will simply not perform this essential role in the National Health Service unless the Government are prepared to find the funds to make the situation compatible with that of other professions to which they may well be attracted.

9.41 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Baroness Trumpington)

My Lords, I am grateful to the noble Baroness, Lady Turner of Camden, for so elegantly and eloquently raising this important matter. I should like first to say to the noble Lord, Lord Lovell-Davis, that I am seldom bland and, I hope, never misleading.

My noble friend Lord Campbell of Croy led a debate on this subject, to which my noble friend Lord Caithness replied, in May last year. The noble Earl, Lord Attlee, paid his tribute to speech therapists. I am glad to be associated with a fellow south paw.

Today's debate gives me the opportunity to say publicly how much we appreciate the value of the work of speech therapists. Many thousands of people throughout the country are forever in debt to them for their expert and painstaking work, and of course I see much of the wonderful work that they do when I am working with disabled war pensioners.

In times past there was limited understanding of the extreme feelings of frustration and isolation experienced by those who were speech impaired and the distress suffered by their families. The noble Lord, Lord Hooson, was quite right to draw attention to that fact. Happily today ignorance is giving way to a greater knowledge both of the cause and effects of this form of handicap and how it may be overcome with the help of speech therapy. Health authorities have recognised this and have expanded their speech therapy services at a greater average rate than the general rate of increase in NHS expenditure as a whole.

The noble Baroness, Lady Turner, mentioned the extremely valuable work done by VOCAL. I am sure that she will be interested to learn that my Department made VOCAL a three-year grant of £20,000 a year to enable it to establish a permanent base.

I should like to reply to another point raised by the noble Baroness concerning the Enderby Philipp Report, which states that the size of the speech and language handicapped population is not known. It goes on to quote the estimates that the noble Baroness mentioned and to which the noble Lord, Lord Ennals, in turn referred. These estimates were gathered from various texts used in speech therapy departments of colleges in the United Kingdom and in the United States. The department has no other figures on the instance and prevalence of speech impairment in the population.

The noble Baroness, Lady Turner, in the course of her excellent speech, raised particularly the question of the pay of speech therapists and the difference between their pay and that of other graduate professions. That indeed was the theme taken up by many other noble Lords.

I should say at the outset that the pay of NHS staff who are not either general managers or covered by pay review bodies is a matter for negotiation within Whitley Councils. Representatives of speech therapists negotiate with the management side of the Scientific and Professional Staffs Council. The management side members are appointed by the Secretaries of State to represent the management interests of the whole NHS in reaching decisions on the sums available to the management side and have regard to the overall needs of the service and the total sums available for pay, prices and service developments. Agreements are made by both sides.

Historically, speech therapists, as the noble Baroness, Lady Turner, acknowledged have hovered between education and health. The Quirk Committee in 1972 described them as preferring: To remain in the perhaps slightly precarious position of a small autonomous profession, between education and medicine, claiming affinity with both, defending their independence against both and enjoying the patronage of neither. I return to a point made by the noble Lord, Lord Lovell-Davis, apart from those speech therapists employed by voluntary bodies such as the Spastics Society, few speech therapists choose to enter private practice.

The noble Baroness, Lady Turner, mentioned the case of Gregory Wallace. I watched that case with interest, and noted that the judgment concluded that the provision of speech therapy was a non-educational provision and was a matter for the health authority. The Government accept that.

I return to the noble Earl, Lord Halsbury. Although it is true, as he said, that speech therapists do not depend upon medical referrals, nevertheless, in normal circumstances referrals are made by doctors and when they are from non-medical sources a relevant medical opinion is sought as soon as practicable.

Despite the fact that speech therapists feared for their independence and status by being associated with the other professions supplementary to medicine, until 1982 they were included with them in the Professional and Technical "A" Whitley Council for pay purposes. One of the recommendations of the committee of inquiry chaired by the noble Earl, Lord Halsbury, in 1974 was that the pay of speech therapists should be formally linked to those professions, and that recommendation, as he well knows, was implemented.

In 1983, the pay review body for nursing staff, midwives, health visitors and professions allied to medicine was set up and speech therapists were invited to take part but refused to do so. While most speech therapists said that they were not opposed to the principle of a review body, they did not wish to be linked with other professional groups with whom they believed they had little in common. The noble Earl, Lord Halsbury, said that speech therapists need a special pay review body, but the present body represents a variety of different professions. It could well have dealt with their special needs but they refused to join, as was their right. Their decision was crucial and one which some speech therapists now regret.

Because the setting up of the pay review body excluded a number of staff groups from the existing negotiating machinery, the system of Whitley Councils had to be rearranged. The present position is, as I mentioned earlier, that representatives of speech therapists negotiate with the management side of the Scientific and Professional Staffs Council. That is an ad hoc arrangement until the trade union side can agree on the formation of a new council.

I understand that in 1985 speech therapists made a formal claim for pay parity with other graduate professions. They eventually received the same percentage increase as other staff groups, but the management side agreed to examine jointly with the staff side the arguments which bore on that aspect of their claim. That examination was to be completed in time for the next 1986 pay round.

Soon after giving that undertaking, the management side became aware that three speech therapists, with the backing of their union, had made claims to industrial tribunals for equal pay for work of equal value with named psychologists and/or pharmacists under the Equal Pay Act 1970, as amended. When the management and staff sides met again earlier this year, the management withdrew its offer of joint examination of the pay parity claim on the grounds that it might prejudice any defence that health authorities might want to make against the industrial tribunal claims. The industrial tribunal has recently found in favour of the health authorities concerned, but I understand that an appeal to the Employment Appeals Tribunal is likely to be made. I am sure that in these circumstances your Lordships would not expect me to comment.

I am informed that the management side conducted its own review of the speech therapists' claims and consulted NHS management. The speech therapists' 1986 pay claim again included a claim for pay parity with other professions. In the light of its consultations the management side told the staff side that it did not believe that the pay of speech therapists should be linked with that of any other profession either within or outside the NHS. Eventually, the speech therapists agreed to accept the management side's final offer of 6 per cent. on the pay bill. I remind the noble Lord, Lord Ennals, that this is the same as that for most other Whitley staff groups and is twice the current rate of inflation. I emphasise that there was no sex discrimination in this award.

I must try to clarify the position with regard to a subject mentioned by the noble Earl, Lord Halsbury. I understand that the management side of the Whitley Council wrote to the staff side over two years ago agreeing to discuss the grading structure and asking for ideas. No reply has been received, and the staff side has not raised the matter again. If the staff side were to put forward proposals even at this late stage, I am sure that the management side would be happy to discuss them without commitment on either side.

Comparisons on pay are difficult. We can argue all night whether profession A should get more than profession B. But the fact is as the noble Baroness, Lady Turner, agrees, that statistics show that there is no shortage of speech therapists against authorised posts. Neither are we aware that there is any lack of applicants for training. Indeed such evidence as we have suggests that the opposite is the case.

The noble Lord, Lord Rochester, stated that there is a growing shortage of speech therapists. However, the number has increased by about 9 per cent. over the year to September 1985 and the number of speech therapists in post has almost doubled since 1974. Pay therefore does not appear to have had any impact on recruitment. The fact that speech therapy is now an all-graduate entry profession does not automatically qualify them for increases in pay. Many practising speech therapists do not have degrees under the old entry rules. Pay ought to be related to service and not qualifications. Other factors such as conditioned hours have also to be taken into account.

We have had an interesting and informative debate. The noble Earl, Lord Attlee, mentioned an ASTMS leaflet. I have seen this leaflet. However, the NHS has many demands on its services; pay is by far the largest. The merits of each demand have to be looked at in the light of overall priorities and available resources. Pay levels must reflect various factors, including recruitment and retention of NHS staff. As the noble Baroness, Lady Turner, said, this House is not the proper place in which to conduct pay negotiations on behalf of any staff group. However, I hope your Lordships will agree that we have certainly reviewed the position this evening.

House adjourned at four minutes before ten o'clock.