HL Deb 14 July 1988 vol 499 cc993-1010

House again in Committee on Clause 7.

Lord Skelmersdale moved Amendment No. 20: Page 6, line 45, leave out ("as private patients") and insert ("under this section").

On Question, amendment agreed to.

Lord Skelmersdale moved Amendment No. 21: Page 6, line 45, at end insert— ("(1A) The Secretary of State may allow accommodation and services to which an authorisation under subsection (I) above relates to he made available in connection with treatment, in pursuance of arrangements made by a medical practitioner or dental practitioner serving (whether in an honorary or paid capacity) on the staff of a health service hospital for the treatment of private patients of that practitioner.").

On Question, amendment agreed to.

[Amendment No. 22 not moved.]

Lord Skelmersdale moved Amendments Nos. 23 to 25: Page 7, line 10, leave out ("for private patients to such extent as he may determine") and insert (", to such extent as he may determine, for patients who give undertakings (or for whom undertakings are given) to pay, in respect of the accommodation and services made available, such charges as the Secretary of State may determine"). Page 7, line 26, leave out ("as private patients") and insert ("under this section"). Page 7, line 26, at end insert— ("(1A) The Secretary of State may allow accommodation and services to which an authorisation under subsection (I) above relates to be made available in connection with treatment, in pursuance of arrangements made by a medical practitioner or dental practitioner serving (whether in an honorary or paid capacity) on the staff of a health service hospital for the treatment of private patients of that practitioner.").

The noble Lord said: I beg to move Amendments Nos. 23, 24 and 25 en bloc. I spoke to them with Amendment No, 15.

On Question, amendments agreed to.

[Amendment No. 26 not moved.]

Lord Wallace of Coslany moved Amendment No. 27: Page 7, line 47, at end insert— ("( ) In all that is involved in the forgoing due regard shall he paid to the existing work of Voluntary Societies in the National Health Service.").

The noble Lord said: I beg to move the amendment standing in my name. This amendment is quite important. The noble Lord wrote to me in his letter dated 9th June: We do not believe that primary legislation is the right place to draw attention to the contribution which voluntary bodies make". If noble Lords read my amendment they will see that it does not involve paying tribute to the contribution of voluntary societies but refers to the part that they play in the National Health Service. That part does not apply in the private sector because there is no voluntary service in the private sector. The amendment is necessary because of the possible conflict of interests between hospital management and the voluntary services such as the friends of the hospitals. At the moment the friends run shops and many other services in the various departments of the hospitals. There is no doubt that their work is appreciated.

I admit that managers have already had a reminder from the new management board and that further guidance will be given when the Bill is passed. The Minister, the noble Lord, Lord Skelmersdale, referred to the work of the friends, which I have already mentioned. The right place to draw attention to this is in the legislation. It is all very well for managers, the management board, to send out the preliminary letter of which I already have a copy and then later on when this Bill is passed to send out further details on the legislation. However, trouble is already occurring and I have personal experience of it.

I do not wish to get involved, because the chairman of the health authority does not quite agree with my point of view. The point concerns car parking where there is a problem with nursing staff and volunteers. I believe this is being ironed out in one hospital but there are problems with others. Many other difficulties arise from time to time and I have found that the best way to solve them is to set up a joint consultative body of management and the voluntary societies concerned in each hospital to try to iron out the difficulties. However, they will continue to occur.

There is an instance of a flower shop proposed in my local hospital. We, the friends, have had to insist that the shop shall not sell anything other than flowers and congratulatory cards. Whether that will be the case I do not know, but in any case the friends already sell some flowers themselves. These problems go on and on.

I feel quite strongly that there is no harm in the words which I have suggested in the amendment before the Committee appearing in the Bill. It is essential in my view that the voluntary organisations should have some part in this legislation which will enforce the co-operation which is desirable. Not all hospital managers are willing to co-operate; it has to be said that some can be quite difficult.

I have great faith in the voluntary spirit which exists within the National Health Service but I am very much afraid that difficulties may arise, which is why I have put down this amendment. It is purely a personal matter, not a party political matter by any means. It is something which I believe in very sincerely. I hope that the Government will see their way clear to inserting these words at the end of Clause 7. That is all I ask. There are parts of Clause 7 with which I agree, but this is essential. I beg to move.

Lord Ennals

In supporting this amendment from my noble friend Lord Wallace. I wish first to pay a tribute to him. He has been involved in voluntary organisational support for the National Health Service for between 20 and 30 years. For most of that period I have known and respected the work he has done through the hospital friends, and the work he did in his own constituency when he was Member of Parliament for Norwich, North. Throughout his period in public life he has been a tremendous champion of the work of voluntary organisations. He has done great work himself and I think he has given a lead to others. It would be very sad, as he himself said, if in putting this Bill through the interests of the voluntary organisations were somehow not fully recognised. This is the right place to do that because, after all, in order to do their work the voluntary organisations have to raise money. I am thinking particularly of the leagues of hospital friends and those who raise money for reseach in hospitals or for scanners or whatever it is to help hospitals in their work.

There is no doubt that in Clause 7 and the provisions for income generation there will be resources which the public will contribute either through sales or gifts or what-have-you which will make it that much more difficult for leagues of hospital friends and others to raise the necessary funds.

It is not only necessary to consult with them—as I am sure should be done so that they are brought in, and I think I deal with this in a later amendment—about what is done in terms of income generation, particularly on the premises of National Health Service hospitals, but it is essential that their interests should be recognised in the Bill. It should be a statutory requirement that action is not taken which damages the interests of the voluntary organisations. Not only personally but for the reasons that my noble friend gave. I warmly support his amendment.

Lord Winstanley

On behalf of my noble friends on these Benches—or those noble friends who will he on these Benches if required—I should like to join with the noble Lord, Lord Ennals, in supporting the noble Lord. Lord Wallace of Coslany, on this amendment. I have always been an enthusiastic supporter of the National Health Service. Indeed I have always been an enthusiastic supporter of what was once known as the welfare state. I would merely say that whoever is the government of the particular day—whether it is the government of the noble Lord, Lord Ennals, or anybody else—whatever is done by the state there will always be gaps. It is my experience of medical life that some of those gaps can only be filled by voluntary organisations.

I have seen at first hand not once but over and over again the way in which voluntary bodies in various parts of the country. and in different functions within the National Health Service, have filled gaps which were inevitably left, and will always he left, whatever the flavour of the government of the day. Therefore it is important that proper regard should be paid to the work of these voluntary bodies.

The noble Lord, Lord Ennuis, was right to pay a tribute to his noble friend Lord Wallace of Coslany for his long service in the voluntary field. I think it is right to say that when your Lordships' House is full, the Benches in all parts of your Lordships' House are festooned with Peers who have worked indefatigably for voluntary bodies. They include the noble Baroness, Lady Macleod of Borve, the noble Baroness, Lady Elliot of Harwood, and many others in all parties. I mention that merely to say that it is not only on this side of the House but in all parts of the House that noble Lords have worked for these voluntary bodies. It is right that proper regard should be paid to them in this Bill, and I am glad that the noble Lord, Lord Wallace, has raised the matter.

Lord Trafford

From this side of the Committee it is a pleasure for once to he able to agree entirely with what the noble Lord, Lord Winstanley, said about voluntary bodies. I was rather surprised to hear that there were any problems arising, because I should have thought that it was very bad management that did not take note of what voluntary organisations wanted to contribute and did not consult them in the manner of their contribution. I can truthfully say that at least half of the high-tech equipment in my department is provided by charity. It is not provided by the National Health Service as such. Without such enormous contributions it would be somewhat difficult to carry on at a level of service that one always hopes can be achieved.

As regards the spirit of what the noble Lord, Lord Wallace, and other noble Lords have said, I fully support the activities of voluntary agencies, particularly in connection with the collection of money, which is invaluable, and for providing all those, if you like to call them, extras that otherwise one would have at least to wait a long time for. They play an enormous and significant part.

Lord Prys-Davies

I apologise to my noble friend Lord Wallace that I was not in my place when he moved this amendment. I want to echo the words of appreciation expressed by my noble friend Lord Ennals of the contribution of my noble friend Lord Wallace. My noble friend Lord Wallace is right to draw attention to the role of the voluntary organisations and the charitable societies in the NHS since 1948. Every hospital up and down the country has been the recipient of voluntary help and financial aid since it was built. Prior to 1948 all our hospitals were voluntary hospitals.

In this Bill the Secretary of State is concerned with cost benefit and the price of everything, but he must not overlook the role of the hundreds of voluntary bodies and charitable organisations and the forgotten army of volunteers who have been in support of groups of patients or of individual hospitals. Today their role, although it may be junior, is nowhere mentioned in this Bill. I think that that is the point made by my noble friend. I am not certain that the wording is perfect and I am not certain that it is in the right clause, but I am sure that the underlying message of the amendment should be acceptable to the Government and incorporated somewhere in the Bill.

8.15 p.m.

Lord Skelmersdale

Yes, the underlying message is certainly acceptable to the Government. I have more difficulty with whether it should be incorporated in the Bill, and I shall explain why to the Committee. The noble Lord, Lord Wallace of Coslany, was alone among those who spoke at Second Reading in confining his remarks to Clause 7. I note that he feels so deeply about this subject that this is the first time he has uttered today.

In bringing forward Amendment No. 27, which seeks to ensure that the existing work of voluntary societies in the National Health Service is not forgotten when new "income generation- schemes are considered, he recognises. as I do, that the income generation activities of voluntary bodies of various sorts in the health service are virtually the only ones which are currently allowed by law. Therefore, of course, it would be a very foolish manager indeed who would interfere with, for example, the leagues of friends or the WRVS. That is why we very much welcome, and agree with, the intention behind the noble Lord's amendment.

It goes without saying—at least, I hope that it does—that the Government greatly admire the selfless work carried out by the various voluntary societies. At the risk of offending those I do not mention, I can cite the leagues of friends and the WRVS as two organisations whose activities are particularly well known to the public. The work done by such bodies is quite invaluable, whether by way of voluntary work to provide services such as snack bars and hospital shops which otherwise would not have been provided, or by fund-raising activities to provide additional items of equipment, and so on, as my noble friend Lord Trafford mentioned.

The noble Lord, Lord Wallace, has expressed concern that the practical effect of the provisions of Clause 7 might be that the work carried out by voluntary societies would be in some way devalued or rendered unnecessary or unwelcome. On an earlier occasion he has himself quoted from the National Health Service Management Board's letter to hospital managers dated 5th April this year that: Authorities will [also] need to take account of any existing activities by voluntary organisations and discuss any changes fully with them with a view to ensuring that their services are channelled into those areas where they can he of most benefit. In short, we expect health authorities to act sensitively over the way in which they undertake or introduce commercial activities". This letter is an example of the correct way to put across such messages.

I hope that the noble Lord will agree that we share his aims. But, as I said earlier, I am less sure that primary legislation is the best way of getting this message across. It needs to be brought directly to the attention of hospital managers. If' the noble Lord, Lord Wallace, or indeed any other Member of the Committee knows of anybody in a hospital who has actually read any of the National Health Service Acts I should be extremely surprised.

Having said that, of course there may be instances where local management may wish to introduce new arrangements for, say, a snack bar or cafeteria where such services are currently being provided by a voluntary society. This is, however, not necessarily wrong. Provided that there is full consultation throughout, and provided that it is clearly the best solution for the hospital, it would not seem to me to be wrong that the society concerned be invited to consider alternative ways of helping. After all the aims of such societies are generally to provide help for the hospital where it is most needed.

To sum up, I repeat the Government's admiration oldie welcome efforts of the voluntary societies in the National Health Service. We hope that they will continue the good work. Let us also look to the positive benefits to be gained from the clause. I shall certainly look at ways beyond the Bill to direct and encourage hospital managers to take into account the wishes and needs of the leagues of friends and other voluntary bodies, but I doubt whether it would be proper to enact such exhortive legislation. Perhaps the noble Lord would like to consider what I have said and come back to it at a later stage.

Lord Ennals

I have no doubt that the noble Lord. Lord Wallace of Coslany, will speak for himself. I wish to speak for myself.

I do not think this is good enough. I do not think that the only job of Ministers is to defend the text of a Bill in every respect. When there is a clear feeling in the Chamber that something should he done, it is surely the job of a Minister to try to respond to it, whether in this place or somewhere else. I know that the Minister said he would try to see whether some non-statutory way could he found in terms of circulars—that of course, is good—but in Clause 7 of the Bill a clear initiative is being taken; namely, Additional powers for financing Health Service". Given the many different ways of producing, manufacturing and supplying goods and selling this and that and so on, I am aware that we are taking action that will affect the ability of the voluntary sector to raise money. I too think of the WRVS, and so on; and particularly of hospital friends, who raise money to a great extent on hospital territory and not just in the city.

I do not accept the argument that this is just an exhortation. It is not. If it is written in the Bill that anyone planning anything set out in the clause should consider the effect upon voluntary organisations, it is a requirement. I know that this is not one of the most fundamental issues in the Bill, but I plead with the Minister to consider whether a place could be found in the Bill for this thought to be incorporated rather than just saying, "Not in the Bill, we'll do it some other way".

Lord Winstanley

I share the point of the view of the noble Lord, Lord Ennals. I welcome what the Minister has said, and agree with much of it. However, he seemed to find a difficulty in every solution.

It is acknowledged that the NHS, since its inception on 5th July 1948, has been heavily dependent on a large number of voluntary bodies. Mention has been made of two, the leagues of hospital friends and the WRVS. However, the Minister knows that there are many more. There is an increasing tendency for voluntary bodies associated with particular conditions to combine to raise money for a specific purpose—research, the provision of technological equipment, to which the noble Lord, Lord Trafford, referred, and many other causes.

Whether or not members of health authorities read the Bill very carefully—the Minister appeared to suggest that they would never look at it—their attention should be drawn to it. It would be regrettable if the Bill was allowed to continue its passage to the statute book without a single mention of the voluntary bodies, bearing in mind that the NHS always has been and always will be very dependent on them. I hope that the Minister, with the assistance of his departmental advisers, may be able to devise some means of giving these essential bodies a mention in the Bill.

Lord Wallace of Coslany

I thank the noble Lords who spoke from the Liberal and Labour Front Benches for what they have said.

I have with me the letter of the management board, which runs to pages. On the penultimate page, a few words appear in a general paragraph referring to the voluntary bodies, and this is an indication of what will go out on the next occasion. I see no objection whatever to mention of the work of the voluntary societies being enshrined in the legislation in the simple way that I have suggested. This will reinforce the fact that there exists a valuable and vital voluntary sector.

The wording may not be acceptable. I do not pretend to be perfect in putting forward amendments to Bills. I appeal to the Minister to consider the matter so that on Report a small item can be included at the end of Clause 7. That would do a tremendous amount of good and go a long way to keep the voluntary spirit alive and well. The voluntary sector is doing sterling work, which is not even appreciated by some people. My own local body raises over £32,000 a year, and indeed much more besides. We are not the only ones involved.

If the Minister will think seriously between now and Report, I am prepared to withdraw the amendment. However, at present I am not prepared to do so.

Lord Skelmersdale

The noble Lord has given me the opportunity to speak again.

I am replying to a particular amendment put down at a particular time. I can imagine what would be said by the noble Lord, Lord Winstanley, for one, and probably the noble Lord, Lord Ennals, for another, if they were arguing about the phrase:

"In all that is involved in the foregoing due regard shall be paid to the existing work of Voluntary Societies in the National Health Service." In my position they would say, "Oh, how super! We can have due regard to it and then totally ignore it". However, I am well aware that that is not the spirit in which the amendment was moved, and therefore I did not use that argument.

I cannot see that the suggested formulation is right. If another formulation can be found to cover the points that the Committee clearly would like to see included in the Bill, obviously I shall consider it. I confess that at present I can see no particularly good prognosis on that score; but I shall do my best to see what can be done.

Lord Wallace of Coslany

I much appreciate what the Minister has said, as, indeed, I appreciated the correspondence that he sent to me.

If the Minister will do that, I shall be satisfied for now and withdraw the amendment. If he does not come forward with a proposal on Report, I shall have to press the matter. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Ennals moved Amendment No. 28: Page 7, line 47, at end insert— ("(12) The Secretary of State shall appoint advisory councils at national and district level to set standards for commencing initiatives with respect to National Health properties. (13) Advisory councils appointed under subsection (12) above shall include representatives of National Health Service management, voluntary organisations (including Hospital Friends and Patients Associations), the Community Health Council and local trading associations.").

The noble Lord said: I hope that the Minister will not accept the wording of the amendment, which is rather clumsy. Something appears to have gone wrong in the printing of it. It says: The Secretary of State shall appoint advisory councils at national and district level to set standards for commencing initiatives".

There is some error in regard to "commencing initiatives". The intention is to set standards for the Secretary of State. Without putting too much stress on the confused wording, I should like to argue the case.

On Second Reading, I said that I should object also to the selling of tobacco products on hospital premises; and I raised one or two other problems about the standards set in income generation. I was thinking particularly of the kind of shops and kiosks that might he set up on NHS premises. I said that while I did not object to that. I wanted to see that it was done with decent standards. I said also that we did not want our hospitals and their entrance halls to look like a tourist attraction or a local bazaar, but that there must he standards, and I wanted to know how these would be maintained. The Minister did not say how they would he maintained. I therefore felt there was a duty upon me to suggest some way in which this should he done.

I suggest that advisory councils should be appointed at national and district level to include representatives of National Health Service management—which has a crucial role to play—voluntary organisations such as hospital friends and patients' associations, community health councils and local trading associations. Local trading associations are included because we are dealing with different aspects of trade, whether it he groceries, flowers, or whatever.

My fear is that unless we take the initiative and find a common approach to the matter, we may find that we have leisure centres containing one-armed bandits, betting shops, tobacco shops—heaven forbid! —or licensed premises. Those services would not be consistent with the standards of the health service and the message that it teaches in terms of health education. I do not know whether the proposed advisory councils should be at regional level as well as district and national levels. Perhaps the composition of the councils should be broader than I have suggested. However. I believe that the matter should not be left simply to management or to private enterprise bodies which may rent or purchase shop fronts in properties of the National Health Service. I want to see the establishment of premises in good taste, handled properly and efficiently. If my amendment is not acceptable, perhaps the Minister can tell me what he will do about the matter. I beg to move.

Lord Trafford

I object to the amendment on two grounds. The first is that it sets up yet more councils and committees. We are inundated with councils, committees, sub-committees, sub-councils, special committees, ad hoc committees, multi-disciplinary teams and all the other apparatus of NHS rule. I feel that if we can avoid committees, councils or advisory bodies, that will be a good thing. That does not mean that I am against the setting of standards. I am not and I do not believe that any reasonable Members of the Committee will be against setting standards. It would not he appropriate to have a roulette table with free drinks set up in the entrance hall of a hospital to attract customers.

On the other hand, I believe that this matter could he left to local management. Let us assume that local management makes a mistake and does something which shows a severe lack of taste. Inevitably, that will be drawn to its attention not only by the community health council and by protests in the local press but also by a local Member of Parliament and—dare I suggest it? —perhaps a resident Peer who lives nearby. We should not go overboard in dealing with this matter.

If we set up national and regional councils, they will not apply the standards to the circumstances of a particular hospital or district. The noble Lord, Lord Ennals, mentioned alcohol and tobacco. It would he totally inappropriate to have any agencies selling those products outside any hospital which deals with children, young persons, adults or even middle-aged people. However, if we consider geriatric units, I am not so sure. I believe that it would be going over the top to suggest that, at the very end of one's life, at age 70 or 80, it is improper for one to be able to get a packet of cigarettes. I do not think that such a provision would be contrary to standards. However, if such sales were encouraged in an ordinary hospital, and particularly in units dealing with children and young persons, it would be quite outrageous.

We must look for a local balance in the matter. I fail to see why local authorities and management should not be able to deal with the problem, controlled, as they always are, by local public opinion. The idea of creating yet more committees and councils, even if it is only a matter of creating one, is abhorrent to anyone who has watched the bureaucratic strangulation of the health service which has taken place over the last 20 years and which is one of its least endearing features. I hope that the noble Lord will not press his amendment too far. I believe that the matters about which he is concerned will he taken care of under the existing system and that the amendment is not necessary.

Lord Winstanley

I am not seeking any opportunity to differ with the noble Lord, Lord Ennals, simply to demonstrate that I sit in a different part of the Chamber. However, I have some differences with him as regards the amendment. I shall comment on the points raised by the noble Lord, Lord Trafford, in a moment.

The noble Lord, Lord Ennals, has already referred to the drafting of his amendment and to the fact that there are certain typographical errors and that parts of the amendment are tautological and otiose. I accept that. I note also that the amendment refers to community health councils. It is not my business, in the absence of certain of my noble friends, to speak for Scotland. However, I assume that the omission of local health councils, which are the Scottish equivalent of community health councils, is an error and that the noble Lord would like to include those councils.

Lord Ennals


Lord Winstanley

Jolly good. I am glad to hear that. The noble Lord, Lord Trafford, is right in saying that we have too many committees. However, he said that the matter should be left to local management. We need consistency in our standards nationally. We shall not achieve that through the agency of' local management. Someone must look at the matter nationally and decide whether what is being done nationally is appropriate. I suggest that your Lordships' House might look at those matters, consider them, and comment when we believe that the wrong things are being done. Some mechanism must be found so that general guidance as to standards can be given.

I shall not enter into the argument about tobacco or alcohol. As a general practitioner, to any of my elderly patients who were teetotallers I said, "On no account have any alcohol". If I knew that my patient liked a drop of drink, I used to say, "I think that a brandy and perhaps a Guinness at night would be very good for you". I was extremely popular with those patients. However, I shall not enter into the argument, save to say that I believe that guidance at a national level would be helpful. We do not want to see totally differing standards in what is provided in various regions. I shall listen to what the Minister has to say about how we shall achieve that laudable aim.

Lord Skelmersdale

It goes without saying that we need standards. I rather doubt that we need another statutory committee. I welcome the opportunity to repeat assurances given in another place that there are adequate safeguards contained in Clause 7 to ensure that nothing may be done which affects adversely the duties of the Secretary of State under the 1977 Act. As I explained earlier this afternoon, that has absolutely nothing to do with either local or community health councils. Therefore, the noble Lord, Lord Winstanley, may strike that matter from his memory. That is to be found in Clause 7(4) and under the new Section 65, which, for Scotland, is Section 57.

I cannot see the need to establish the sort of advisory council network which is envisaged in the amendment. Nonetheless, we need standards. My right honourable friend the Secretary of State has a unit within the Department of Health and Social Security to maintain standards so far as income generation is concerned, to issue advice, to issue statuory guidelines if necessary and to inspect hospitals that go in for income generation. Lest it he thought that that is just another minor unit, let me assure the Committee that the unit is headed by the ex-District General Manager of the North Hertfordshire District Health Authority, Mr. Ron Kerr, who knows from experience what is necessary for the management of hospitals and, perhaps even more importantly, what can interefere with the management of hospitals. One does not want income generation to be so burdensome on management time that proper management of the hospital goes by default.

Further, we already also consult widely on major issues such as the authorisation of pay beds where the views of the community health council are taken along with those of private sector health care providers and National Health Service staff. In the case of relatively minor income generation activities, such as the letting of accommodation to, say, a florist or a newsagent, it would seem to be overkill to require by law that the health authority consult an advisory body. Nonetheless, it is possible to maintain standards and I hope that I have convinced the noble Lord that that is so.

Lord Ennals

When one gets no support from anyone for a proposal it always seems that the best course is to drop it. If I am prepared to do so, I hope that if there are occasions later in the Bill when the Minister finds, as on Second Reading, that he has no support at all for some proposals in the Bill which are condemned all round, he may be prepared to do the same.

Given the Minister's assurances that standards will be maintained I am certainly not prepared to press an amendment that clearly has only one supporter. I would need a Teller. so it might not have a vote at all. I beg leave to withdraw the amendment.

Amendment. by leave, withdrawn.

Clause 7, as amended, agreed to.

Clauses 8 and 9 agreed to.

Clause 10 [Dental services]:

Lord Colwyn moved Amendment No. 29: Page 9, line 8, leave out paragraph (b) and insert— ("(b) the following paragraph shall be added after paragraph (a) of subsection (1) — (aa) to arrange, to such an extent as he considers necessary to meet all reasonable requirements in England and wales, for the following dental services—

  1. (i) for the dental inspection of pupils in attendance at schools maintained by local education authorities and for their dental treatment and for their education in dental health (and the additional provisions as set out in Schedule 1 to this Act have effect in relation to this paragraph);
  2. (ii) for the provision of facilities for the inspection and treatment of such other groups as he considers to be in need of special care, and for their education in dental health where appropriate.".").

The noble Lord said: My purpose in moving the amendment is to improve the Bill in a way which I hope will find favour in what is left of all sides of the Committee. As it stands. Clause 10 seeks to amend the National Health Service Act 1977 to remove the present statutory duty on the Secretary of State to provide dental inspection and subsequent treatment in schools and to replace that duty by an enabling power to provide such services. My amendment would also amend the 1977 Act but would retain the duty on the Secretary of State, albeit in a modified form.

The provision of those services is carried out by the community dental service. I believe there is general agreement in the Committee that the 1977 Act is in need of amendment in order to provide better targeting of the CDS. That Act imposes a duty which extends to provision for all school children, including some who are already covered by the general dental service. That leads to a duplication of effort and a waste of resources. An example of that is the fact that my two young children were recently checked by the CDS at their school despite the fact that I had checked them myself some three or four weeks earlier.

The amendment would permit the targeting of services to where they are most needed. It would do so in a form which retains the statutory duty. It is necessary to retain the statutory body to prevent health authorities making inappropriate economies in their CDS for the sake of short-term financial expediency.

The CDS does important work but it is not a glamorous part of the National Health Service. Moreover, a service which there is a duty to provide seems somehow more important than one for which there is only a discretionary power. By amending the 1977 Act in the manner now contained in Clause 10, I fear that we would he sending a signal to health authorities that the CDS is less important than it was previously. I do not believe that that is the intention of my noble friend the Minister. I am sure he is aware that in the past two years over 14 health authorities have sought to cut back or close their CDS but have been inhibited by the existence of the statutory duty.

I should say a few words about subparagaph (ii) of my amendment. My purpose here is to extend the coverage of the statutory duty to cover groups for which the general dental services cannot provide. Those include expectant and nursing mothers, the elderly, the mentally or physically handicapped and others who are housebound. Such people find it difficult or impossible to visit a dentist's surgery; nor is the average dental practitioner equipped to seek them out. Thus the CDS provides dental inspection and treatment for patients who would not otherwise receive it. I must stress that that service is already provided in practice by the CDS. The amendment would merely extend the duty to provide it by amending the 1977 Act. It would not impose any extra burden on the National Health Service.

At Second Reading my noble friend the Minister more than hinted that he would be willing to compromise on this point. He said: I am prepared to look at another formulation to see whether it is possible to avoid wasteful duplication in another way if such a proposal is presented to me at a later stage of the Bill".— [Official Report. 26/5/88; col. 1088.] I know that many dentists shared my gratitude for that encouraging statement. I suggest to my noble friend that this amendment is such a proposal and I hope that he will give further favourable response. I commend it to the Committee. I beg to move.

8.45 p.m.

Lord Ennals

I should like to give my total support to the noble Lord, Lord Colwyn, and the amendment he has proposed. The Committee will recall that at Second Reading I strongly criticised the Government for their move to abolish the statutory role of the CDS. I tabled my own proposal to remedy that mischief. I then saw, on the same day, the amendment tabled by the noble Lord, Lord Colwyn, I recognised that it was more comprehensive and more suitable, that it took in groups such as pregnant and nursing mothers. the elderly and the handicapped. Therefore. I decided that I would withdraw my amendment and give my support to his.

I totally agree that there needs to be a statutory duty. I do not think that it is enough simply to leave it to discretion. I was glad that the noble Lord quoted the fact that there are so many health authorities which, because there is at present a statutory duty, have decided that they could not drop the service, which they would otherwise have done. I think that that is a very important argument. I think that we would find the service collapsing, particularly in some parts of the country where we really cannot afford to have that happen.

I know that there is an awareness in the Committee and the Minister may very well say that there has been a great improvement in dental health. The condition of teeth and gums of children in this country has improved dramatically. I think that we would all welcome that fact and congratulate those who have had any part in it. But there is still very much to he done and we cannot be complacent. We have to acknowledge the important work of the community dental service and we must also look to the future to see how we can meet the targets which we have set ourselves.

The World Health Organisation's goal is that, by the year 2000, 67 per cent. of children should be without caries. In Wales only 33 per cent. —that is only half—of' the children are caries free at five years old. The World Health Organisation's goal for the year 2000 is 50 per cent. at that age. In Scotland the position is even worse: only 25 per cent. of Scottish children are caries free despite the 50 per cent. target. In Northern Ireland the situation is worse still, with only 22 per cent. of children of the age of five being caries free. Therefore I think it must he seen that there is an enormous amount still to be done.

All the evidence is that the service is very cost-effective. Since 1974 the community dental service has been an integrated part of the National Health Service, now run by district health authorities. Health authorities have funds to spend according to their own assessment of need, so the role and pattern of the service tends to vary from area to area. It is perfectly reasonable that it should be so. In areas that are well supplied with general practitioners the emphasis of the community service has been to move away from the routine treatment of children toward priority groups among pre-school children, nursing mothers, handicapped children, the housebound and institutionalised elderly. In rural areas of course, there is greater use of mobile clinics.

There is much more that one could say but I want to emphasise that the proposals that are contained in this amendment are generally welcomed and supported by the British Dental Association, which the Government, until recently, felt was the only association that needed to be consulted on these issues.

There is an amendment to be discussed later that will be moved by the noble Baroness, Lady Gardner of Parkes, who is herself a dentist. In this Chamber we have the privilege of hearing people whose whole life may have been devoted to the welfare of children and the health of their teeth, and it is bounden upon us to take their views very seriously. When the noble Lord, Lord Colwyn, speaks from his own experience, I do not believe that we, as laymen, can say, "Silly Colwyn, you don't know what you are talking about; there is no need for a statutory obligation". One of our great advantages is that this Chamber is composed of people who have wide yet deep experience and whose lives have been dedicated to the subjects on which we legislate. We must take them seriously.

When we know that an amendment tabled by the noble Lord, Lord Colwyn, which I am honoured to support, has the total support of the profession, it should be taken very seriously. One is not asking that the Government should start spending new sums of money. As the noble Lord, Lord Colwyn, said, that is not the case. However, we do not want to see the statutory obligation disappear because we think that if it goes we shall see a deterioration in the health of some people in some parts of the country where the battle has yet to he won. I hope that the Minister will take seriously the plea made by his noble friend Lord Colwyn.

Lord Winstanley

On behalf of my noble friends on these Benches—and I am sure that noble Lords will have noticed that the number has now doubled—I should like to add support to the amendment moved by the noble Lord, Lord Colwyn. The amendment will go some way to repairing some of the damage which may be done by this Bill to the dental health of our nation in other ways—some way but not necessarily all the way. However, it is a very important way, particularly in so far as it affects our children.

In my experience the work of the community dental service has not been sufficiently recognised. It has not been so recognised because in some areas of the country it barely exists. We need not merely the maintenance of the community dental service but an expansion of it, in particular in many areas where it is understaffed and the work which it does is minimal in relation to the extent of the need.

The dental health of children is crucial. I shall not repeat the type of arguments used by the noble Lord, Lord Ennals, but we all remember the deplorable state of the dental health of the nation before the National Health Service started in 1948. In Europe, Britain ranked very low in the league of dental health. It took only a very short time for our position to change and that was largely owing to the splendid work of the dentists in those days. I do not say this critically, but fellow students of mine who practised dentistry rather than medicine used to be paid on a piecework basis and they made a great deal of money. They made hay while the sun shone in those very early days of the National Health Service because an enormous amount of work needed to be done to repair the ravages of many years of serious neglect. As a result, in Britain the state of the nation's dental health changed dramatically, as I am absolutely sure the noble Lord, Lord Colwyn, would confirm.

I think that it would he lamentable if Britain were allowed to slip back into the low place that we occupied before the National Health Service began. I am sure that the work of the community dental service could go a very long way towards protecting us from that possibility. I honestly believe that there is not sufficient recognition of the importance of that service. In some areas it is not recognised simply because it does not exist to a sufficiently substantial extent. I hope that when he comes to reply the Minister will have some favourable comments to make about this amendment.

Lord Skelmersdale

Since this matter was first raised with me by the noble Lord, Lord Prys-Davies, before Second Reading a good deal of unanimity seems to have broken out around this clause. Noble Lords may be relieved to hear that, although I do not believe that it is yet complete, we are certainly getting there. I believe that we are unanimous in welcoming the dramatic improvements in the dental health of the country, particularly among children. I have disgraceful teeth myself, with a large number of fillings which were needed when I was at a much younger age than are my two children now, and I am well aware of the enormous improvement achieved in the dental health of children by dentists under the National Health Service, which the noble Lord, Lord Winstanley, has pointed out.

I hope that the noble Lord did not think me discourteous, but while he was speaking I was trying to whistle through the speech made by my noble friend Lady Gardner of Parkes during the Second Reading debate, in which, although at this moment I confess that I cannot find the exact words, she said something to the effect that dentists were working themselves out of a job. I would not be quite as bullish as was my noble friend on that occasion. Nevertheless, the dental health of the people of this country certainly in part has been improving in leaps and bounds.

The noble Lord, Lord Ennals, pointed to the fact that there are parts of the country which have still a long way to go in dental services. I certainly agree with him but, as I said on Second Reading, I do not think that that is any good reason for legislating for overkill; in other words, why there should be a duty placed on the Secretary of State in every area of the country for every category of person in the country where that service is being provided perfectly well by the ordinary dental service.

I believe that there is pretty well unanimous recognition that the dramatic improvement in children's teeth, together with the increase in the numbers and effectiveness of the general dental service, mean that the time has come for a reexamination of the role of the Community Dental Service. I therefore welcome my noble friend's amendment. I welcome the spirit in which it was tabled and the fact that the noble Lord, Lord Ennals, felt that it had slightly more points in it than had his own amendment.

The amendment that we are discussing now seeks to replace the current absolute duty to provide for routine inspection and treatment of school children by a duty to provide those services in such a way as, "to meet all reasonable requirements". I welcome this approach, which seems to me to avoid the requirement for the Community Dental Service to duplicate the services provided by family dentists, while at the same time meeting the concerns of this Chamber and the profession that services might be reduced to an unreasonable level.

However, I am afraid that I cannot say quite the same for the second leg of the amendment, which goes on to adopt the same approach in relation to other groups of people with special needs. Although I very much welcome the intention behind it and I believe that it reflects our proposal that the Community Dental Service should put greater emphasis on prevention and treatment of those who otherwise might have difficulty in getting access to services, such as people with handicaps, I must say that I am less convinced that a change on the lines of the second part of the amendment is needed.

The first part is a specific duty whereas, as I am sure my noble friend will recognise, the second part is much more general. The Secretary of State is already under a general duty under the National Health Service Act to provide dental services: To such extent as he considers necessary to meet all reasonable requirements". The second part of this amendment would overlap with that provision and might even cast doubt on the generality of the duty.

While the words in the amendment may not be quite right, I very much welcome the approach that it adopts. If my noble friend is prepared to withdraw the amendment now, I undertake to come back with a government amendment at Report stage which will impose a duty to provide dental inspection, treatment and health education of school children to meet all reasonable requirements. We may then be able to reach total unanimity.

Lord Colwyn

I am most grateful for the support that I have received from the noble Lords, Lord Ennals and Lord Winstanley, and his supporter. The noble Lord, Lord Ennals, stressed the point I made about the need for a statutory duty, its cost effectiveness, and the need in different parts of the country. I am most grateful for his help. I am obviously delighted to hear the words of the Minister. I shall look forward to seeing the planned government amendment. I am very grateful for his help in the matter. I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

On Question, Whether Clause 10 shall stand part of the Bill?

Lord Ennals

In view of the concession from the Minister, which I warmly welcome, I do not wish to oppose this clause.

Clause 10 agreed to.

The Earl of Arran

I beg to move that the House do now resume.

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

House resumed.