§ 3.10 p.m.
§ Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)
I am sorry that we have not present here a representative of the Ministry of Health to deal with what is one of the most serious matters of administration which could have been raised on the Adjournment during the last few months. I have no doubt we shall find someone who cares to come in and listen to the debate on this matter, few Members as there may be in the House.
It is very unfortunate that we have to raise this question in so short a time, because this is a matter which affects every hospital in the country, and may have serious effects on the development of our Health Service. The fact that 10 minutes after the time we expected to open the debate we should not have a representative of the Ministry here, I think, is shocking, and the attention of the House and the country ought to be drawn to it.
I am glad that the Minister of Health has come into the Chamber. I am grateful to him for putting in an appearance at this time. I was hoping that his hon. Friend would stay to hear this short debate because, to some extent, he is implicated; but I understand that he has another important and pressing engagement and I willingly release him.
It is important, in my opinion, that we should have this short time to try to elicit some information about the new step the Ministry of Health has taken in issuing this circular, a copy of which I hold in my hand. It is a circular on economy in manpower which has gone out to regional hospital boards and the boards of governors of teaching hospitals, and which makes certain important and striking changes in the staffing position of those hospitals.
As the time is so short I cannot hope to do more than merely open the matter for the attention of the country, and to ask certain questions to which I hope we may have replies. It will, of course, be understood that we on this side of the House will certainly seek the earliest possible opportunity of raising this matter 1875 much more fully as soon as the House reassembles; and when, no doubt, there will be more evidence available about the effect of this circular upon the hospital.
This is a circular which certainly affects every hospital and will embitter the relationship between hospital management committees and regional hospital boards, a difficult problem at any time, but one which is made much more difficult by the task imposed upon regional hospital boards by this new circular. It certainly adds to the amount of centralisation, an odd result in view of the proud boast of right hon. and hon. Members opposite that one of the great features of their administration in the health field was the reduction of the amount of centralisation.
I have noted an extract in that rather extraordinary Conservative Party document just published called, "We shall win through," which says, so far as the hospital field is concerned:Arrangements governing hospital finance have been made less rigid and less centralised.I hope that in view of this circular, which everyone must agree makes the whole arrangement more centralised, that at least they will submit, for the general edification of the population, an erratum to this document.
There is no doubt that the proposals in this circular will affect most unfairly the position of one hospital as against another which is a matter to which I wish to refer later. There is no doubt, either, that in so far as services are maintained economies will not obtain, and in so far as the circular succeeds in achieving financial economies, to that extent services will be effected detrimentally.
What does this circular provide? First, that there should be a comprehensive review of hospital staff. We can have no objection to that. Indeed, that has been going on for some years, and a great deal of progress has been made by the various forms of investigation carried out both by the survey teams and in other ways, and by the actual staffs in the separate hospitals. No one would suggest that that is not a proper matter for full investigation and most careful control.
But, in addition, the circular provides that there has to be an immediate return of the existing staffs of all hospitals and what amounts to a freezing at that wholly 1876 arbitrary figure. It is a freezing with the proviso that, so far as staffs may be subject to appointment by management committees, increases can be achieved only by reference to the regional hospital boards, and, so far as appointments are made by regional hospital boards, they must be subject to approval by the Minister himself.
A further point in the circular is that there has to be an attempt to reach a target reduction of 5 per cent. in a miscellaneous category of staff which includes domestic and maintenance staff and certain professional groups in hospitals. Finally, there has to be a quarterly return submitted to the regional hospital boards and to the Ministry of the numbers of staff changes which have taken place and a report upon what the general policy of the management committee may be.
My first comment is that the hospital management committees are, by the operation of this circular, being stripped of some of the last vestiges of their authority. This cannot but have the effect of making many persons who have given most valuable voluntary service doubtful whether there is any further use to the country in the work they are doing. I should like to know whether this proposal means that the Ministry are in the process of disbanding the hospital management committees. It is important that we should know. It would appear from this decision that that is what they intend to do.
This means much more centralisation. It means that matters which were within the competence of the management committees will now be transferred to the regional hospital boards and that matters which were within the competence of the boards will now be referred for the decision of the Ministry itself. The Ministry is the last authority which should have the power of dealing with these detailed administrative matters which I always thought that the Minister himself was most anxious should be left to local determination.
I wish specifically to ask one important question. Why have the Ministry of Health changed their view on this matter? A short time ago the Select Committee on Estimates recommended that there should be a full review of staffing, a review which, by that time, had already started. 1877 The Committee also recommended that regional boards should have wider authority over management committee staffs. What did the Ministry say in reply to that recommendation? In the Third Report from the Select Committee on Estimates, they said:With regard to other types of hospital management committee staffs, it is an essential feature of the current review of establishments already mentioned that, when the proper establishments has been determined for a particular management committee, no increase shall be made in it without the prior authority of the regional board concerned.I have no objection to that. I do not object to the securing of an agreed establishment figure and then saying, "If you go beyond that, you must have authority."
That is another matter; but it is not proposed to do that. The Ministry are taking an arbitrary figure of the number of staff which may happen to be there at this moment, and saying, "You can redress inequalities between one hospital and another only by reference to the Ministry, in certain questions, and by reference to the regional hospital board in others."
The Report goes on to say:Accordingly, in the case of administrative and clerical staffs, where establishments have been determined after review, management committees are now required to seek the approval of the hoard before making additional appointments; and boards have also been empowered to control increases in the administrative and clerical establishments of other management committees over the levels existing in December, 1951. It is proposed as already indicated to empower boards to exercise a similar control in relation to other types of staff as and when establishments are determined on review.That is the crucial point. Why have the Ministry given up the view, which they took as recently as February this year, that proper establishments should be worked out and agreed upon, and that they should be made compulsory, if necessary, subject to review by higher authority? Why have they given that up and insisted, probably because of Treasury pressure or something of the sort, on having this day-to-day review of a whole host of individual cases, which will clearly block up the whole machinery?
It means, of course, and this is one of the anxieties which regional boards and management committees have expressed to us, more and more forms and people required to deal with them. As I suppose the right hon. Gentleman knows, 1878 those responsible in the regional boards are saying that they will need more staff in order to provide the extra information for which he is asking. I do not know how he is dealing with that. Perhaps the Prime Minister will review any increases of staff of that kind requiring to come before higher authority?
§ The Minister of Health (Mr. Iain Macleod)
Is the hon. Gentleman suggesting that official representations have been made to me by regional boards that they will need more staff to deal with this problem?
§ Mr. Blenkinsop
I am merely saying that the Minister will know the comment that is made in the country to that effect. I have no information.
§ Mr. Macleod
I am very sorry, but the hon. Gentleman is speaking in the House of Commons, and I asked him if he has any evidence for what he has just said. I now understand him to say that he has no information.
§ Mr. Blenkinsop
No, none at all. I only know that many of the members of regional boards and management committees have expressed these views, and I should be very surprised indeed if they had not expressed them also to the Minister. I hope he will take the view that there is something in this.
What is to be the provision, and what sort of criteria will the Minister use, in deciding whether additional staff are to be approved or not? If he has no criteria, how are the regional boards to carry out the task which he imposes upon them, and what sort of criteria are they to use, because they will be appointed to do the job, and the most odd cases are bound to arise?
There is bound to be delay, and, as is surely well-known, there is the possibility that, in making these appointments, suitable and desirable types of person may not present themselves at the right moment. The delay may very well mean that we will not be able to get the people best qualified for the job. There is, in fact, great concern throughout the hospital world, and I hope the Minister realises it, about the developments that are likely to ensue from these decisions.
I am sure that we on this side would not complain about any proper steps being taken to ensure full control of the 1879 staffs, while ensuring also that there is proper economy in the running of the hospitals. What is the reason for the general attitude taken up by the Ministry in reply to the recommendations of the Select Committee, which seem to be most sensible? The Minister has thrown over their proposals, and has drawn up this entirely new apparatus of running the hospitals, with a new form of centralisation which we understand the party opposite were most anxious should be removed.
I raise this matter as a mere preliminary to a debate which I hope we shall have in the House at the earliest possible moment, when the matter can be gone into much more thoroughly. I hope that the Parliamentary Secretary will be able to give replies to some of the immediate points which I have raised, and that the Department will maintain very careful control over the operation of this circular, in view of the serious effect it will have on hospital services throughout the country.
§ 3.25 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)
I agree with the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) to the extent that the matter he has raised is a very important one, and we welcome the opportunity of replying to some of the points he has made.
I wish to say, first, that the planned programme for dealing with the staffing of the hospital service under the National Health Service Act is not something new, or something that has just started, but has been going on for some time. In fact, the idea of reviewing and fixing the establishments was conceived by the right hon. Member for Ebbw Vale (Mr. Bevan) as far back as 1950 when he issued a circular in which he suggested that the review of the staff should be made. The circular concluded by saying:On receiving the Report, the Minister will consider the recommendations and inform the board or committee of what in his view is their proper establishment in the field under investigation. The boards and committees will then be required not to exceed that establishment in any grade without first obtaining his authority in the case of officers appointed by the board or, in the case of officers appointed by the management committees, the authority of the regional board.1880 So there is nothing new in the idea that the size of the staff of the hospital management committees must be decided by the regional hospital boards and the staff of the boards by the Minister. I think it a little hard that, having been, as it were, the political midwife to that child, the hon. Gentleman should now abandon it when it is two years old.
§ Mr. Blenkinsop
The hon. Lady is merely repeating what I said. I said that we entirely agree with that policy. All I want to know is why they are changing it.
§ Miss Hornsby-Smith
I will deal with that in a moment.
Four years have already passed, and it is essential that progress should be made in this matter, particularly in view of the fact that there is disparity—and in some cases wide disparity—between the staffing of hospitals and this will speed this up and help us to see where the gaps exist. Far from making the position worse, as the hon. Gentleman suggests, it will make it better because we shall get the staff where we most need it.
Finally, the circular of 1950, which, incidentally, went much further than the present instructions in the memorandum issued by my right hon. Friend specified the numbers in each grade. The present circular, now under review, merely specifies that there should be no overall increase in the establishments within a group. So it is possible, within a group, to iron out the places where there is a deficiency in one case and an excess in another.
§ Mr. W. R. Williams (Droylsden)
Is there an underlying assumption in what the hon. Lady says, that there are redundancies in some hospitals in the region and shortages in others?
§ Miss Hornsby-Smith
There are shortages in certain areas and there are other areas where there is ample evidence—obtained from the review conducted—that in some hospitals there has been over-staffing, and there have been reductions as a result.
In April, 1951, following the circular of 1950, the right hon. Member for Middlesbrough, East (Mr. Marquand) reaffirmed the policy outlined in the 1950 circular in his foreword to the 1950 Report of the Central Health Services 1881 Council. He again accepted the principle of control about which hon. Members opposite are complaining so bitterly. He said quite firmly:Once the establishment is fixed"—and this is merely another method of fixing the establishment—authority will be required before appointments in excess of it are made.It is, therefore, a very small point which the hon. Member opposite is challenging, because the whole principle of establishing the staffs and placing authority upon the regional board and the Minister for their increase is one which has been accepted throughout the hospital service since its institution. The difference is that the hon. Gentleman wants us to tack on another year, or however long it may take to do the remaining areas, whereas we are satisfied with the present arrangement. My right hon. Friend has made it quite plain that where there are shortages it is his intention that permission shall be given for those shortages to be made up.
§ Mr. Blenkinsop
But does the hon. Lady not realise that the difference is the difference between detailed control of individual appointments by the Ministry and the determination of an agreed establishment, which was agreed to all along?
§ Miss Hornsby-Smith
My right hon. Friend's instruction is not as firm and as rigid as was the intention of the right hon. Member for Ebbw Vale when he sent out the circular in August, 1950. I have merely quoted the actual words, and if the hon. Member was not aware of the circular which was then sent out I cannot do other than quote it exactly.
So far as reviews are concerned, 264 out of 435 regional hospital boards, boards of governors and hospital management committees have now been visited and in 180 cases establishments have been determined for administrative and clerical staff and in all these there has been no engagement of extra staff without prior consent. So, in that respect, there is no variation with regard to this circular.
Hon. Members opposite are ignoring the disparity of staffing. To take two examples, in one of the teaching hospitals there are 102 on the nursing and midwifery staff to every 100 staffed beds. 1882 In the average general hospital there are 53 nurses and midwives to every 100 staffed beds, and in the mental hospitals there are 15 on the nursing staff to every 100. If hon. Members opposite think that a vitally important matter like this should go on being delayed then I must say that my right hon. Friend does not agree.
Where reviews have been carried out, certainly in the case of one regional board area, very firm control has been taken over the appointment of staff. In the Croydon Group Area, where efforts were made to find whether there was redundant staff, there has been a reduction in 1952 of £21,000 a year without any detriment at all to the efficiency of the service.
§ Miss Hornsby-Smith
The £21,000 refers to the administration of the hospital.
The Select Committee on Estimates which, after all, is an all-party body, recommended in July that the whole question of the staffing of hospitals should be reviewed on a national basis by the Ministry of Health and, further, that the individual regional hospital board should be given more extensive powers of controlling the size of the staffs of hospital management committees than they possess at present. That was the opinion of the committee reporting on the Ministry of Health. It was a view which was accepted, and I believe it is a view which was confirmed by the Central Health Services Council itself.
The memorandum which my right hon. Friend issued recently was referred to the Committee of Regional Hospital Board Chairmen, who held a special meeting to discuss it and in the latter half of that meeting they had joint consultations with Ministry officials. They ironed out certain points of detail and agreed to operate the scheme, as one would expect from these very public-spirited men and women who give their services to the exacting task of chairing these vitally important regional hospital boards.
What the memorandum does is to require hospital boards and hospital management committees to obtain the prior consent of the next highest authority before they increase their staff. In many 1883 institutions that has been in operation for some time already. It asks the boards and the committees to carry out a detailed and far more rapid review than has been in process, to see what savings they can achieve by re-examination of duties. There have been some remarkable successes in the re-organisation of duties, in putting in new equipment and labour-saving devices and in the discontinuance of inessential work.
The regional hospital boards will participate in the reviews of the hospital management committees and my right hon. Friend has called special attention to the question of non-medical and non-nursing staff, in which they are asked to try to make a reduction by 5 per cent. before next October. But this is adjusted to the circumstances of the group. If it is found that there is undermanning a group may not make this 5 per cent. reduction, and others who may be found to be over-staffed may be called upon to make a reduction which is slightly above 5 per cent.
There is to be no blind or arbitrary cut of staff and my right hon. Friend has laid it down quite categorically that the essential services are not to be curtailed. So far as staffs themselves are concerned in any reductions, the normally established practice will be followed in that the longest possible notice will be given to anyone who may be redundant.
What the memorandum does not do, and what right hon. Gentlemen opposite still endeavour to claim that it does do, is to curtail essential services. It does not stop the continuity of recruitment of staff in undermanned institutions. Hon. Members opposite are well aware of my right hon. Friend's grave concern about the undermanning of certain sections of the hospital services. If it is known that vacancies exist and that other hospitals are adequately staffed and need not take on additional staff, then staff can be diverted to the hospitals where it is most needed. We all know that it is most needed in tuberculosis and mental hospitals, and we are bearing that point very much in mind. The effect of the memorandum will be to make it easier to fill those gaps.
Further, this memorandum does not propose any target for the reduction of any medical or nursing staff; nor does it 1884 impose control over individual appointments. Vacancies will be filled as an ordinary matter of routine, and it is only those increases in total numbers of staff in their broad categories which will have to be justified before they can be permitted.
The memorandum does not require consent for normal replacements and it does not put all the control into the hands of my right hon. Friend or of Whitehall, inasmuch as most of this staff is employed by hospital management committees—same 400 of them—who will receive their authority from the regional hospital boards.
There has been a need for speeding up the planned programme which has been in operation for over three years. The need for financial economy and prudent spending is known to all hon. Members, and when one realises that 65 per cent. of the total of £225 million spent on the hospital services alone goes to salaries and wages of hospital staffs it is obviously absurd to think of any review of the finances of the National Health Service if one is to ignore this vast field of expenditure.
So far as manpower is concerned, in 1951 there were 15 per cent. more full-time staff and 33 per cent. more part-time staff than in 1948. We do feel that we must be fully satisfied that there is no waste of national manpower and that any additional appointments over this vastly increased number must be justified. Where they are needed my right hon. Friend is as anxious as anybody to see those gaps closed. Frankly, the purely financial control of the budget is not enough. In the budget the effects on manpower are quite often masked by pay increases, salary increments and the like.
I am convinced of the rightness of this new measure because the reviews of existing staff and the restriction on their increase can only be fairly challenged by hon. Members opposite if they are to accept two premises. Do they suggest that the hospital services ought to give employment to, and, therefore, the taxpayer ought to pay for, more staff than are necessary to maintain essential services to the public? Or do they suggest that nowhere in the whole of the National Health Service is there more staff than, with proper organisation and a proper use of labour saving devices, would be 1885 needed to maintain a proper standard of service and care? If hon. Members opposite accept those two premises, they are justified in their opposition, but if they do not accept them—and we ourselves reject them—they are not.
I am convinced that neither of these propositions can be sustained. It is our responsibility to see that both the manpower and the finance of the National Health Service are conducted with the greatest care and prudence and, as my right hon. Friend intends, that we use the proposed measures to see that the very severe gaps and shortages in some of the services are filled, and also to see that we provide the most efficient service we possibly can provide.
§ Mr. Blenkinsop
I am very grateful to the hon. Lady for repeating so much of my speech. I should like to ask her how she believes this circular will help the position of the understaffed hospitals? Under the scheme previously followed by the Minister, establishments were agreed and hospitals could build up to establishment without reference to higher authorities. Under these proposals they would have to approach their higher authority before making the additional appointments which are needed by the understaffed hospitals.
§ Miss Hornsby-Smith
What is more important is that staff will not be absorbed where they are not necessary. In the case of opening an additional wing and finding perhaps 20 or 30 nurses, obviously the authority of the regional boards would be needed under present circumstances.