§ Considered in Committee, reported, without Amendment.
§ Motion made and Question, That the Bill be now read the Third time, put forthwith pursuant to Standing Order No. 93 (Consolidated Fund Bills), and agreed to.
§ Bill accordingly read the Third time and passed.
§ Order for Second Reading read.
§ Mr. Speaker
Before calling the Secretary of State for Social Services to move the Second Reading of the Bill, I should inform the House that I have selected the amendment standing in the names of the Leader of the Opposition and his colleagues:That this House cannot assent to the Second Reading of a Bill providing for a reorganised National Health Service which is too managerial in aspect, unrepresentative in character, and fails to meet the need for a democratic health service.
§ 3.40 p.m.
§ The Secretary of State for Social Services (Sir Keith Joseph) rose—
§ Mrs. Renée Short
On a point of order, Mr. Speaker. Before the right hon. Gentleman starts his apologia in support of the Bill, may I ask whether he will give the House some information? He will be aware that he has been asked on many occasions in the last 12 months when he intends to produce his reply to the Expenditure Committee's Report which deals with many problems, difficulties and abuses of the National Health Service to which no solutions are provided in the Bill. Will he make a statement about these matters this afternoon?
§ Mr. Speaker
Order. I have ruled that it is not a point of order. It is a matter 924 perhaps for an interjection when the right hon. Gentleman is speaking, but it is not a point of order.
§ Mrs. Short
On another point of order, Mr. Speaker—[Laughter.] This is not a laughing matter but a very serious business. On several occasions the House has been told by the Leader of the House and by the Minister, and I have been told in writing by the Prime Minister, that we would have the Department's reply for the guidance of the House before this debate took place. The information is not before us today. Can you, Mr. Speaker, give us some guidance about what we should do? We have been promised this information by the Minister, but it is not forthcoming.
§ Mr. Speaker
I think that my advice to the hon. Lady is to attack the Minister vigorously in debate—
§ Sir K. Joseph
I beg to move, That the Bill be now read a Second time.
In order to help the hon. Lady the Member for Wolverhampton, North-East (Mrs. Renée Short) a fraction may I tell her that the Government propose to publish the White Paper next week.
§ Sir K. Joseph
The Bill covers Wales as well as England, and my right hon. and learned Friend the Secretary of State for Wales, who is beside me on the Bench, will seek to catch your eye, Mr. Speaker, and to deal with the Welsh position where it differs from the English. These differences are limited mainly to matters flowing from the absence of a regional health authority for Wales. In all the main essentials, what I say will relate equally to England and Wales.
The whole purpose of the health service reorganisation which the Bill proposes is to provide an improved service for the patient. How? By facilitating 925 positive and balanced decisions by a single health authority responsible for the health needs of a given population in the light of professional advice, all coupled with a system by which, for the first time, the consumer's voice is clearly taken into account via the new community health councils.
We have—and I think the House will acknowledge this—potentially a superb National Health Service, excellent in parts, with high standards of acute care, but I think all hon. Members will agree that there is much to improve. If an outsider were asked to judge I think he would say that, above all, the present system places no duty on any authority to keep constantly under review the changing health needs of its population and, in the light of changing technical possibilities, to provide the necessary services to the best practicable standard. There is no such duty laid upon any authority, and there is no such authority.
The fact that despite that and other shortcomings the service works relatively well, at least for acute health needs, reflects the greatest credit on all concerned, and in introducing the Bill I should like to pay tribute to the members of all present health authorities and all who work for them—the men and women who make their careers in the service, whether in direct contact with patients or in related services, and the voluntary workers. But there is very much that is not satisfactory, and I shall touch briefly upon some of the shortcomings of the present service, not to enlarge upon them, but simply to remind hon. Members.
First, perhaps the less familiar and the less glamorous needs of patients tend to be neglected. We all know the phrase "Cinderella sector", particularly the long, relatively neglected services for the elderly, the mentally ill, the mentally handicapped, the physically disabled and other groups. With the present fragmented services it is very difficult to achieve the essential continuity of care across the whole spectrum of health services. I think the House recognises that waiting lists are still far too long. Some children are not reached by the health services that are available to them, as anyone who has read the National Children's Bureau booklet "From Birth to Seven" will readily acknowledge. Some disabilities are virtually ignored by the 926 health service, and there is a pervasive indifference to rehabilitation.
Hon. Members are free to say that if there were more money all the shortcomings would vanish, but there will never be enough money for everything. The money available now is greater than in any previous period. A larger share of the GNP than ever before in the country's history goes to the health and personal social services. But even with what, at all times, is bound to be inadequate money we have to recognise that it is the use of resources, the use of the money, that matters. That is why the structure of the service and the way that it is managed is so important.
Under the present structure, hospital authorities do not match local authorities. Hospital regions are too remote to tackle local needs. Hospital management committees and local authorities are just not equipped to cope with the full task that needs doing. No doubt in a perfect world, recognising those defects, the answer would be to unify the health services within local government. That would provide what many of us would like to see in a perfect world, namely, one decision-making authority in every area, with one budget. But we do not live in a perfect world, and that is not practicable. The Labour Government did not believe, nor do this Government, that it is practicable to unify the health services within local government.
As we cannot have a single structure our objective is to get as near as we can to the advantages that that would bring to the country, and we are therefore aiming at two parallel and interacting structures—a health structure and a local authority structure, each working to serve the same population. At the centre of the new unified services there will be the area health authority operating through districts with co-terminous boundaries with the new local authorities and linked to the Secretary of State and his Department by new regional authorities.
Clauses 1, 2, 3 and 4 unify the local authority health services and the school health service with the National Health Service. Clauses 5, 6 and 7 create the new area and regional health authorities. By Clause 5 family practitioner services are brought within the unified local administration. Family practitioner committees will be created, co-terminous with 927 area health authorities, to administer the contracts of family doctors, dentists, pharmacists and opticians.
Area health authorities, the central units of the new service, will have the duty of identifying the health needs of their populations and, through their districts, based on district general hospitals, of organising and meeting those needs to the optimum satisfaction of their populations.
There will be 90 area health authorities in England. We cannot know until the local liaison committees have completed their task how many districts there will be, but I can tell the House that, as far as we can judge at this stage, of these 90 area health authorities, 34—that is more than one-third—will have only one district, 24 will have two districts, 17 will have three districts and 15 will have more than three districts. Among those there will be three with six or more districts. For effective teamwork the authorities should be small, and in our view should contain about 14 members plus a chairman. There is no magic in the number of 15 in all. It seems to us about right for the normal case.
It will be the function of members of the area health authorities to see that the right questions are asked and answered in the preparation, operation and review of plans, and to ensure a full awareness of all the health needs of the population as a basis for the design of policy, for decisions on priorities and standards and for the monitoring of the performance of their districts. On each area health authority, there will be at least four local authority members, and there will be doctors, a nurse and someone nominated by the university in the region.
The chairman of each area health authority will be appointed by the Secretary of State, and in seeking chairmen we shall look for people who combine drive, humanity, judgment and diplomacy—humanity in the interests of the public and of all the patients, drive and judgment to get the right things done for the patient, and diplomacy because leadership is involved of a great range of skills and services. The members, other than the chairmen and the nominees of the local authorities and 928 universities, will be chosen by the regional health authority.
The area health authority will be a decision-making body. It will normally nominate individual members to take a continuing special interest in particular health districts. To help with the visiting which will be necessary to see to the execution of its policies, an area health authority will be able to co-opt. I would expect at least one or two co-opted people for each district, although this will be for the area health authority to decide.
But area health authorities on their own would suffer from two grave defects, which weaken the present service. First, there is at the moment no mechanism for ensuring that all the health needs of the local population are set before the decision-makers with proposed priorities and plans. That defect will be supplied by the district management teams, which I shall describe later, helped by the health care planning teams, to which I shall also refer. The second defect of the present service is that there is no mechanism by which users can have their say, and that lack will be supplied by the new community health councils.
Let me now describe the four innovations which make our new structure particularly responsive to the changing health needs, standards and wishes of the people.
First, we intend that there shall be health care planning teams, some on a continuing basis, some ad hoc, to review and plan for specific health needs, such as those of the elderly, of particular groups of the disabled and of the mentally handicapped. These teams will comprise representatives of all the relevant medical, administrative, nursing and social disciplines, they will work at district level and of course they will certainly include a representative of the local director of social services.
The second innovation is that, at area level and at district level, there will be multi-disciplinary teams with direct responsibility to the area health authority chairman and members. These teams— at the district level, the district management team—using the work of the health care planning teams as necessary, will prepare the plans for the consideration of the area health authorities.
929 The third innovation is that there will be a new development of the historic and respected figure of the medical officer of health. He will reappear in the new structure with even wider responsibilities, in the form of the new community physician. The community physician will have three sets of functions. He will advise his clinical colleagues so that they are aware of the scale and the variety of health needs in their districts and areas. Second, in partnership with his clinical colleagues, he will identify health needs and help to organise and plan to meet them, including the co-ordination of preventive care services. Third, he will advise the matching local authority on environmental and personal social services and other issues, and the local education authority on school health. It will be the community physician who will help organise the medical staff work for the health care planning teams.
Thus equipped, the area health authority should be far better able than local health authorities or hospital management committees at the moment to provide the health services that the public need. But there is still no mechanism so far by which the public themselves, as users of the services, can make their voices effectively heard. Here, I come to the fourth innovation—the community health councils, which are covered in Clause 9.
In another place, there was criticism of the community health councils and their features. As a result of that criticism, my noble Friend in another place tabled a number of amendments which are now embodied in the Bill. The present position, therefore, which I think makes these councils particularly responsive to the voices of the users is that they will be appointed, as to half, by the new elected district councils, a third will be chosen by voluntary bodies from a list prepared, after discussion with the district councils, by the regional health authority, and the last sixth of membership will be appointed by the regional health authorities, after consulting counties and metropolitan districts, from such bodies as churches, women's organisations and trade unions.
The community health councils will choose their own chairmen, they will be funded by regional health authorities and their function will be to be consulted by area health authorities and to make the users' views on the services known to the 930 area health authority. I should emphasise that there will be one council for every health district—probably more than 200 councils in England. The community health councils will have the right to visit the hospitals and other health establishments in the district, they will have access to the area health authority members and officers and they will, of course, have the right to report.
The significant point is that the area authority will be required to publish answers to its reports and to declare what action has been taken as a result of any community health council recommendation.
Hon. Members on both sides who represent Lancashire have expressed to me their worry over the size of the Lancashire Area Health Authority. I have seen my hon. Friends and am to see some hon. Members opposite later this week. I should like them to know that I am studying the case that I have heard and which will be made to me and am not, in my speech today, ignoring the points that they have made.
Mercifully, and despite the defects to which I have briefly referred, in both the hospital and the community health worlds, we have in this country a number of centres of excellence. Among these are the teaching hospitals. The very special importance of teaching and research is recognised in the Bill by the creation of teaching areas—Area Health Authorities (Teaching). There are particular arrangements for them, including an additional member from the university and two additional members from the teaching hospital. There will be a specific revenue allocation for research and teaching, and the teaching areas—I am listing only some of the points—will employ their own consultants and registrars, whereas elsewhere the regional health authorities will employ them.
There will be great mutual benefits from bringing the teaching hospitals into the area and regional structure. Their teaching and research will feed on the wider health needs of the district, and the district will gain from the standards and the capacity for general excellence of the teaching hospitals.
The quality of the service to the public will depend on linkage of health and local authority work. The new health authorities and the new local authorities are, 931 under Clauses 10 to 12, given a duty to collaborate and to plan their programmes and services together, so that community and health services can interact, and to provide reciprocal services, with the local authority supplying social advice to the area health authority and the latter providing medical advice to the local authority.
The School Health Service will benefit from integration into a comprehensive child health service, and the doctors, dentists and nurses providing the service will have the advantage of being in the main stream of their professions. But we intend also to ensure, through the collaboration arrangements, that the service is sensitive to the needs of schools and works closely with the local education authorities. We shall shortly be setting up a committee to review the whole of the health services for children before and during school age. This will help to point the way to the best means of developing the school health service as part of an integrated service for children.
The House will be aware—my hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight) is particularly interested in this matter—that a decision is urgently awaited on the future of social work in hospitals. My right hon. and learned Friend the Secretary of State for Wales and I have studied the conflicting arguments with great care and will announce this week the Government's decision.
Local authorities and area health authorities are required to set up joint consultation committees. These committees will be expected to report, so that any disagreements between the area authorities and the local authorities will certainly be brought into the open.
The new local authorities will be required, as axe the present local authorities, to continue the annual publication of the ten-year rolling social services development programmes, so that the country as a whole and the local people and special interests will be well aware of what local authorities are intending by way of improvement in community service.
The area health authority will be the main unit operating through its health 932 districts. But with 90 area health authorities we need a mechanism for ensuring that they follow the general strategy and priorities of the Government of the day. There are too many in England for direct dialogue between the Secretary of State and them without there being even worse delays in reaching decisions than occur now. So the Bill provides for regional health authorities, 14 of them in England, as agents of the Secretary of State, responsible to him for long-term planning, hospital building, regional services, and the allocation of resources.
The areas will prepare their plans and budget. There will no doubt be a continuing dialogue between area health authorities and regional health authorities. Once the plans and budgets are approved by the regional health authorities, the area health authorities will be able to get on without interference from the region, subject only to monitoring via the agreed plan and budget
So much for the main structure. I remind the House that it is all for the benefit of the patient and should produce a more co-ordinated, sensitive, positive effort to meet all the health service needs of the public in acceptable ways. But I cannot disguise from the House, even before the right hon. Member for Deptford (Mr. John Silkin) catches Mr. Speaker's eye, that there is some well-meant criticism of our proposals. It is said that there should be more participation by the public and by staff. But never before have the public, through the community health councils, and the professions, through participation in the health care planning teams, the management teams and the advisory machinery, been given the opportunity to participate so fully. The fear is expressed that, as up to now, the obvious will be done, more or less, and the less obvious will be neglected. But I emphasise that even with hospital management and local health committee members of intense good will and good intentions—no one doubts the good will and good intentions of HMC and local health authority members—many local populations have not avoided neglect of Cinderella sectors, nor has the medical profession, under the present arrangements, managed to provide a generally equally good service in all disciplines in all parts of the country.
933 Of course, issues of money are involved here, and always will be. But I am simply stressing that to pack area health authorities with local authority members and with doctors and staff—as I gather the Opposition intend—will in itself give no guarantee of balanced decision-making. Packing area health authorities with local authority members and with doctors and staff, as the Opposition evidently propose, will not help the Cinderella sectors but will create divided loyalties and confused functions. The Government prefer a separation of functions—decisions by the area health authorities, helped by health care planning terms and working with professional advice, and representation of the public by community health councils.
Parallel to all this, the key to the reorganisation is, as we all know, the staff of the National Health Service, the doctors, dentists, nurses, midwives and the many other professions and supporting skills and services indispensable for treating, diagnosing and caring for the public.
Clause 18 provides for the transfer of staff to the new authorities. For the great majority of staff there will be no change except that of employer. Clause 19 protects the salaries and terms of service of the transferred staffs. Clause 20 establishes the Staff Commission which, in shadow form—as the Staff Advisory Committee—has been already in action for some months, and the purpose of which is to safeguard the interests of the staff.
We attach the greatest importance to strong professional advisory machinery, and accordingly Clause 8 provides for the statutory recognition of local professional advisory committees in each English region and in each area. Medical, dental, nursing and midwifery, pharmaceutical and ophthalmic committees are specifically provided for and, if it is in the interests of the service, committees of other categories of staff may be recognised.
The new service, unlike the existing service, will develop—some hon. Members will say "About time, too"—a personnel function. Training has already skilled service for all types of staff.
We shall continue to develop our partnership with the indispensable and 934 invaluable voluntary organisations, and Clause 13 gives a useful supplementary power.
Clauses 21 to 30 deal with the transfer to new health authorities or, in some cases, to special trustees, of the endowments of the present hospitals and local health authorities.
Clauses 31 to 39 provide for the Health Service ombudsman, whose creation has been generally welcomed. Hon. Members should remember that the ombudsman for the National Health Service will be operating against a changed background, inasmuch as the Government await this summer the report of the Davies Committee on complaint procedures, which should lead to an improved system of handling complaints.
§ Dr. M. S. Miller (Glasgow, Kelvingrove)
When dealing with the ombudsman, will the Secretary of State clarify paragraph 178 of the White Paper, which makes it clear, at this stage at any rate, that the ombudsman for the Health Service will be the same person as the Parliamentary Commissioner? That is not quite so clear in the Bill.
§ Sir K. Joseph
It has been announced, because there were essential preparatory tasks to be done. But subject to the approval by Parliament of the Bill and the creation of an ombudsman, the present ombudsman will be the National Health Service ombudsman as well.
I turn finally to family planning. Ministers very early in the life of the present Government decided that it made sense to bring help and advice to those who seemed most to need it, and we therefore set in hand over two years ago a trebling of expenditure, mainly on the domiciliary services. Last December I announced a further multiplication of expenditure— from £1 million per annum when we came to office to £17 million per annum —to give free advice to all who sought it and free supplies for certain groups of the public, perhaps 15 per cent. in all.
In bringing local health authorities to an end, the Bill concentrates all public family planning programmes in the National Health Service. This is sensible because it enables counselling, which is so important to many, as well as medical advice to be provided, as the service builds up, wherever needed, to a high standard.
935 The Bill provided when introduced that charges would be made to those not entitled to free supplies. We did not think that it was right to provide free supplies for all when a large majority can and do provide their own. But there is no doubt that public opinion has come to regard unwanted pregnancies and abortions as so undesirable that great efforts should be made to abate both. The Government agree. But how to do it is not so obvious. A majority in another place seemed to think that free supplies would cut sharply into abortion and unwanted pregnancies, and struck out the charging power.
I do not think it is as simple as that. Free supplies alone will make no difference to some groups of irresponsible parents. For them, intense and difficult efforts are needed by encouragement by counselling, by domiciliary and clinic services, by hospitals, by general practitioners, coupled with free supplies. All these efforts would have been deployed under our December proposals and do of course remain at the heart of our policies.
On the other hand, Ministers recognise that in the December proposals, for which I was responsible—advice free for all, supplies free for some—there were two disadvantages. First, family planning was not going to be, as it were, normalised. There are those who argue that until it is taken as the normal thing that people—by whatever means they choose and subject therefore to their personal beliefs—do regulate under God the number of their children, until then I say, a responsible attitude to procreation will not reach some large groups.
Secondly, there may be some with weak motivation and, or, low but not very low incomes who might not have been helped or might not have been sure that they would be helped by my proposals and who would therefore not plan their families.
The question is whether for the un-quantifiable benefits I have just described —to normalise the service, on the one hand, and to remove all doubt about whether a charge and, if so, what charge, will be made—we should follow the lead of another place at a time when many are urging us to restrain any growth in public expenditure.
§ Mr. Marcus Worsley (Chelsea)
I am still not clear what exact meaning my right hon. Friend is giving to the word "normalised" in its context. Will he help me?
§ Sir K. Joseph
Yes. I think that a majority of the population do already—I repeat the phrase, under God or under providence—seek to regulate the number of children they have. There are very large minorities who do not see it as normal so to behave. There are those, I was saying, who argue that until the service of contraception is made normal by being part of the National Health Service, those large minorities may not feel the impetus to change their attitudes and habits. That is what I was trying to express.
We are being urged to go free by a very wide range of bodies, including the Church of England's Board of Social Responsibility and the Women's Institutes— [Laughter.]—I could have quoted a very long list, but I have named two very responsible bodies which are not likely to make such recommendatitons frivolously, not that I am suggesting that any group would make recommendations in this field frivolously.
It is true that some reduction of unwanted pregnancies may be achieved and that is certainly a high priority.
We have, therefore, decided to modify our original proposals so that, instead of the majority of people being required to pay an economic charge for their supplies, as from 1st April 1974 contraceptives will be placed on the same basis as other drugs and appliances under the National Health Service—that is, family planning will become a normal part of our health service arrangements. The maximum cost to the patient will be the prescription charge and the normal arrangements for exemption from that charge will apply to the supply of contraceptives. The extra cost of this in Great Britain will, we estimate, be about £13 million a year when the family planning services are fully developed.
There are those who argue that an expansion of family planning will pay for itself and that no extra expenditure will be required. It may well be that an expanded family planning programme will eventually result in some savings in health, 937 welfare and education costs, but it would be wrong to expect these in the short term, since it will take some time for an effect to be felt on the birth rate and even longer for any appropriate adjustments to be made in the services which follow a birth. It will not be possible, for example, to shut a maternity unit because there has been a small reduction in the number of births in the area.
The Government have not at this stage decided how the extra cost should be met.
§ Mr. Anthony Fell (Yarmouth)
In another place, Lord Gardiner talked about a reputable body which had reported and which had somehow included in the ordinary cases of unwanted births the third, fourth and sixth child in a family. Before my right hon. Friend goes any further will he tell me this: what is the criterion of an unwanted pregnancy?
§ Sir K. Joseph
I did not myself use the phrases "unwanted births" or "unwanted children". An unwanted pregnancy is one that the parents did not intend to occur. It is the parents' decision. The Government's object is to make available to parents for their own use counselling, advice, knowledge and supplies within the context of what I am announcing.
§ Mr. J. Enoch Powell (Wolverhampton, South-West)
I understood my right hon. Friend to say that supplies would be available on the same terms as National Health Service prescriptions. Does that mean that they will be available on prescription? If so, is the prescription given, as all other prescriptions are, by the doctor on the doctor's responsibility, and will he be giving it on his view of the medical needs of a person for whom he is prescribing?
§ Sir K. Joseph
To all parts except the last part of my right hon. Friend's question the answer is "Yes", but the doctor will be authorised to prescribe the medically suitable contraceptive for a patient who asks for a contraceptive but no longer because of a medical need. The vast majority of the public who use contraceptives have an appropriate contraceptive for their personal condition. Where that involves a doctor, the doctor will be entitled to prescribe. Where there is no 938 need to go to a doctor—for instance, for a sheath in cases where a sheath is not medically necessary—there will be no prescription for a sheath. If a couple, or a woman, wants an oral contraceptive, even though after 1st April 1974 it is not a medical necessity that there should be an oral contraceptive, the appropriate oral contraceptive will be prescribed by the doctor.
§ Several Hon. Members rose—
§ Sir K. Joseph
I ask hon. Members to allow me to finish, because this is not the occasion to go into all the details. It will be on prescription, as are all other prescriptions in the National Health Service.
§ Mr. Leo Abse (Pontypool)
It is quite clear from the reply that the Secretary of State has given, despite the elaboration in his reply, that he is using the doctor to make a social levy, to extract a payment from a patient. That is the obvious obstruction being place all the way. In view of the rising number of abortions in Great Britain, why should there be this final obstruction, an obstruction in particular against those who are most irresponsible and who are therefore most likely eventually to need an abortion? Why does not the Secretary of State take the final jump?
§ Sir K. Joseph
I was going to explain that. Our new proposals do not go quite as far as the amendment made in another place as that would require supplies to be completely free to everybody. The extra cost would have been up to £3 million. Not only financial considerations made the Government decide to adopt the prescription charge arrangement; there was also the anomaly that would be caused if contraceptive supplies were placed on a more favourable basis than, for example, life-saving drugs.
I ask the House to heed what I am about to say. There are some false expectations about. I hope that people will not expect too much of family planning. There will be no sudden fall, as a result of this decision, in abortions after 1st April 1974. The arguments in the recent booklet on Aberdeen can be questioned and the results do not to my mind prove what the author, admittedly with some qualifications which the newspapers do not usually print, claims that they prove.
939 There may be some benefit if the new National Health Service provides a persuasive and effective service of which supplies on prescription will be a part, but only a part.
I know that there are those who fear that the widespread development of family planning services will do harm as well as good. However, these services will be an integral part after 1st April 1974 of health care within the National Health Service. We shall encourage the development of responsible counselling and advice for those who need it most.
§ Dame Joan Vickers (Plymouth, Devonport)
There are now 21 councils that already give this service free. What will happen to them if the Bill is passed?
§ Sir K. Joseph
First, local health authorities will be vanishing after 1st April 1974. Councils will not have any responsibility or powers in connection with family planning. Area health authorities will provide the service which I have described, including a prescription charge for those not exempt.
I hope that the House will discharge me of any discourtesy. I have explained to the right hon. Member for Deptford that the Prime Minister is meeting the General Secretary of the Trades Union Congress and representatives of the health service ancillary workers trade unions shortly after five o'clock. I may have to leave the House before the right hon. Member for Deptford has finished his speech. I hope that no one will accuse me of discourtesy. I think that the House will wish me to go.
I have not wearied the House by describing the various Green Papers and the proposals that have been in the air for health service reorganisation. They have been going on for over 10 years. It is surelv time to get on with the reorganisation. There is, despite what the right hon. Gentleman will say, a great amount of agreement on our purpose. There is some disagreement on our method. The Bill is for the benefit of the patients, and I commend it to the House.
§ 4.23 p.m.
§ Mr. John Silkin (Deptford)
I beg to move to leave out from "That" to the end of the Question and to add instead thereof: 940this House cannot assent to the Second Reading of a Bill providing for a reorganised National Health Service which is too managerial in aspect, unrepresentative in character, and fails to meet the need for a democratic health service.The Secretary of State has given us a careful and lucid account of the Bill and its purposes. In the detailed and complicated art of describing trees the right hon. Gentleman has no equal. It is only when he comes to the wood that his vision seems to fail. Before I deal with the wood, I shall give the House some indication of the various trees which my right hon. and hon. Friends and I shall seek to mark out for special attention in Committee. There are some to question and some to fell.
The framework of the Bill presents all hon. Members with the difficult problem of construction. The Bill, as has been said many times, is an enabling measure. It gives the right hon. Gentleman power to make so many regulations that the Commissioners in Brussels will be green with envy. In addition, the Bill cannot be read alone. It has to be read in conjunction with the White Paper and the management document. I only hope that when the time comes the rules of order will be generously interpreted.
Labour hon. Members will make the most searching inquiry into the framework of the proposed reorganisation. The right hon. Gentleman proposes to establish an organisation of extreme complexity, consisting of five tiers, starting with the Secretary of State at the top and descending from regional health authorities to area health authorities to the district management teams and finally to the community health councils. It is our present view that the framework is too cumbersome and could do with a little slimming: "If you have tiers, prepare to shed them now".
We accept the first of the main proposals of the Bill as set out in the explanatory and financial memorandum— namely:to unify the local administration of the National Health Service under new health authorities covering the whole field of health care".Integration has been in the air for many years now, as we all agree, but when we consider the third purpose of the Bill—to ensure that the views of the health professions are given full weight in the planning and management of services941 we shall want even greater reasssurance than we have on the information before us. We shall want to be certain that all the professions can play their proper part —for example, medical, dental, nursing and the others.
We shall also want to examine most closely the total divorce between the health services and the social services at local level. My hon. Friend the Member for Manchester, Wythenshawe (Mr. Alfred Morris) pointed out to me—and he knows better than anyone—that there are so many problems—for example, the young and chronically sick—which are more social than medical but take an aspect of both.
We are concerned, too, by the position of the community physician, which is the new name for the medical officer of health. The health of our community is not, for all the good work that they do, primarily in the hands of the consultants, the hospital doctors or general practitioners. Of all those practising in medicine it is to the medical officers of health that we owe the deepest debt of gratitude. The elimination of cholera, smallpox and diphtheria was due to their unselfish acts and sometimes opposed obstinacy in tackling the danger at its source. The years have brought them increased responsibility in community health. The present reorganisation will give them even wider responsibility.
It is impossible for the community physician to confine himself to taking only a part in the management structure. As the right hon. Gentleman told the House, one community physician is required to play his full part in each district management team while, I suppose, using his spare time to deal with all the items of community health that concern him, and working at one and the same time with the local authorities, the health care planning teams and the community councils. Not Simon nor Daly nor any of the great Ministers of Health in the past could envisage performing so large a rôle by himself!
In our view—and this is a tree which we have searched for in vain in the Bill —no health service can function effectively without the active participation and representation of the non-professional health service workers. We are alarmed to find that there is no real provision for such representation. We shall seek to 942 remedy that situation at the earliest possible moment.
We are not satisfied that the arrangements that have been made for London in the proposed regional set-up or in the proposed areas will meet the need. We note that the proposals for the capital are inconsistent even with the Secretary of State's criteria.
We will, in the light of the Secretary of State's latest ideas, consider the whole question of family planning, That, together with the ombudsman and private practice, which the Secretary of State did not mention, will be dealt with by my hon. Friend the Member for Halifax (Dr. Summerskill) should she catch your eye, Mr. Speaker. She will also deal with the omission of an occupational health service.
My right hon. Friend the Member for Cardiff, West (Mr. George Thomas) will, I hope, be dealing with the proposals for Wales tomorrow. This is not the first time that in a Bill which proposes a massive reorganisation the Government have chosen to embody provisions for Wales, which should more properly follow the lines of the separate Welsh White Paper and be presented in a separate Bill. Nevertheless, it would be churlish of me not to recognise that the Government have given another day for debate so that the voice of Wales can be heard.
In another sense, of course, whenever this House discusses the National Health Service, still more its reorganisation, the voice of Wales continues to be heard, for it was one of the greatest Welshmen, Aneurin Bevan, whom many of us knew and loved, who created this service of which we are all so proud. I wonder, however, how he would have viewed these proposals for reorganisation. The health service that he created was certainly not, I concede, a democratic one, but all his writings show that he hoped and intended that as the years went by the form would become more democratic. He had enough difficulty in setting up the health service, fighting, as he was, those who totally opposed the concept, and facing the general scepticism of a public which wanted a health service but doubted that it would be viable.
There remains no doubt of the kind of persons whom he wished eventually to be administering the service. In "In 943 place of Fear "he wrote that the appointment of members to various administrative bodies should not involve the Minister of Health. Election would be a better principle than selection, for the reason that no Minister could possibly feel satisfied that he was making the right selection over so wide a field.
I have no doubt what he would have said about the criterion for membership laid down in paragraph 96 of the White Paper, Cmnd. 5055. I will read it:The work to be done by the members calls for general ability and personality. They will need to be interested in the NHS; to have an unbiassed, questioning yet constructive approach and good judgment; to set high standards and provide vigorous leadership. A diversity and a proper balance of relevant ability and experience are also called for.So far so good. In fact, on this definition these paragons could well be selected from among hon. Members here present —certainly the Secretary of State and possibly, even at a pinch, myself. But the paragraph goes on:These needs can best be met if, in the main, members are chosen for their personal qualities after appropriate consultations, not elected as representatives reflecting the views of particular interests.That proviso, of course, damns all of us— poor elected honourable creatures that we are. The annual award for bureaucratic arrogance has many contenders, but whoever wrote that paragraph is the undisputed winner of all time.
Unfortunately, the assumption is one that runs through the whole of these proposals. Of course, from the point of view of the Secretary of State this is not criticism; it is praise. He has chosen appointment by selection as a deliberate act of policy, and he has carried out that policy ruthlessly to the end. Firmly under his control, dominating the whole new integrated organisation, are his regional health authorities, all of whose members are appointed by himself, admittedly after consultation involving the universities, the local authorities and the main health professions, but there is no doubt whose servants they are and whose instructions they must follow. Under them come the area health authorities, whose chairmen again are chosen by the Secretary of State. I concede that the Secretary of State, before appointing these chairmen, will have to consult with the 944 chairmen of the regional health authorities, but, since they are also his nominees, their views, if any, will tend to be formal.
As to the remaining members of the area health authorities, apart from the four chosen by the local authorities, and the one or two chosen by the universities, depending upon the teaching areas, the remaining large majority will have been chosen by the regional health authorities who will, as I said, have been chosen by the Secretary of State in the first place. This is hardly the recipe for an exciting, experimenting, forward-looking health service containing—what is it?—drive, humanity, judgment and diplomacy.
But, of course, the Secretary of State wants something else. He wants it tame, docile and grateful to its master. As Patrick Henry said of the American Presidency, "It has more than a squint towards monarchy". I appreciate that the Secretary of State will not count that as criticism either. He takes the view best summarised by Alexander Pope:For forms of government let fools contest;Whate're is best administered is best:—particularly if it is administered by himself.
It must have come, therefore, as quite a shock to the Secretary of State when, even judged by his own lights, his scheme of organisation was found wanting. The Times, looking at it purely as a question of organisation, made a savage criticism, and, as if it was not enough to have the "top people's paper" against him, the "top managers' paper", the Financial Times, on 23rd January last, was, if anything, even more scathing. That newspaper said:It is as much the thinking of a bygone era as would be a motorway up Oxford Street.The analogy is a sound one. What is needed in the National Health Service is what is needed in Oxford Street—a pedestrian precinct, where the consumers and the workers in the industry play their part in the decision-making, free from the juggernauts of dictated authority.
One can go through the whole of this Bill, the White Paper and the management document without ever really being aware that what we are trying to do is to achieve a service for the patient. But that is what the health service is all about. It was not created to make easy 945 lines of command from Whitehall downwards. It was not created even for the benefit of those who work in the service, although it would be as well for the smooth running of the service if they were considered. It was created for the patient.
However, it occurs to me that perhaps I have been too hard on the Secretary of State. At a later stage it came to him that perhaps there was a need to consider the patient. That was why he introduced his community health councils. But his attitude all along has been that these are necessary but none the less unfortunate interpolations into his neat, tidy little scheme. One can see his real attitude in his first thoughts. Originally his community health councils were half manned by the area health authorities which provided the money and staff to run them. Since they were supposed to act as a watchdog, he must have known that they could never really be effective. A watchdog that is half owned by and wholly fed and maintained by the burglar is unlikely to bite when the burglar comes in through the window. It is much more likely to lick the burglar's hand. Certainly as a result of all-party pressure the Secretary of State has changed his watchdog, but it is still some way from the sort of beast that is truly representative of the people who use the service.
What is essential is that the service should be democratic and not monarchical. I know the difficulties that have faced successive Ministers of Health, even if they believed in a democratic system. The obvious democratic machinery is that of local government, and when the scheme was set up it is interesting to note that the reasoned amendment of the then Conservative Opposition, in the name of Sir Winston Churchill and other distinguished Members of the time, attacked the organisation because itweakened the responsibility of local authorities.A number of Conservatives and some Labour Members at that time argued eloquently in favour of local authority control. Mr. Messer, for example, Labour Member for Tottenham, South, asked why we should lose faith in what we believed to be democracy. Sir Harold Webbe, whom many of us remember, the Member for the Abbey Division of Westminster, deplored the fact that the Bill took away from the local authorities the 946 administration of the hospitals and left the local authorities, as he felt,emasculated, truncated, deformed and completely open to future attacks on their autonomy."—[OFFICIAL REPORT, 1st May 1946; Vol. 422, c. 222 and 272.]Aneurin Bevan's answer was that local authorities at the time were too small and too poor to operate a health service and for many years after the service was set up his successors had to face this challenging reality. We heard an echo of this from the Secretary of State today.
However, the position is changing today, and changing radically. We shall, by virtue of the Local Government Act of last year, have much larger and more powerful areas of local government. Indeed, this is the reason why the start of the Secretary of State's proposals for reorganisation is timed for the same day as the start of the new local authorities. In addition, we are, I hope, moving ever nearer to the setting up of provincial councils in England. If that happens, a whole new avenue of possibilities will open up—including a further review of local government itself—one more logically attuned to the health service.
Certainly it is, as one looks about, that even the Skeffington view of participation is beginning to be out of date, and there is a clear requirement on the part of ordinary people to play their part in decision-making. Any sensible and lasting reorganisation of the health service must take that feeling into account, and, however it be done, the need for democratic control of the health service must be provided for. As a first step, we shall press for greater representation by the local authorities and the trade unions.
It will be our purpose to move the Bill in the direction of democracy. But it will be a difficult task. What Aneurin Bevan said in 1946 remains unhappily true today—Many of those who have drawn up paper plans for the health services appear to have followed the dictates of abstract principles and not the concrete requirements of the actual situation as it exists. They drew up all sorts of tidy schemes on paper which would be quite inoperable in practice".—[OFFICIAL REPORT, 30th April 1946; Vol. 422, c. 43.]To which we may perhaps add, "inoperable because they ignore the very people whom they are supposed to serve." The Secretary of State's scheme brings to the administration of an essentially 947 human service all the vision and imagination of the cost accountant and all the warmth and compassion of the balance sheet. Let him take the Bill away and think about it again. I call upon the House to reject the Bill and to accept the reasoned amendment.
§ 4.42 p.m.
§ Sir David Renton (Huntingdonshire)
Looking round the Chamber, I find that I am the only Member on this side who was on the Committee which considered the National Health Service Bill in 1946; though, glancing across the Floor, I see two or three old stagers who look rather as though they ought to have been present. I remember the late Sir Winston Churchill saying in 1946 that the Bill would have been more appropriately described as the "National Disease Bill", because, he said, there was no attempt at prevention in it. To some extent, that is a defect which the present Bill looks like remedying.
The right hon. Member for Deptford (Mr. John Silkin), doing the best he could to show antagonism on behalf of his party, was good enough to acknowledge, by the fairly constructive criticisms which he made from time to time, that there were defects in the 1946 Act which have become entrenched, and that this Bill is a good, thoughtful attempt to overcome those defects.
Before I go further, I wish to point out—I believe that I shall be in order in so doing—that the Bill is part of a great trilogy of Tory social reform, of which last year's Local Government Act and the Water Bill now in Committee are the other legs. Also—the relevance of my remarks will become a little more apparent in a moment—I wish, as the father of a mentally handicapped child, to acknowledge at least one of the many social reforms within his responsibility which my right hon. Friend the Secretary of State has introduced, having been more successful than his predecessors appeared to be in extracting the necessary funds from the Treasury.
I am in favour of the Bill. I like the idea of a partnership between the Secretary of State, the professional people upon whom the health services depend, and the community. I am glad to see that under Clause 13 voluntary organisa- 948 tions are specifically invited to take a part. If I felt it feasible to do so, I should like to share the full-hearted desire of the right hon. Member for Deptford for democratic control. It is a good thing in nearly all circumstances, though it becomes rather less of a good thing when too much party politics enters into it.
Let us take stock of the situation in which members of local authorities will find themselves with effect from 1st April 1974, when the Local Government Act and the Water Bill come into force. At that time, members of local authorities, who even in present circumstances have a tremendous number of calls made upon their time, will find it virtually impossible to give all the attention which is demanded of them in the committees and sub-committees of their own councils, with their enlarged areas and responsibilities—which will mean fewer members—and with the responsibilities placed upon them by the Water Bill and various other statutes.
I hope that my right hon. Friend will not expect too heavy a manning by members of local authorities of his various new bodies. Otherwise, we could lead them into a very dangerous situation. To that extent, therefore, I disagree with the right hon. Gentleman.
It will not have escaped the attention of the House that there is one field of preventive medicine in which not enough progress has been made, namely, the prevention of the common cold. I am sorry to be inflicting that on the House at this moment.
It will not surprise the House that on this occasion I give a special welcome to Clause 4, which deals with the family planning service. In my opinion, the other place was right to make this service entirely free. I remind the Government, and, in particular, the Patronage Secretary—I am sorry that he has just left the Chamber, though I have no doubt that what I say will be brought to his attention—that there is a large number of us on this side who will strenuously resist the attempt, which my right hon. Friend the Secretary of State appears to be about to make, to reverse, or at any rate to modify, the Lords decision. I think that we should make that plain at this early stage.
In the other place, the Lords did not have the advantage when they had their 949 debate of having in their hands the Report of the Population Panel, which was published only last Thursday. It is, I believe, one of the most important and interesting reports presented to Parliament since the war, and it fully justifies the decision which the other place took. If anyone wishes to doubt that, let him turn to paragraphs 43 and 448 of the Report of the Population Panel.
In a series of closely reasoned arguments, the Panel concluded that we should try to stabilise the population of Great Britain at 64 million, which the Panel expects to be reached early in the next century. That would be 10 million people more than our population was in 1971— and 10 million more means the equivalent of 10 cities the size of Birmingham or 100 towns of 100,000 people each. Where will all the people live? Scotland, Wales, the Lake District, Dartmoor and Exmoor will not take them—at least I hope not. But poor old England will have to have them. Much of the land which will be taken and turned into concrete jungle will be good farming land. What an awful prospect!
The Population Panel said that when the population reaches 64 million 50 per cent. of the developed area of the North-West will be urbanised. Kent is already more than 20 per cent urbanised. This is an intolerable situation for England to have to bear. The South-East, the Midlands and the North-West will bear the brunt of it. If the Population Panel is to be believed and accepted, we must face this situation anyway. We should ensure that by getting the birth rate down to replacement levels a later generation does not have to take far more stringent steps than the very moderate steps included in the Bill, which involve no compulsion, no dictation to parents, nor the limiting of families to two children.
§ Sir D. Renton
If we in our generation fail future generations by not offering free family planning and drawing attention to the advantage of it, then, in my opinion, the next step which a future generation would have to take is that of financial stringency, which I have always wished to see avoided. For quite a long time I 950 have suggested what Clause 4 contains and that is why I think we should welcome it.
§ Mr. Timothy Raison (Aylesbury)
Is it not the case that the Population Panel, in its admittedy excellent report, played down the land point in paragraph 317 in which it says:… we do not see urban land problems during the next 40 years as primarily due to increases in the national population"?It goes on to talk about the difficulties caused by migration.
§ Sir D. Renton
Surprisingly, the panel did play it down. In spite of this, it recommended that family planning should be offered under the National Health Service so as to stabilise the population. I was hoping that I had, in a tactful way, pointed out that it had overlooked what was involved for England in terms of further urban development in what is already one of the most densely populated countries in the world.
There are several arguments used against a free family planning service, with which I venture to deal briefly in conclusion. The first is that the birth rate is falling and will continue to fall indefinitely. This is not the case. It has fallen largely because it fell 20 years ago, and, therefore, temporarily there are not as many girls of child-bearing age as there were until fairly recently. But the birth rate could, and probably will, rise again when the large number of girls born between 1959 and 1968 are able to produce children.
Secondly, it is suggested that to bring down the birth rate will cause an imbalance between age groups. This is a strictly statistical matter, but I am advised that if we spread the attempt to stabilise the population over about 30 years the imbalance will be avoided.
Finally, there is the important moral argument. I believe we should teach our young people that the permissive society, which has had a pretty good run, causes not only irresponsibility but frequently unhappiness. We should tell our young people to be good, but if they will not be good we must make sure that they are careful. There is nothing worse than young girls producing children of whom they cannot take care and whose fathers take not the slightest interest in them. 951 With so many children born illegitimately and 150,000 abortions a year—admittedly 50,000 of them apply to foreign girls—in my opinion the so-called moral argument vanishes into thin air.
I welcome the Bill and hope that when it leaves the House Clause 4 will still be in its present form.
§ 4.58 p.m.
§ Mr. Laurie Pavitt (Willesden, West)
The right hon. and learned Member for Huntingdonshire (Sir D. Renton) dealt extensively with Clause 4, with which I hope to deal later. I wish to say how much I welcome his comments and the way in which he brought before the House some of the important factors in the Report of the Population Panel published last Thursday, which is germane to the debate and which the House must consider.
The approach of the Secretary of State in making a minor prescription charge for family planning rather than going the whole hog, as was proposed in another place, is typical of this Government in being penny wise and pound foolish. It is similar to their proposal which saved £5 million on school milk and yet, as they decided last week, wrote off £30 million deficit to the farmers; in short, a milk subsidy. The consequence of the Government's action, if they get away with it in Committee, will be a small saving on prescription charges and greatly increased costs on the National Health Service, on the welfare services and on every other social service.
I am probably the most disappointed hon. Member present, because I made my maiden speech in 1959 on this theme, a better health service. In 1962 I had the privilege of writing a pamphlet for the Fabian Society in which my basic theme was the need for integration of the tripartite system into a unified structure. In 1962 Sir Arthur Porritt, on behalf of the British Medical Association, made a strong recommendation along the same lines. As the Secretary of State said today, for the last 10 to 15 years we have been talking about the best way to implement it.
I am pledged and committed to the purpose of the Bill. The Bill's objective should have been a giant stride forward 952 in the provision of health care across the board. However, the Secretary of State has failed so lamentably and appallingly in what he has produced that I commend the wise words of my right hon. Friend the Member for Deptford (Mr. John Silkin that the best thing to do with the Bill is to get rid of it at the earliest possible moment and to put something better in its place.
I reject the whole managerial hierarchical structure which the Secretary of State makes the basis of his approach and the concentration of absolute power in his own hands. I reject the elimination of the local health authorities and the local executive councils in the structure the right hon. Gentleman is proposing because it means diminution of even the vestiges of democracy which exist in the present NHS. I reject also the fact that participation is confined only to the professions, leaving out entirely two-thirds of the workers who are running the service day in and day out. I reject, too, the preservation of hospital domination, a matter on which the right hon. Gentleman previously made a pledge, because the regional authorities will be the hospital boards writ large, with the same chief officers and the same personnel often using the same offices as at present.
However, the classic instance of where this Bill fails is in divorcing the social services from health and trying to knit it back by some of the most clumsy liaison arrangements. If my right hon. Friend awarded the palm for bureaucracy in his speech, I think the second prize should go to the very cumbersome structure whereby the right hon. Gentleman seeks to bridge the gap between what is done in the community for social services and welfare and what is done for health.
My hon. Friend the Member for Halifax (Dr. Summerskill) will, I hope, deal with Clause 43(2). That clause gives the Secretary of State absolute power to hand over just whatever he likes of the present facilities inside the NHS to private factors outside it. That is one of the most sweeping of powers to give to any Minister.
The Secretary of State today sought very much to rectify the fact that the patient does not appear anywhere in the Bill. He tried in his speech to cover up 953 that omission. He tried time and time again to bring the patient into the picture. It was as well that he did that, because the patient does not appear anywhere in the Bill.
My right hon. Friend referred to two analyses of the managerial concept, one in The Times and one in the Financial Times. The Times referred to this Bill as beinga new bureaucratic monster.After a devastating analysis the article concluded:If the Government's proposals were the best that business has to offer the Civil Service I would say bring back the mandarins. In fact, it is not, and I suggest that even the board of the ICI would come up with something better.I do not know why the writer says "even the board of ICI". I suspect that the board of any company would come up with something better.
The best testimony in our behalf today perhaps comes from one who is not a devoted Socialist but the Tory leader of the Greater London Council, Sir Desmond Plummer, who refers to this new NHS as being "a largely bureaucratic system."
The article in the Financial Times of 23rd January, to which my right hon. Friend referred, was even more scathing. It referred to the grey book of managerial detail asthe result of Sir Keith's fancy and a 174-page piece of wonderment for future historians'The article went on:You want to read this marvel of modern management to believe it. It is full of organisational charts that look like London Underground maps without the simplifying advantages of the Circle Line. It is written in prose that is so turgid and complicated that to get from page one to page two it is necessary to have a night's rest in between. It is peppered with references to Area Health Authorities by their initials, so that one hopefully stops every other page at the words 'AHA' as if this was an exclamation of exultation at some revelation. It never is.The biggest waste of NHS resources since I have been interested in the subject has been the expenditure of £220,000 plus paid to the American business consultants, McKinsey Incorporated, for the report on which this Bill is based. I was fortunate in being able to get hold of what was the McKinsey first tentative hypothesis; 954 that is what they called it, and it was so incomprehensible that they had to issue a glossary of the jargon of management in order that it could be understood by ordinary common or garden people. I must be one of only a few hon. Members who have waded through the grey book, though I am pleased to say that the Under-Secretary of State has, and also the hon. Member for Aylesbury (Mr. Raison). I submit that out of 630 of us three is a very poor percentage.
If this Bill reaches the statute book, apart from all the other jargon within the Bill about managerial areas we shall have a spate of initials. We had NHS; trite and elementary. Now we start with DHSS at the top, and we shall move on to RHA, AHA, AHA(T), FPC, DMT, ATO, CHC, RTOs and the DMC. Having dealt with that lot we shall go on to DCP, DNO, DFO, DA, AMO, ANO, AT, A A, RMO, RNO, RWO, RT and RA. All of these appear in this grey book; I am not making this up; it is all part of it. We finish with RAO, ADO, DPO, APO—all issued by HMSO on behalf of DHSS. I thought I might find somewhere Cs—the citizens—or even P, meaning patients.
§ Mr. Pavitt
We are not even there. We do not exist.
The Secretary of State has been just as-much misguided by his other source which led to the Bill, the source of managerial expertise provided by Professor Jaques and Brunei University Health Services Organisation Research Department.
At the time when I served on the North-West Metropolitan Hospital Board I had some occasison to look at some of the material which Professor Jaques was putting forward. Because so many of my colleagues want to speak in this debate I have not time in this speech to go into detail of the Glacier Metal concept. The Glacier Metal Company is a company which exists in my constituency. Here was an outstanding example of the managerial approach in a business context; but what was good for a company is completely wrong for the NHS. I would commend to the House, however, the analyses which emerge from two doctors, Dr. Draper and Dr. Smart, and 955 the Rowntree project at Guy's Hospital. They show that this Bill, based, as the Secretary of State thinks, on managerial efficiency and the managerial concept, is based on managerial concepts which are outmoded and have found little support in modern management for the last 10 years, so much out of date that not only are they no good for the NHS but they would be no good for industry in the 1970s.
I come now to the point raised by the right hon. and learned Member for Huntingdonshire on the question of Clause 4. Family planning prescription charges will be nonsense. All prescription charges are nonsense, and the Secretary of State knows that. It has already been pointed out that there is an exemption for children under five and people over 65. For contraceptive pills? A lot of people are not going to have to worry about them anyway, but all prescription charges were put on mistakenly in the first place, and the House knows that I have not changed my view since with 150 back-bench supporters I tried to prevent prescription charges from being imposed in the first place.
The idea at that time, six years ago, was to get £25 million. We have raised the charge to 20p and last year raised £17 million in England after six years. The The taxpayer paid eight civil servants £10,000 to check for cheating in the London Executive Council and then produced £143.50 last year. The more one looks at it the more nonsense prescription charges are seen to be. The Under-Secretary knows that we are to spend an extra £30 million this year for medicines, and that prescription charges have probably played a part in securing that increase.
There are special reasons why it is wrong to have prescription charges for family planning. First, it will mean a switch of the work load from qualified and specialist clinics to the general practitioners, from the local authorities to the general practitioners. The result will be that because of the extra work load they will have to receive more pay which will not be offset by the charges. So we get back to square 1. Extra remuneration would certainly be demanded for extra counselling.
956 What is more important is that the hard-pressed, hard-working general practitioner has not time for this counselling. So what happens? If somebody comes in and asks "Can I have the pill, please?". there will not be diagnosis by the doctor; he will not have time; there will be self-diagnosis instead, whereas the essence of the present service is advising and counselling, and the important thing is how one organises this.
From experience in my locality I have no doubt that this will be a backward step. We have a free service in Brent, and in the last 12 months there has been a 67 per cent. increase in the number of people coming for advice. As a result of an analysis that we are making of the 100 people who came recently, we find that we are now getting more irresponsibles, more of the poorer section of the community, the people who most need advice who were not coming before. The advantage of free supplies is that the people who are in need of counselling and advice are more likely to come for it. In addition, health visitors can follow through the family case, so that not only are unwanted children not brought into the world but other social problems that emerge can be dealt with.
I presume that the only way in which the clinic can put a charge of 20p on the prescription is by doing what is done in the out-patients' department and using stamps. A stamp machine costs £350. What would be the cost of installing all these machines just to put stamps on prescriptions?
The mother who has a baby has free prescriptions for the first 12 months after the birth of the child. If the baby dies, the mother has to pay for her prescriptions and she will immediately have to pay prescription charges for contraceptives. Will the Under-Secretary deal with this problem when he replies? I hope that in Committee we shall be able to preserve Clause 4 in its present form so that there will be no prescription charges, and to amend Schedule 5, which repeals some extremely important Family Planning Acts.
Perhaps the most revealing decision in the Bill is contained in Clause 5, which retains all the mechanisms that are at present within the local executive council 957 sector. We are pretending that there is a change, but all that we are doing is to change the name of the local executive committee, including the local medical committee and the local dental committee, to the family practitioner committee.
My fear is that in this gigantic shake-up of NHS administration we shall end up with a continuation of vertical divisions. We shall end up precisely where we are already, like Omar Khayyám, back through the same door through which we came. There will be a vertical structure with sub-committees of hospital boards, sub-committees of local health authorities, sub-committees for the family practitioners, all doing the work that is done now, the only difference being that they will be under a new umbrella. We are merely preserving the old under a new hat.
I hope that the Secretary of State will look again at his proposal for units for the young chronic sick inside hospitals. The whole point of the Chronically Sick and Disabled Persons Act was to integrate services to these people not just in hospitals but right across the board. The right hon. Gentleman is now proposing to put back responsibility squarely on hospitals. That proposal misses the whole point of what we are seeking in the reorganisation of the NHS, for, although the proposed units are an improvement upon the old arrangements, we want more community and less institutional care.
I should be interested to learn more about the new committee of inquiry into health of schoolchildren. How powerful will it be? What are its terms of reference? Is it to be a Royal Commission? The whole area of preventive medicine is extremely important. It is right that the school service should come into the NHS. but we should like to know more about how it will be done.
In my view, the whole crux of the reorganisation is to knock down the vertical walls and to have functional bodies on horizontal planes, comprehensive to the communities of the patients for whom they provide care. What I want is for all the doctors in the community— general practitioners, consultants, junior hospital doctors, community physicians— to be in a comprehensive set-up and not split up into hospital doctors and general practitioners. A person should not be 958 looked at separately according to whether he is in hospital, at home or in a factory. He is the same person. I hope that the Bill will break down the hospital walls and enable the whole of medical skill to move across to where the patient is, with the same applying to nurses, dentists and pharmacists. We do not want district nurses and hospital nurses; we want nurses. We want them to be co-ordinated as a professional body right across the board.
The more I learn about health, both here and from the many other countries I have been privileged to examine the more it emerges that it can be an administrative convenience and at the same time the height of folly and unnecessary administrative muddle to put medical disciplines into watertight compartments and to divorce health care from welfare, social services, environment, housing, employment and the nutrition of schoolchildren.
The Bill is wholly unacceptable to me. We shall, naturally, seek to improve it in Committee, but we face a pretty hopeless task. So much will depend upon the timing—not of the passage of the Bill but of the fall of the Government. The devoted workers in the NHS cannot stand too many upheavals, but I hope that a Labour Government will throw out this bodged-up piece of high Tory managerial "tycoonism" and replace it by a genuine reorganisation, full of participation opportunities and democratic controls, and charged with community understanding and compassion. The NHS is not there for the administrators or even for the doctors and nurses, it is there for the patient— the patient first and last.
The Bill has missed the opportunity to move away from curative care to preventive measures. That is the goal we have been searching for ever since the NHS was first established. This Bill will not achieve that, but it could have given us the opportunity to do so. A great opportunity has been missed, and I look to a future Labour Government to seize it.
§ 5.17 p.m.
§ Mr. Airey Neave (Abingdon)
I think that the hon. Member for Willesden, West (Mr. Pavitt) may have exaggerated when he said that the Bill was an example of 959 Tory "tycoonery", although I know he has a great practical knowledge of the National Health Service.
I agree with what the hon. Member said about the speech of my right hon. and learned Friend the Member for Huntingdonshire (Sir D. Renton), and I support my right hon. and learned Friend in his view on the family planning service. I hope that the Government will take note of what the hon. Member for Willesden, West said about a free service, about which I shall say a few words. I shall speak only on Clause 14.
I devote my remarks to this subject because of a motion in the name of my hon. Friend the Member for Dorking (Sir G. Sinclair) which takes note of the recommendations of the Fifth Report of the Select Committee on Science and Technology, of which I am Chairman, and also because of the amendment to the Bill which was passed in another place.
In July 1972 the Select Committee recommended that comprehensive family planning and birth control services should be a normal part of the National Health Service. In this respect the Bill and what my right hon. and learned Friend said represent some progress towards what we had in mind, but the Select Committee did not have as its terms of reference the question of prescription charges. That may be a matter for discussion in detail in Committee.
Speaking for myself alone, I should like to see a completely free family planning service as to both supplies and advice. I wish that my right hon. Friend the Secretary of State had gone much further in what he said on this. In 1971 the Select Committee published a report urging population control and ministerial responsibility. When my right hon. Friend the Secretary of State gave evidence before the Select Committee on 12th July 1972 he said that his responsibilities for family planning were quite separate from population issues and that he was concerned only with health. The Select Committee did not share that view at the time. I felt that it was—and still is—an artificial description, and that view has now been supported by the report of the Population Panel under Mr. C. R. Ross.
960 The panel's report is moderate and wisely-written. It does not go far enough for some people and may go too far for others, but it is an excellent production. Following the publication of the Select Committee's report in July 1972, I made some rather sarcastic observations about the panel which I should now like to withdraw. I said that the panel was somewhat low-powered and would not have enough influence. That remains to be seen so far as the Government are concerned, and I hope that the panel's decisions will be implemented. At that time I was seeking on behalf of the Select Committee to urge the Government towards accepting our recommendation that family planning should be a normal part of the National Health Service.
It is most important and relevant that in paragraph 43 of the panel's report we find these words:Policy in regard to family planning services should take account of population implications instead of being decided as at present entirely in terms of its effect on health and social welfare.That important statement makes an overwhelming case for a free service, and I hope that the House will eventually support that point of view. The Select Committee two years ago, despite much opposition, pursued its aims in its two reports, and I consider the Committee's view to have been justified. Therefore, I hope the Government will share its view and implement the panel's conclusions. Paragraph 43 of the panel's report, which I have quoted, means that family planning is a matter not only for the individual but is a matter for the community. It may seek to relieve distress and hardship and to reduce illegitimacy and abortion, but it is also a matter for the community as a whole. This is the important message which has come out of that recent publication by the panel
§ Mrs. Elaine Kellett-Bowman (Lancaster)
Did my hon. Friend see in February the comment by Professor Potts of Cambridge, that increased use of the pill will lead to increased abortions and that a doctor will be required to give a larger follow-up service?
§ Mr. Neave
I have not had the advantage of either reading or hearing from Professor Potts to that effect, so I cannot comment on what my hon. Friends says.
961 But I should be surprised at that comment, and it would be against the weight of opinion, which is that a comprehensive family planning service, if carried out reasonably boldly in humane terms, would reduce the demand for abortion.
§ Mr. Phillip Whitehead (Derby, North)
Is the hon. Gentleman also aware of a survey, reported in New Society on 14th December last, which said that of the women who had consulted the British Pregnancy Advisory Service with a view to abortion over a quarter of the married women and a half of the single women had taken no precautions whatever, and certainly had not been on the pill.
§ Mr. Neave
That is much more likely to be the case than the argument put forward by Professor Potts, whom I do not have the benefit of knowing. I cannot say very much about that.
I believe that as soon as the Government come out with their conclusions on the Population Panel's report the House should have a debate. This is one of the most important questions in this generation, and we should discuss it fully. I have no doubt that my right hon. Friend the Leader of the House will take note of what I have said.
The social and environmental problems will be much greater if we do not have a population policy—and a credible one. Although I welcome the statement made by my right hon. Friend on 12th December extending family planning services, I feel that he has not gone far enough to implement what has been said about population policy. I believe that the population questions cannot be dissociated from government in the future. If the Government decide to have a population policy, my right hon. Friend will have to change his attitude. If he wants to encourage interest in this problem among the public in general, it will need to be shown that this policy will apply to all families and not only to those in the low income groups. There should not be an artificial distinction such as that between health and population. The panel says in paragraph 416 that the full cost of the service would be a matter of concern not only to those in the low income groups. I hope that this matter will be considered when the Bill is discussed in Committee.
962 We hear a good deal about unwanted births, and I would ask the House to look at the section of the Population Panel's report which deals with this subject and points out that at least one-third of unwanted births take place in wedlock and occur to women over the age of 30. This point came out in the Select Committee's evidence, and we bore it in mind when making our recommendations. In seeking to persuade people of the advantages of family planning, we must overcome a good deal of ignorance and misunderstanding through all the income and age groups.
Since my right hon. Friend's policy has been to encourage local authorities in family planning, many areas, such as Aberdeen, have provided free services. This shows that my right hon. Friend will need to re-examine this matter. Aberdeen shows clearly how a free birth control service justifies the expenditure by a local authority and results in a saving on its social welfare services. The same would be true of the National Health Service, and I do not think there will be any argument about that.
My right hon. Friend will have to look at the position of the London boroughs in regard to the number of new patients. If the previous patients were able to get free supplies and services, what will happen to new patients? There is obviously a clear anomaly in what is now suggested. Those who are now automatically entitled to free contraceptive supplies should continue to be so entitled, but once we look at population policy—a policy which the Government will soon have to announce to the House—clearly the rest of those families should be able to benefit from free family planning services.
§ Mrs. Kellett-Bowman
On a point of order, Mr. Deputy Speaker. May I, with your permission, correct one word in what I said earlier. I should have referred to Dr. Malcolm Potts, the Medical Director of the International Planned Parenthood Federation, who saidAs people turn to contraception, there will be a rise, not a fall, in the abortion rate.I erroneously referred to him as "Professor"
§ Mr. Deputy Speaker (Sir Robert Grant-Ferris)
Order. That is not a point of order for me. If it is more than just a 963 word, the hon. Lady should raise it tomorrow, perhaps by way of a personal statement. I cannot allow a long explanation of something which the hon. Lady said wrongly and which she now seeks to raise as a point of order.
§ 5.28 p.m.
§ Mrs. Renée Short (Wolverhampton, North-East)
This debate takes place against a sombre background of unrest and concern throughout the whole of the hospital services. But not one word in the pedestrian, mediocre speech of the Secretary of State for Social Services gave any indication that he understood what he was playing with.
I think that the right hon. Gentleman in bringing these proposals forward is dealing a serious blow to the National Health Service. These proposals, as my hon. Friend the Member for Willesden, West (Mr. Pavitt) said, are based on Glacier Metal's big business plans—proposals which have no part in the rest of the National Health Service because they do nothing to benefit the patient, who should be the most important person in the National Health Service. If the right hon. Gentleman wants to improve the efficiency and costing of the National Health Service—and it certainly needs improving—there are other ways than this of achieving his aims.
When the Expenditure Committee investigated the National Health Service we elicited a large amount of evidence which threw up the shortcomings in the National Health Service. We heard criticisms which mirrored the frustration and anger of many sections of workers. We heard complaints about the build-up in waiting lists, queue-jumping by private patients, and swapping from a private bed to a National Health Service bed within a few days to avoid costs. Conversely, we heard about patients being admitted into National Health Service beds and then, quite contrary to the Minister's own regulations, being charged for the use of them.
We had evidence about the use without charge by private patients of National Health Service facilities, X-ray and path lab facilities and about medical and technical staff employed full-time in the National Health Service even sometimes being used in other premises by consultants with their private patients. None of 964 the Minister's suggestions will alter this state of affairs. We had evidence of secretarial services provided by the National Health Service being used by consultants for their private patients.
There is no argument about it. Private patients pay to get into hospital before thousands of people who remain on waiting lists. What is more, they get into hospital when it suits them to go in. People can jump the queue if they can afford to pay. All this acts to the detriment of patients on waiting lists. No witness could deny this. Consultants, junior hospital doctors and representatives of the Institute of Health Service Administrators admitted that it happened.
We know that private patients get better conditions. The Royal College of Nursing gave us interesting information from first-hand experience about better conditions, more liberal visiting time, no restrictions on children's visiting, better food, a better choice of menu, better crockery, food more attractively served, rooms with showers and lavatories, better furniture and better facilities for keeping patients' clothes in rooms, radio, television, more privacy and a general relaxation of hospital rules and regulations. The nurses told us that on the medical side private patients get personal attention and daily visits from consultants. Diagnostic facilities for private patients have priority over those for National Health Service patients. Relatives have greater access to consultants if they wish to discuss cases with them. We were told that on the nursing side ward sisters and senior nurses give paying patients more attention, and patients get clean sheets and towels more often. Private patients are seen more promptly in outpatient departments. Often they do not have to pay out-patient charges.
If we believe in the National Health Service, should not we ensure that all patients get these facilities and better treatment and that they should not be only for those who can afford it? What is the Minister doing? Most nurses told us that they prefer to nurse National Health Service patients because they are less demanding and less arrogant. Private patients tend to treat them as slaves. ladies' maids, domestics or worse.
The Minister must know that his proposals will do nothing to help deal with these wrongs. They will not right them. 965 The Minister denies that many of these wrongs exist. On many occasions he has been asked about them, but he denies that wrongs exist. He does not agree that queue-jumping exists. But from time to time all Members must receive complaints from their constituents that others get into hospital before they do or that they have to remain for long periods on waiting lists before urgent operations are performed. We have heard of cases having to wait 18 months or two years for gynaecological operations, from four to six months for hysterectomies, 18 months for tonsillectomies, two years for vasectomies, and many months for varicose veins operations. The Minister's proposals will do nothing to reduce the waiting lists.
What about the evidence from the medical secretary of a large ophthalmic clinic? The Minister says, when asked about private practice, that no urgent health service case has to wait. That is not true. What about the ophthalmic surgeon who said "If we keep them waiting long enough they get fed up with being unable to see and agree to become private patients"? What about the old lady who had an operation as a National Health Service patient on one eye, was told that she needed an operation on the other and that there was no knowing when a bed would be available, but that if she was prepared to pay £250 she could have it done immediately? What about the ambulance service being used to bring in private patients? What about the old lady of 98 who waited 18 months for a cataract operation? What could be more urgent than a cataract operation at the age of 98? What about the cancer patient who was told that there was a three-week wait for an urgent operation but that if he went in as a private patient, which he did, it could be done the next day? What could be more urgent than a cancer case which apparently is operable? What about the instruction given by a consultant to an appointments clerk in a chest clinic to build up a waiting list where none existed before so that the consultant could deal with patients privately? What about the priority given to private patients on operating lists? One consultant wrote to me saying:I cannot recall a single operating list where private patients did not get put first on the list. This is for the convenience of the consultant, not the patient. Consultants 966 can easily perform private work and then leave National Health Service patients' operations to registrars. This releases him for more private work if he wishes.Many doctors, consultants, hospital technicians and organisations gave evidence to us in public. Many others including patients wrote to me after seeing Press reports of our meetings. They cited cases from their experience of abuses and malpractice by some consultants—and I emphasise that it is "some". But the loopholes are there and advantage is taken of them.
One eminent gynaecologist wrote to me about a county medical officer promoting private practice among his nurses and midwives by doing propaganda for a private insurance scheme.
Why does the Minister push all this evidence under the carpet and close his eyes to the abuses that exist? Why does not he reply to the criticisms made and the evidence given in public to a Select Committee of this House? His bile should rise when he reads of this unequal treatment to certain unhappy people. In my view and that of my Committee, he is guilty of a gross dereliction of duty if he does not deal with the evidence of these abuses and continues to refuse to take steps to see that they are put right.
I emphasise again that this Bill will not deal with the problems. It may be, of course, that the Minister wants us to believe that the doctors, consultants, unions of hospital workers and individuals who gave evidence to the Committee are all liars. He cannot have it both ways.
How does the Minister think that his proposals will help regional hospital boards which are short of consultants, often because the opportunities for private practice are difficult to come by? The average number of consultants per 100,000 population in England and Wales is about 16.48. In the Leeds, Sheffield, East Anglia, Birmingham, Manchester and Welsh regional hospital board areas, they are well below average. In some the figure is as low as 14. Is it by chance that the metropolitan areas have more than 20 per 100,000 population? More affluent people live there. It is a part of the country near the large teaching hospitals.
967 I ask the Minister again: do not all National Health Service patients, wherever they live, have the same right to the best consultant cover as those who live in the metropolitan areas? The Bill will do nothing to deal with this problem.
We have had a speech from the right hon. Gentleman putting forward his proposals for reorganising the National Health Service. They are proposals which will introduce the ideas and principles of big business. But they will ignore completely the patients and their relatives. The proposals for an ombudsman are quite ludicrous. There are two main groups of complaints in the National Health Service today. Those in the first group come from patients and their relatives about the kind of treatment that they receive in hospital. Very often it is treatment that they receive from doctors and consultants. The Minister will not be able to deal with that group of complaints. Those in the other group come from junior doctors who wish to complain against their seniors. There is a mass of evidence before the Minister about the iniquities of the present system whereby junior doctors dare not make what use they can of the present totally inadequate complaints system simply because they rely on consultants for good testimonials when they apply for promotion up the ladder.
§ Captain Walter Elliot (Carshalton)
Is the hon. Lady suggesting that the health commissioners, when they are appointed, should investigate diagnosis and that kind of matter?
§ Mrs. Short
One health commissioner will be appointed, the present ombudsman, and he will then investigate complaints which are made. The whole basis of the ombudsman will be undermined if he and his staff cannot deal with this large section of complaints. A large proportion of the complaints come from the general public. Are not the general public important?
§ Mrs. Short
No, not again.
We must understand that considerable vested interests are being given a tremendous amount of influence, even more than 968 they have today, in the National Health Service and the work of the hospital service. That is saying a good deal.
The organisations whose representatives gave evidence to the Select Committee have connections with many people who support the growing practice of private insurance, which is one of the greatest supporters of private practice in this country. Indeed, a member of the Committee was a director of one organisation. The Secretary of the BMA is a director of another of these private insurance organisations. Many top consultants who are heads of the Royal Colleges are also directors of one of the three largest firms supporting private insurance. Therefore, a good deal of their evidence is highly suspect. However, the Minister chooses to accept their evidence rather than that from a broad cross-section of workers in the hospital service and a large number of patients and their relatives.
There is a great deal in the Bill which we must put right if it is to deal with the abuses which I have hurriedly gone through as I promised not to take too long. In my view, the Minister should take the whole rotten Bill back from whence it came and think again. If he does not want to do that, we will think for him.
§ 5.42 p.m.
§ Mr. Anthony Fell (Yarmouth)
I know full well, before embarking on my speech, which I shall try to make not too long, that I shall be most unpopular because of what I say—at least among some hon. Members here this afternoon.
I should like to ask questions, first, of my right hon. Friend the Secretary of State for Social Services and then of my hon. Friend the Under-Secretary of State.
My right hon. Friend, who made a tremendous speech, said that public opinion now supports free contraception for all, or certainly those were almost the words that he used. I do not know on what he bases this assertion. I do not think that there has been any serious research into public opinion on this matter. [Interruption.] I warned the House that I should be unpopular. Perhaps the hon. Gentleman will contain himself for a couple of minutes. I do not wish to go further on that topic.
969 My right hon. Friend said that doctors can prescribe various forms of contraceptive. What he did not say was whether doctors can prescribe—I presume they can if they think fit—sterilisation for women or vasectomy for men. I do not know whether that comes under Clause 4. I presume that is a general cover of every form of preventing children being born. I should like to know the answer to that question, if possible.
I pose the next question, which arises on the same subject, to my hon. Friend the Under-Secretary of State. Last year, when we discussed the National Health Service (Family Planning) Amendment Bill in Committee, which brought in vasectomy, some of us had the impression that at least the requirement would be that for somebody to be vasectomised the husband and wife should be agreeable— [Interruption.] The hon. Member for Wolverhampton, North-East (Mrs. Ren6e Short) was not a Member of that Committee. Perhaps she knows better than I do. It so happens that I was a member of that Committee.
On 13th February Baroness Wootton, in another place, asked:whether it is a fact that neither under English or under Scottish law a woman must obtain her husband's permission for a sterilisation operation, but a man can have a vasectomy performed without the permission of his wife?
§ Mr. Deputy Speaker
Order. The hon. Member is out of order in quoting from a speech made in another place unless it is a ministerial answer to a Question.
§ Mr. Fell
It is the ministerial answer that I want to quote now. It is very short. The Minister of State, Department of Health and Social Security replied:My Lords, I am advised that there is no legal requirement either under English or Scottish law that the consent of a spouse must be obtained to the sterilisation of the partner."— [OFFICIAL REPORT, House of Lords, 13th February 1973; Vol. 338, c. 1400.]That is a complete change from what some of us understood when we discussed the vasectomy Bill, which I understand has been taken under the wing of the Bill that we are now discussing.
I, like my hon. Friend the Member for Abingdon (Mr. Neave), wish to speak only about Clause 4. I realise that this is a Second Reading debate, but my only argument with the Bill is basically about 970 Clause 4. As I see it, there are several backgrounds to the clause, but one of the most insistent which has been argued by certain societies, and so on, has been that to provide free contraceptives to everybody would help to reduce abortion. My right hon. Friend was not keen on that argument. He did not think that any such view could be substantiated—at least for the moment.
The next argument is about the avoidance of unwanted pregnancies. I am careful about the words. My right hon. Friend is very careful about the words and insists on "unwanted pregnancies". He does not even go so far as Lord Gardiner who talked about unwanted births, which I can see is a slightly different matter.
I raised this matter earlier because a survey has been made by a reputable body called Political and Economic Planning. I do not know what it represents, but it was referred to in a speech in another place. It has dividedunwanted births into ordinary cases, into the third, fourth, fifth and sixth child in a family which has never made any provision for contraception at all, and illegitimate children."— [OFFICIAL REPORT, House of Lords, 19th December 1972; Vol. 337, c. 989.]We are told by an authoritative body that has come to advise us out of the blue that it is possible that the third, fourth, fifth and sixth children will, by natural rejection rather than natural selection, come into the category of unwanted children or unwanted births—[Interruption.] I said at the beginning of my speech that what I should say would not be popular. It will be much less popular before I finish.
§ Mr. Fell
I should like some closer definition of "unwanted pregnancy". I know that my right hon. and learned friend the Member for Huntingdonshire (Sir D. Renton) and my hon. Friend the Member for Norwich, South (Dr. Stuttaford) have strong views on these matters. I am endeavouring to put them as reasonably as I can from the other point of view. [Laughter.] I do not think that it is very funny to be talking about this subject. I do not think that it is cause for amusement that thousands of unborn children are being killed every year. I do not think that it is very amusing to discuss what the Bishop of Southwark called 971 "near infanticide" being practised generally all over the country. I do not think that this is a matter for fun and games.
I want to try to establish what people mean when they talk about unwanted pregnancies. I can see that there are certain occasions in certain families when it can be said that a child, even when it is born, is unwanted, but I should like to be told the percentage of so-called unwanted children who are born following an unwanted pregnancy—unwanted because the parents are not married, because they are poor, or for a hundred and one other reasons.
§ Mr. Thomas
I am obliged to the hon. Gentleman, but I am sorry for my hon. Friend the Member for Glasgow, Kelvin-grove (Dr. Miller). Does the hon. Gentleman think that a married couple have the right to decide for themselves that they do not want a pregnancy? If they have that right, are we right to withhold from them the facilities which would enable them to fulfil their ideas?
§ Mr. Fell
The right hon. Gentleman knows my answer to that. Of course a married couple have the right, as my right hon. Friend said earlier this afternoon on two occasions, "under God", to decide how they will plan their family. The danger of Clause 4 is that the decision may not be "under God" but under the Minister, whoever he is, with his advice to everybody on how to run their lives 972 coming with the blessing of the Government.
§ Mr. Whitehead indicated dissent.
§ Mr. Fell
I know that the hon. Gentleman does not agree with me, but it is no use his sitting there shaking his head. He looks wiser than ever when he does, but it is no good his doing so.
My hon. Friend the Member for Abingdon made the most extraordinary remarks about the report of the Population Panel. He said that he had made rude remarks about the panel some time ago but he withdraws them now because of this marvellous report. I think that (he report is a load of rubbish. The whole thing is based on a guess.
There was an eminent man called Sir Winston Churchill, who, speaking of population trends, said:There is no branch of human knowledge in which we can pierce the mysteries of the future so clearly as in the trend of population.The report, on the other hand, says:our best guess is that policy should be based on the assumption that the population of Great Britain will increase from a 1971 level of 54 million to about 64 million at some time during the first decade of the next century.That is not quite as precise as the great man, Sir Winston Churchill, gave us to believe it could be as a result of his experience, and his experience was much longer than many of us have had.
The report goes on to say:Our third conclusion is that given a not too unstable world situation, Britain should be able to find means of accommodating any likely increase in population over the next 40 years. The situation is not such as to require immediate policy initiatives'".That sentence does not tell me that there is great danger of Britain being unable to take care of a normal population expansion which may follow if nothing is done.
The report is saying that, in a general sense, there is a public opinion which wants everybody to have free contraception and that births should be controlled. Controlled by whom? They are to be controlled not by the family but by busy-bodies operating under the Minister or under local authorities.
§ Mr. Whitehead
The logic of the hon. Gentleman's attack on the report of the 973 Population Panel is that we should not entrust these difficult matters to learned and dispassionate committees of inquiry, but should take refuge in the thoughts of Sir Winston Churchill. Is the hon. Gentleman saying that that is how we should solve the problem?
§ Mr. Fell
The logic of what I am saying is that we have to start to think much more carefully about the people to whom we entrust these things.
Recently there have been half a dozen or more television programmes about euthanasia. That will probably be the next thing that we shall deal with in the House, but I shall not go further into that or I shall be in serious trouble with the Chair.
The hon. Member for Derby, North (Mr. Whitehead) referred to the learned men on the Population Panel; but they make all sorts of prophecies which mean nothing in their report. Table 16, which deals with population models for Great Britain, is the most extraordinary thing that one has ever read. The report takes three standards, and the difference in the increase over 10 years between the lowest and highest standards is incredible. The figure for the lowest is 2.9 per cent., while for the highest it is 10.7 per cent. There is such an enormous variation that nothing factual or sensible can be derived from guessing the resultant figure. As the panel says in its conclusions its guess is that nothing better than that can be done.
Of course these people are clever, and of course they are honest, but, judging from the quotation which I have just read, Sir Winston Churchill would have thought them extremely stupid. They are honest, but they are guessing. Therefore, the report cannot be factual. It is based on guesswork. I therefore say that it is a travesty to base the Bill upon the report. This measure is based on guesswork and, in my view, this House should not pass legislation which is supposed to appeal to the public if the basis of it is guesswork. I do not believe that that is good enough. I now turn to what was said by my right hon. and learned Friend the Member for Huntingdonshire. The so-called moral argument falls to the ground. This is the dreadful difficulty about the argument that I am trying to put forward, in that I am trying to stop Governments taking responsibility away 974 from people. I do not want Governments to interfere with the responsibility of people.
§ Sir D. Renton
If I may say so, my hon. Friend is trying to answer an argument which has never yet been made in this House. Nobody is suggesting—the Government are not suggesting, and none of us who are keen about a family planning service has suggested—that anyone should tell parents how many children they should or should not have.
§ Mr. Fell
I am sorry. My right hon. and learned Friend has made his speech and he is missing my point altogether. The point is that the moment that the National Health Service (Family Planning) Amendment Bill, the vasectomy Bill, became law, the idea was automatically accepted into this Bill. It will be accepted almost without an argument. My right hon. and learned Friend says that I am missing the point because the Government would never take such action but would only advise people. But what does advice mean to the people about whom we are talking? What is advice if there is a split in the family at the time, if the father and mother are not getting on too well, if they have had a child and are having terrible rows? The local health visitor or counsellor hears about it, gets one of them to come along and persuades them in the torment of their row perhaps that the man should be vasectomised. [An HON. MEMBER: " No."] This is what it is all about, from one point of view.
§ Dr. Tom Stuttaford (Norwich, South) indicated dissent.
§ Mr. Speaker
Order. I must ask hon. Members not to provoke the hon. Member. He has already been speaking for 20 minutes.
§ Mr. Speaker
I think that I was very tactful in suggesting that other hon. Members might need protecting, too.
§ Mr. Fell
You will know, Sir, from the protection you just gave me, that I nave been under assault ever since I have been on my feet, both before and since you came into the Chamber. It is difficult to get through my speech in these circumstances. I told hon. Members that I was going to be controversial but that I wanted to get on with it. I am in some difficulty and will have to give up some of what I wanted to say.
I want to end on this question of responsibility, which my right hon. and learned Friend the Member for Huntingdonshire helped me towards. I just do not believe that the House is giving enough thought to the way that the nation is going, to the way that authority is impinging on ordinary people. We have had battles in this House on all sorts of matters. Hon. Members opposite are against me on this, but they are the first to scream about democracy.
But here we are ready to accept a new band of paid people who are to tell people how to run their lives—not the so-called "best" people, the wealthy or the well-off or the better-off but the poorest people. We have the temerity to condemn them because perhaps they have too many children—[Interruption.] I know the hon. Member's views very well. It is all very well his disagreeing with me, but it is as well for all hon. Members occasionally to stop and think what we are doing and how these things will work.
It is easy enough for Parliament to become a grand-aunt who will look after all the people who are in difficulties. It is easy enough to say that we shall pass laws willy-nilly, but this is to disregard a prime fact, that if one continues to take away from people their own sense of responsibility they will be left in the end without any sense of responsibility. Then the nation has to look after the whole of that section of the population.
This is a matter which must be given some thought. The murder of children in their tens of thousands that has been going on over the past few years and has accelerated ever since the Medical Termination of Pregnancy Act was passed, the terrible expansion of disease—
§ Mr. Whitehead indicated dissent.
§ Mr. Fell
This all comes under Clause 4. There has been a terrible expansion of disease, which is surely allowed to be mentioned in a debate on the revamping of the National Health Service, a terrible expansion of gonorrhoea, apparently, since the pill has been pushed out in vast numbers. Who is to say that Clause 4 will not lead to a worsening of that situation? No one could say with any confidence that the passing of this clause will make for a more robust or self-reliant people or a people less beset by the diseases brought about in the last few years since the passing of that dreaded Act.
You will be delighted, Mr. Speaker, to hear that I am about to sit down. I will not say that this is my last word five times, either. I simply appeal to the Government to think a little more about what they are doing in Clause 4 of this otherwise reasonably good Bill.
§ 6.7 p.m.
§ Mr. Christopher Mayhew (Woolwich, East)
It is extraordinary what passions Clause Fours seem to arouse, and also what loquacity, if I may say so without offending the hon. Member for Yarmouth (Mr. Fell). It takes an effort of will to recall that there are 56 other clauses in the Bill. The Secretary of State's announcement about contraception seems to have sterilised discussion about them.
However, I should like to come back to them, particularly to a point made by the right hon. and learned Member for Huntingdonshire (Sir D. Renton). He began by congratulating the Secretary of State on his success in squeezing money out of the Treasury for the mentally handicapped and mentally sick. That was justified. The Secretary of State has built up a good reputation for personal concern about the mentally sick and mentally handicapped.
This is surprising in one sense because, if one looks at the Bill from the point of view of the needs of the mentally disordered, its weaknesses become very apparent. The objective of the Bill is shared by all of us. We all hope that the Bill succeeds in attaining its objective and we mean to do our best to ensure that it does. But let us look at it from 977 the point of view of the mentally disordered. It goes without saying that the needs of the mentally disordered and those of the physically ill and handicapped for the health services are different in one or two very important respects.
For example, the mentally disordered have much greater need than the physically sick or handicapped for continuity of care or treatment across the whole range of health and welfare services. Most people who leave hospital after, let us say, having their appendix out simply want to pick up where they left off as soon as possible; but, as we know, many mental patients need continuing care, both medical and social, and if possible from the same people as looked after them in hospital. It may be a bad thing for a mental patient to try to pick up where he left off. There may be good medical reasons for different accommodation, a different job, and so on. How does the Bill cater for this need for continuing care across the board?
On the positive side, of course, the Bill produces health boundaries which match with local authority boundaries. That is immensely important, as the Secretary of State rightly said. We also have the joint consultative commissions between the area health authorities and the local authorities and also the health care planning teams. If these bodies work well they, too, can contribute a great deal towards the continuity of care which is so important.
All the same, though the gap between medical and social care may be bridged, it is not being removed. It is still true, for example, that a decision to discharge a patient into sheltered accommodation involves one authority in a clear financial gain and the other authority in a clear financial loss. It is still true that the hospital authorities get a strong financial incentive to discharge mental patients, and local authorities get a strong financial disincentive to provide those patients with sheltered accommodation. Financially this system might have been specially designed to increase the army of utterly miserable people who are in effect discharged from mental hospitals into reception centres or prisons, or on to the Embankment or under the bridges.
Granted the structure of administration proposed by the Minister, cannot this 978 particular problem be overcome within the structure? I can see doctrinal reasons for not requiring health authorities to contribute towards the cost of community care. There is a doctrine that a clear frontier exists between health care, on the one side, and social care on the other side, and that medical care is part of a health service but social care is not.
That may make some sense when we are talking of physical health, but mental health is only partly a medical problem and there are increasing reasons for saying that it is mainly a social problem. Even if we accept and stick to the Minister's doctrine—which I do not— what are the practical objections to making health authorities contribute to community care? For example, why should not area health authorities be required to pay local authorities a sum of money every week for each mental patient discharged into local authority sheltered accommodation? Might not that be a better way of encouraging local authority provision of community care than contributing to the rate support grant?
I turn to a second example of how the health service needs of the mentally disordered differ from those of the physically sick and handicapped, namely the fact that the mentally disordered have a significantly greater need for protection. I am not thinking only of those rare but important cases of ill treatment, but more generally of the neglect which can so easily happen to those who cannot speak up effectively for themselves. It is not only the fact that the physically sick can and do complain more readily and effectively than the mentally sick and handicapped; it is that the physically sick need the health services for comparatively short periods, whereas many mentally disordered people have to rely on them for large periods of their lives. Their need for protection is greater and their ability to express that need is much smaller.
How do the Secretary of State's proposals cater for this need for protection? The establishment of the health Commissioner is particularly welcome from that point of view. The hospital advisory service is doing admirable work but it cannot handle specific individual complaints. For the rest, however, almost 979 all our hopes are pinned on the community health councils. I hope profoundly that they prove equal to their task. They have no executive powers. They have to rely simply on their powers of persuasion. Above all, they are on the outside looking in. One of the laws of administrative life is that, other things being equal, the man on the inside will always out-argue and outwit the man on the outside. That is the danger that lies ahead of the community health councils.
In another place useful amendments were passed to increase the authority and independence of these councils, but I should like to suggest to the Secretary of State a proposal put to me by a number of leading voluntary organisations, including the National Association for Mental Health, or MIND as it is now called. We should like the Bill to provide for a central community health council which would consist, of, perhaps, about 14 representatives of community health councils from all over the country and which would have an independent chairman and, perhaps, five representatives of special interests appointed by the Secretary of State. Such a central council would have the right to co-opt and it would be financed by the Secretary of State. Its functions would be to encourage and support the 200 community health councils, to supply them with information, to act as a focal point for discussion of issues which arose locally, to be available to the Government with advice on council matters, to evaluate the workings of the community health councils and, in general, to represent at a central point the interests of consumers of the health services. Such a council could be of considerable value in increasing the authority, importance and influence of the community health councils.
The Secretary of State is determined —he has explained why—not to give the consumer a due place on the management side. What I am suggesting does not conflict with that principle if he insists on sticking to it; but it may help to meet some of the just criticisms that have been made about the apparent inadequacy of the community health councils. I hope that the Secretary of State 980 will pay serious attention to that suggestion.
In conclusion, I have serious doubts as to whether this new management structure will work well from the point of view of the mentally sick and handicapped. The Secretary of State will no doubt argue that a structure which gives full scope—as this one does—to management ability, technical skill, drive and energy is very much in the interests of all sick people, whether mentally or physically sick. No doubt that is true. If we enter a hospital, for instance, with a broken leg, we want to be put right safely, efficiently and quickly. But if we go into the health services because we are suffering, let us say, from a severe depressive illness, we need humanity, warmth, judgment, personal contact and continuing care. The Bill does not provide for those things.
I admit that the logical solution to the problems about which I have been talking would be attained not by simply bridging the gap between the health authorities and local authorities but by abolishing it altogether. Logically that could only mean making the local authorities responsible for the health services. We know of the powerful financial and professional obstacles to that. After all the delays, debates and Green Papers, it would not be very helpful or responsible to suggest tearing up the Bill now and starting again from scratch. But if from the beginning the problem of health service organisation had been approached rather less from the usual point of view, that of the physically ill, the articulate and influential ill, and rather more from the point of view of the mentally disordered, who are inarticulate and lack influence, a different structure might have emerged.
I hope that the new structure succeeds. As time goes on, however, as mental disorder fills a proportionately larger number of our hospital beds, as it will, and claims a proportionately larger share of health manpower and money, as it should, I think we shall be driven towards that more radical solution.
§ 6.19 p.m.
§ Dr. Tom Stuttaford (Norwich, South)
I start with a tribute to my right hon. Friend the Secretary of State. He has been misunderstood by the Opposition. They feel that my right hon. Friend has 981 a sinister, malevolent approach and that he is not interested in the patient. I feel certain that he is interested in the patient but that he is going about serving the patient's needs in the worst possible way. He has introduced a management scheme which is very top heavy in administration and strikes terror into the heart of many members of the medical profession who will have to operate within that scheme. In all sectors of medicine, speed is essential. Speed will be lost with what amounts to almost a five-tier structure. If speed is lost, the problems which may arise right down at ward level will take time to solve.
If, on the other hand, there is a neater structure, even if it is less likely to meet the approval of McKinsey, it will meet with the approval of the patient. As has been said already today, no one is in medicine except to serve the patient, whether it is the Secretary of State or the most junior nurse.
We have produced in the Bill a manual which is outdated before we start. We attack the diseases of the 1940s and the 1950s with the management ideas of the early 1960s. This is bound to cause trouble in the future. We have failed to take account of the changing pattern of disease.
Disease is constantly altering. The Victorians had their plagues—their cholera, their smallpox, their childbed fever, which decimated their population from time to time. We too have plagues: plagues caused by stress—coronary thromboses; plagues caused by small families, to please my hon. Friend the Member for Yarmouth (Mr. Fell)—for instance carcinoma of the breast; plagues caused by changing sexual habits —carcinoma of the cervix. These changing habits must be dealt with by a changing public health system.
We are not giving due credit to what has been achieved by local authorities and the medical officers of health of the past. They are not just people to stand by as powerless oracles. They have an active part to play in combating the modern diseases, the diseases which may well kill other hon. Members and me in a stressful atmosphere in the House of Commons. They are not just community physicians to talk and not to act. They 982 must act, and to act they must have a team with them. We are destroying a system which has grown up.
On the subject of Clause 4, where would we have been today if it had not been for the example set by many local authorities, people who have not only preached but have practised what they have preached and have supplied free advice and free services in family planning to anybody who has come and asked for it—not, as my hon. Friend the Member for Yarmouth has said, only to the poor, but to the needy, whether the needy are rich or poor? That should be the basis of public health.
Another point which should be corrected is the idea that teaching hospitals do not play their part. They do play their part. They have an important part to play. It may be true that they have fewer geriatric wards than the local hospitals or that they do not have as many wards where the mentally subnormal may go. However, surely it is far more important that by their work and research they may help to prevent mental subnormality and that they look into problems of old age intellectually so that others not only may go forth from" their teaching and provide the correct service all over this country but, indeed, may go from the British medical schools to all over the world.
A terrible misconception is growing up in medicine. There is a misconception growing up because it is very easy for anyone inside an in-group to hoodwink those outside it. What has happened in medicine is that doctors who have failed to make the grade in one of the major specialties—failed to become princes in an established kingdom—have established their own empires elsewhere, somewhere where they can lord it over everybody; they have their own kingdom, after all, but a different kingdom.
This can happen all too easily in such new subjects as geriatrics. What is needed in geriatrics is a basic knowledge of medicine, coupled with kindliness and concern, and a basic understanding of the problems of old age. These problems of old age will be eased by the right selection of doctors to work in geriatrics, and more by the example set in teaching hospitals than by taking away some of the influence of the teaching hospitals so 983 as to have some degree of parity between all hospital services. The teaching hospitals have been denigrated in a very unfair manner.
While on the subject of old age I return to the question of community medicine, because the problems of old age occur in the community. We must realise that many of the new diseases occur because of social problems. They occur because we in medicine and in our social services have not learned how to deal with old people before they become old and decrepit. We must look after old people when they are still fit and active so that they do not need hospital care right at the end.
I want finally to make one or two comments about private practice. I have a vested interest in private practice and I am happy to declare it. Unfortunately, I had to be out of the Chamber when the hon. Lady the Member for Wolver-hampton, North-East (Mrs. Renée Short) was speaking. I should very much like to have heard what she said.
One of the problems in medicine in Britain today is that people die in a hospital with real privacy and real dignity only if they pay, and a mother can have her baby with safety and consideration only if she pays. Apart from these two areas and the scandalous length of waiting lists, private practice is on the whole beneficial to the State and to everybody in the country rather than detrimental.
§ Dr. Stuttaford
Because Britain retains the best doctors in the world, which is one very good reason for having private practice.
To summarise, the Bill is inadequate for the needs of the 1970s, it is top heavy in management, it will prove to be cumbersome in performance and I think that we will rue the day when we changed the existing system for one which is not an improvement.
§ 6.26 p.m.
§ Mr. George Wallace (Norwich, North)
My hon. colleague the Member for Norwich, South (Dr. Stuttaford) has spoken as a practising doctor and one who frequently brings his medical experience and knowledge to debates in the 984 House. In contrast, I shall speak as one who has served for many years at hospital management committee level.
For the information of the right hon. and learned Member for Huntingdonshire (Sir D. Renton), I should say that I was one of the dear old boys now existing who was in at the birth. I played my part at Aneurin Bevan's celebration dinner, but I will not tell the House what happened to me thereafter.
Although from time to time I have had some criticism of the system of nomination to management committees and regional boards, my impression of those amongst whom I have worked is that these people are dedicated and involved right up to the heart in the work they are doing, and at times one cannot judge whether they are Tory, Liberal, Labour or non-political. All that is apparent is their dedication and drive to getting a better service and achieving the highest possible standards.
At some stage during the proceedings on the Bill a tribute should be paid to the many hundreds of voluntary workers who have attended in their own time without payment or reward, save the satisfaction of serving and seeking to provide the best service for the sick. We do not pay them sufficient tribute, nor do we recognise what they do. They are not by any means bungling amateurs.
The Bill makes a fundamental mistake in not recognising that the drive comes at local level. I speak with some knowledge, having battled since 1937 for a new hospital which will shortly be opened. However, the good will and best intentions of hospital management committees have been restricted and frequently frustrated by long-distance control, by ministerial regional boards. With freer and greater control at local level much more would have been achieved, because we all know what delays can occur with planning teams and so on. Those at local level who know the needs of the people often have severe attacks of blood pressure because of the frustrating and sometimes bureaucratic delays. Unfortunately, the Bill will not change this. We shall have community health councils but they will be no more powerful than the present visiting or house committees. It may be that they will have less power. House committees have their reports published. 985 the management considers them and discussion takes place. Members of house committees are members of management committees.
There is a chain of communication in the health service administration which is of vital importance. We are told that the community health councils will make representations and that they will receive written replies. Will those replies be discussed? Will there be people available to give the viewpoint of the community health councils on how to manage the area health boards?
It is essential, whatever the shape or form may be, for each hospital to have its own committee and not to share a committee which is spread over a large number of hospitals. If each large hospital has its own committee there will be more personal contact with staff and patients. That contact is vitally needed.
It would have been far better to set up groups composed of the existing management groups, but of a slightly larger size and with increased powers, which would be directly controlled by the Department and would have direct access to it, and to abolish regional hospital boards. That would have reduced public expenditure, increased efficiency and reduced time-wasting. It would have allowed decisions to be made and would have helped people to get on with the job.
In the last 12 months or so since the emergence of the Green Paper, the White Paper and the Bill, the question of joint consultation for committees and staffs in individual hospitals has emerged in the proposed drastic changes. There is no mention in the Bill of joint consultation at all levels between management and staff. By "management" I refer not to senior officials of a regional board but to outside people who are appointed representatives to deal with the staff and who are not involved in the internal administration. This is a matter of vital importance because drastic changes are obviously bound to lead for a while to grievances, rumours and an unsettled atmosphere.
That happened when a regional board, with approval and support, amalgamated two hospital management groups. The result was that the administration of the management committee was moved 986 from one hospital to another. It was moved from Sidcup to Orpington. Any hon. Member with a knowledge of public opinion in Orpington will know the problems that that move caused.
I am chairman of the joint consultative committee of Queen Mary's Hospital, Sidcup. The committee began the job of consulting management and staff as a result of the frictions and difficulties that arose from the centralising of administration. Consequently all the frictions and difficulties have gone. That is because we discussed the problems and rumours and scotched the rumours. As a result the staff were extremely happy.
My next point is important, bearing in mind the present industrial situation in the hospitals, which I do not want to discuss. Will there be joint consultative committees for hospitals under the new set-up? It is essential that there should be because, as I have already pointed out, in the early years of the new regime staff relations must be considered.
I strongly protest against the timing of the Bill. By the time it has passed all its stages we shall be only a few months away from the appointed day. That will give only a short time to deal with the reallocation of staff. The Leader of the House, when I pressed him about the matter, told me that the Bill was in another place. It has eventually reached this House, and hon. Members must consider the Government's timetable. I do not know their timetable for the Bill before it receives Royal Assent, but I cannot see that stage being reached before the end of June. In that case we shall be a matter of only a few months away from the appointed day.
I can illustrate my point. Not long ago, under the Salmon proposals, we appointed a chief nursing officer. Under the new set-up our hospital management group is to be split three ways. Where will that lady go? I do not know and she does not know. In fact, nobody seems to know. The same applies to administrative officers and others. They do not know what their future arrangements and their family arrangements will be. Those arrangements are still in the melting pot.
What is the position of hospital secretaries? No mention of them is made in the Bill. Those of us involved in hospital administration know that at local level 987 hospital secretaries are the vital go-between of staff, patients, the public and committees. They are invaluable people who are grossly underpaid. They perform a vital service. Will they remain or will some of them become redundant? They do not know.
All these people in the administrative grades have been under extreme pressure in negotiations and discussions since the issue of the White Paper and the introduction of the Bill. All these matters are dependent upon the passing of the Bill and further amendments in committee. In the reorganisation news sheets issued by the right hon. Gentleman's Department— I agree that it is a good thing to issue that news—there is a small paragraph at the bottom of the sheet which says that what is contained in the news sheet is subject to the Bill passing all its stages unaltered.
We are not dealing, thank heavens, with the Industrial Relations Act or the European Communities Act, on which there was no opportunity for full democratic discussion. There must be such an opportunity with this Bill. No guillotine should be imposed upon it. The drastic changes which are proposed in the Bill cannot, in my experience, be undertaken without creating chaos and confusion. So far everything has been decided in working party groups, and administration officers have enough on their plate already. There is every justification for the Government to realise that and to postpone the appointed day for at least one year so as to be fair to the service.
I warn the House that I can see the health service being under great strain due to the changes taking place and the difficulties which will arise and because staff will not know what is to happen to them. I spoke to one senior officer only a few days ago of what was in my mind about postponement. He said "For God's sake, don't put that forward. I am fed up with the whole shooting match. We are talking a lot of hot air and getting nowhere fast."
That is what the staff think, and they are the people to whom we look. I believe that there is every justification for a postponement. However, I do not expect that the Government will bring about a postponement as they are determined to 988 get their legislation through. I can understand that.
I have been critical but I hope that I have also been constructive. I was one of the few hon. Members who took part in the birth of the National Health Service in this House many years ago. That legislation, and what preceded it during the latter part of the war, captured my imagination and still has a hold on my idealism, as it has for so many people. Benefits have been received and services have been given, and I say in all sincerity that the health service, if properly operated, is the parable of the Good Samaritan in active operation.
There is on both sides of the House general support for the National Health Service. The only differences between us are on certain principles. May we be united in showing to the world Britain's greatest example, a health service to bring happiness and to ease suffering to our people.
§ 6.41 p.m.
§ Sir George Sinclair (Dorking)
I welcome the Bill in some ways because I believe that it contains far-reaching improvements in bringing many parts of the National Health Service into better working relationship and in developing the services for the patient. On the other hand, it has some disturbing and disappointing features.
I should like to confine myself to three aspects—public involvement in the management of the National Health Service, relations of the National Health Service with private practice, and family planning.
During the Second Reading in another place on 4th December it was stated that public participation in the management of the National Health Service would be reduced from 13,165 to 1,640. In this figure the community health councils were excluded because they were purely advisory bodies. I question whether such a drastic reduction in public participation in the management of the health service, as is proposed in the Bill, is in the interests of the service or its relationship with the public, or in the interests of the patient.
It has been argued that doctors had demanded less lay interference in the running of the service. That may be. It is 989 natural enough for busy professional people—and I do not know any who are harder worked than the doctors, but it is, I am sure, good for them to have to justify their proposals and their policies to a sample of laymen as they go along; otherwise they are exposed to the risk of becoming bureaucratic and being alienated from the public and the neighbourhood which they are paid to serve.
On the positive side, laymen involved in the decision-making process can help the professionals to avoid mistakes in assessing public reactions to their policies, and they can help to explain those policies to the general public. They can also greatly help to build up local support in finance and in voluntary work in the hospitals and other national health services in their areas.
Now that the involvement of laymen in the management is to be so drastically reduced, it is of the greatest importance that those appointed to management bodies should be first-rate. So, a great deal will depend on the calibre of those appointed to the regional health authorities by the Secretary of State and those nominated by the regional authorities to serve on the area health authorities.
I very much hope that the Secretary of State will not be persuaded to increase local authority representation on these bodies. The new local authorities—I have served on old local authorities—will have such heavy burdens of direct responsibility that they can ill spare the time and energy of their best members for this additional work. I leave the Secretary of State to draw his own conclusions.
I hope that the Secretary of State will ensure that the voluntary services, which are mentioned in Clause 13, will be fully used. I should like to see a number of appointments based on the great voluntary services which have served our hospitals and our health services, especially in rural areas. If we are to have a humane and compassionate as well as a professionally efficient National Health Service, we must so far as we can involve the voluntary services in helping to form an additional sensitive membrane of local concern, care and compassion between the patient and the paid staff of the institutionalised National Health Service.
990 I ask that some experienced and active workers from these voluntary services should be appointed to the regional and area health authorities. They would help to ensure that the National Health Service makes the best possible use of our old-established as well as some of our new voluntary services that are achieving so much for those in distress. The voluntary services can add to the humanity of the health service and can help to care for and reassure patients at times when they are vulnerable individuals. They can also, if they are efficiently used, help to reduce public expenditure.
I hope the Secretary of State will, in the National Health Service, leave open opportunities for voluntary services to the community by the old and the young, by the rich and the poor. For these volunteers this service will be a justifiable form of personal fulfilment. It will also make good use of unused and under-used manpower seeking community service. This is especially important in view of the increased leisure that will soon be available to the community. It is for this reason that I give the warmest welcome to one new initiative of the Secretary of State— the provision of funds for paying organising secretaries for voluntary groups working with the National Health Service.
Another innovation of the Secretary of State is the community health council. As I see these councils, they are an attempt to bring public opinion to bear on the management of the health service but also to insulate these volunteers from the making of day-to-day decisions. It is quite uncertain at this stage whether the managers of the health service will treat these community health councils in a positive way and seek their help and involvement or whether they will regard them as irrelevant advisory bodies which are nothing but a nuisance. I should like to hear from whoever is to reply to the debate what steps he proposes to take to ensure that the managing authorities pay real respect to these councils and enable them to become active partners in improving the service and in establishing a relationship of real confidence and understanding with the population in their areas.
I should now like to make a few remarks on the private sector. I am disturbed by the lack of encouragement in the Bill to the private sector. I have examples from my constituency, which I 991 have passed on to the Minister, of local hospitals, because of a ministerial circular, changing their practice and demanding that pathological services, which are free under the health service, shall be charged to patients because they are in a private nursing home nearby which does not offer pathological services. I cite this only as an example of the withdrawal of help to the private sector. I hope that my right hon. Friend will look into the support which the National Health Service should be giving to private practice, which is still taking a good deal of the workload from the National Health Service.
I come now to my last point. Family planning has aroused a great deal of passion as well as a great deal of thoughtful argument in this debate. I am deeply disturbed by the Secretary of State's indication that he does not intend to accept Clause 4 as it stands. That clause now provides for a comprehensive and free family planning service, including free supplies. It means basically that the family planning service is to be regarded as part of preventive medicine and as a service to the community. This is the way I believe that it should be looked at. For this reason I believe we are justified in supporting this clause on the basis of the recently published report of the Population Panel—especially paragraphs 43 and 448. My right hon. Friend has indicated that he does not intend to accept the amendment made in another place and the clause as it now stands. In this, he seems to be disregarding the great change that has taken place in public opinion, not only in this House but in the country outside.
§ Mr. Raison
Is it not a fact that neither paragraph 43 nor paragraph 448 states that family planning services should be provided free? They both state that they should be part of the National Health Service, and nowhere do they recommend categorically that these services should be provided free.
§ Sir G. Sinclair
I believe that if the clause is changed family planning services will be reduced rather than expanded, and I shall come to that point in a moment.
§ Mrs. Kellett-Bowman
My hon. Friend referred to the family planning service as being a preventive service. Would he not 992 regard the provision of such things as antibiotics as a preventive service? They are on prescription, and that does not reduce their intake.
§ Sir G. Sinclair
I have not so referred to that aspect because I was trying to deal with the broad sweep. Preventive services by and large are provided free as a community service and I believe that family planning services should be on an equal footing with them.
The Secretary of State gave us examples of organisations, with widespread support, which are not given to hasty, emotional approaches to matters and which have weighed this issue carefully and have debated it all over the country. I refer to the same organisations—the Church of England Board of Social Responsibility and the National Federation of Women's Institutes—but there are many others which regard a free and comprehensive service in this field as urgent and necessary. Also there are 64 back benchers on this side of the House, among others, who have signed Early Day Motion No. 77 calling for such a free service. We hope that the Secretary of State will listen to the arguments in the Chamber. We hope that he will listen also to the arguments in Committee. We hope that he will, in the end, decide to accept Clause 4 as it now stands.
At the moment my right hon. Friend is going in the opposite direction. In replying to an intervention by my hon. Friend the Member for Plymouth, Devon-port (Dame Joan Vickers), he seemed to indicate that he intended to discontinue, when they came under the National Health Service, the free services already provided by a growing number of boroughs. I regard this as a retrograde step and a disaster for family planning.
These clinics, because they are specialised, have had a great appeal. They have carried out a service that has been increasingly welcomed, as the attendance figures show, in the areas where they operate. They have been popular with their own people—the ratepayers of the area—and they have pioneered the service and have shown that it can be operated satisfactorily in parallel with National Health Service provisions. To wipe out this service seems to me to be entirely retrograde. That answers the point I 993 was making to my hon. Friends who questioned me just now.
Far from wiping out this free local authority service, I hope to see my right hon. Friend establish under the National Health Service a network of specialised clinics covering the country and providing a comprehensive and free service. It is these clinics that can be of the greatest service to the young and to many more who may not wish to go to hospitals or to get involved, at any rate initially, with their family GP. I predict that before many years have passed such a network of clinics will be established throughout the country by public demand. I ask the Minister to take the initiative in developing it, and not to wipe out those free services that have already been established.
I at any rate believe that many of us on this side will do all in our power to try to persuade the Secretary of State to accept Clause 4 as it now stands.
§ 6.58 p.m.
§ Mr. David Steel (Roxburgh, Selkirk and Peebles)
I agree with the latter remarks of the hon. Member for Dorking (Sir G. Sinclair), and I am sure he will agree that one of the unfortunate features of this debate is that we are really running two debates in parallel—a debate on the reorganisation of the National Health Service, which is very important, and a debate on family planning, which is also important. I regret that they are being run together in this way. For the sake of brevity I say at once that I shall address myself to the family planning aspect, leaving it to my hon. and learned Friend the Member for Montgomery (Mr. Hooson) to seek tomorrow to deal with the reorganisation side.
In a speech I made in July 1972 on the National Health Service (Scotland) Bill [Lords] I drew to the attention of the House four recent reports then available on the provision of family planning services under the National Health Service. I quoted from the report of a working party of the Royal College of Obstetricians and Gynaecologists which said quite specifically:There should be no financial disincentive to the provision of advice and services by any doctor working within the National Health Service.994 I also quoted from a PEP report and from the report of the Office of Health Economics. I also quoted the resolution just passed that year by the British Medical Association, which stated:That a national and uniform family planning service should be set up, including the provision of free planning advice and equipment by general practitioners.On top of all those reports recommending the establishment of a comprehensive and free family planning service under the National Health Service we have had The report of our own Select Committee on Science and Technology and the much-quoted report of the Population Panel, as well as the various outside bodies which have been mentioned—the Women's Institutes and so on—which have indicated their views to the Government. In addition, in December of last year—just a week before another place amended Clause 4 to its present form—a National Opinion Poll was carried out. That poll showed that 64 per cent. of the electorate thought that the Government should provide a free birth control service for all men and women. That is a clear answer to those who still doubt whether public opinion is behind us. Indeed, I argue that the Government are lagging behind public opinion in their attitude on this matter.
It seems to me that the benefits of effective family planning may be briefly summarised in this way. First, it would help to stabilise and contain the growth of population. In this connection the pamphlet published last week outlining the experience of the city of Aberdeen is extremely valuable. Aberdeen is the only area in the country with several years' experience of comprehensive birth control provision free of all charge. It has succeeded in bringing down the birth rate to replacement level, from 17.2 births per 1,000 population in 1950 to 14.4 births per 1,000 in 1970. I believe that the specific experience gained in Aberdeen proves that a comprehensive free family planning service plays a part in stabilising population growth.
Second, it brings health benefits to the population as well. In Aberdeen the number of comparatively high-risk pregnancies—that is, pregnancies in women aged 35 or over, or in those with large families already—has been greatly reduced, with the result that there were no maternal mortalities in 1969 or 1970, 995 while the stillbirth and perinatal and post-neonatal mortality rates showed an impressive fall. In Aberdeen the infant mortality rate of 12.3 per 1,000 is one of the lowest in the world.
Third, an effective family planning service provides social benefits. An effective family planning policy can reduce the pressure on other resources in a number of ways. It can lower the risk of large unplanned families. It can prevent illegitimate births. It can prevent recourse to abortion. Also, it can indirectly improve housing conditions and generally ease the lot of the less affluent groups in our society.
If I understood him aright, the Secretary of State said that the revenue from the prescription charge to be levied would be about £3 million a year. That seems a relatively paltry amount when set against the cost-effectiveness of a comprehensive family planning service as shown in the PEP study, which said that for every £1 spent on family planning we could save up to £100 in public expenditure on health and welfare services.
At the same time we must bear in mind that the cost of an abortion on the National Health Service is anything from £80 to £120, and in 1971 there were 53,000 abortions in National Health Service hospitals in England and Wales.
What is more—I think that this answers the hon. Member for Yarmouth (Mr. Fell) —the cost of keeping a child in care for one year is about £1,000. In 1971, 90,000 children were taken into care and of these about 5,000 were under two years of age. In the same year about 800 children were abandoned or lost. About 3,000 illegitimate children were taken into care because the mother was unable to provide for them, and a further 25,000 were taken into care because of the incapacity of the parents to look after them. As I say, I regard that as the answer to the hon. Member for Yarmouth and others who argue that society does not know what an unwanted child is. Alas, those figures show that it does.
The medical officer of Aberdeen, Dr. MacQueen, has estimated that for his city the two items of expenditure of £17,000 on contraceptive services and £18,000 a year on health visiting and health education represent a total annual saving in 996 rates and taxes of about £200,000. We must keep the whole cost of this exercise in perspective, and I do not understand why the Government have failed to go far enough in providing a totally free service.
In many areas, so we understand from today's announcement, the Government propose to move backwards. In areas where contraception is already free, the numbers of new patients have risen dramatically. Brent reports a 60 per cent. increase in new patients, Hammersmith a 50 per cent. increase, Lambeth a 59 per cent. increase and Islington a 74 per cent. increase. These are dramatic figures showing that the provision of a comprehensive free service in a given locality has resulted in more people coming forward and making use of the service.
The medical officer of health for Lincoln, writing in the British Medical Journal earlier this month, said:the case for free family planning services is overwhelming. The local authority family planning service became completely free in September 1972, and the number of women attending in the first quarter was twice the average for the previous four quarters. This proves"—the Government should be seized of this important point—that although the cost of supplies may appear to be insignificant, it is indeed a disincentive to many women, and particularly many of the women whose needs are greatest.I shall end by quoting from a letter which I received from a constituent, a lady whom I do not know, who cites her own experience in going recently to a family planning clinic, not in the town where she lives, because there is not one there, but to a clinic 15 miles away. She says:My aim in going was to get specific advice on contraception and to have a cervical cancer test taken. Both of these I was able to get, but in order to obtain the former I had to ' join ' the clinic for a yearly fee of £2. There was also a charge of £2.46 for six months' supply of oral contraceptives … and also I paid £1 for the smear test.This is the important sentence:For all I know, these charges may be very reasonable for the services provided, but why should I have to pay a total of £5.46—which I quite honestly cannot afford—for a service which the Government should provide?".I hope that, after the Bill has been passed by the House, the Government will have provided it.
§ 7.7 p.m.
§ Mrs. Jill Knight (Birmingham, Edgbaston)
I was delighted to hear my right hon. Friend say that the care of the patient was the underlying intention of this vast reorganisation exercise. He will know that there are many groups and associations which are extremely worried about just that. I was glad to hear him say, not once but two or three times, that he had the patient very much in mind. But others will want to be sure that the patient will actually benefit from what we are endeavouring to do.
The hon. Member for Norwich, North (Mr. Wallace) referred to the Association of Hospital Secretaries. I have had some communication with these important gentlemen, and I know that, although they warmly support the idea of unifying the health service, they are worried about whether the Bill does it in such a way as to benefit the patient. In expressing their concern, they used what I thought a telling phrase—Patients do not come to the National Health Service to be administered—they come to be cured.The hospital secretaries referred to the importance of the planning cycle. It all sounds rather like "The House that Jack built." It goes something like this. This is the Department of Health and Social Security, which suggests the plans. This is the regional health authority, which looks at the plans suggested by the DHSS. This is the area health board, which gives planning consent to the regional health authority for the plans suggested to it by the DHSS. This is the district management team, which will look at the plans and prepare them at district level— and so on.
We go all down that pyramid, and then, apparently, we go back up again because the plans have to go through all these bodies and levels of function. The Association of Hospital Secretaries is concerned, as it puts it, that there is too much scrambling up and down pyramids and not enough authority vested in any one level.
The hospital secretaries say that much the same will happen in regard to catering. At present, the catering officer employed at the hospital does the job. Now, apparently, there may be a catering manager at district level, another at the 998 area, and another at the region. Whether all this will provide better food has yet to be established.
Reservations are expressed from the teaching hospitals. I have a copy of a memorandum from them in which they appear to express considerable worry about their future status. I hope that my right hon. Friend will be able to smooth away these fears, because they say:The great teaching hospitals, as for the last two or three hundred years, have during the last 20 of the National Health Service given legion service. Why destroy their internationally and nationally famed distinctive aura in a system acknowledged as the finest in the world for something untried merely for the sake of change …?I do not like changing things merely for the sake of it. I wish to be assured that the change will be for the better. The memorandum goes on to say:The relationship between the teaching hospitals and the medical schools should be left inviolate as it has produced doctors whose skills are sought all over the world. We have no assurance that the present proved and excellent state of affairs is to be maintained.That is something about which I would wish to be sure when we are working our way through the Bill in Committee.
Hospital managers have reservations. Lay members on hospital boards of governors and management have been immensely useful in the past. I do not wish to labour the point, but some of them are concerned about what is suggested in the Bill. The reservations of consumer groups may well be assuaged by what my right hon. Friend said about community health councils.
Apart from all the other aspects of the tremendous edifice which we appear to be building, has anyone yet quantified the cost of paying increased staff? The National Health Service already regularly runs us pretty heavily into the red. Many of us want to see many more extensions to the health service, and we are frequently told that one of the difficulties is that there is not enough money. What will be the cost of paying increased staff and the people engaged on administrative work? There may well be a considerable increase in the number of civil servants working within the National Health Service. What will be the cost of them? I am not talking only 999 about salaries. Extra personnel mean extra costs in many ways.
The enlightened residents of Edgbaston did not elect me as their Member simply to sign a blank cheque for unspecified large sums of money to establish a bureaucratic hydra of mammoth proportions. I instance the decision to build a number of new district general hospitals. Why do we need to build these enormous places? I imagine that they will be edifices of between 500 and 1,000 beds, and the cost of £10,000 per bed is not excessive. Yet the Office of Health Economics recently showed that only 5 per cent. of all general patients need district general hospital facilities. In other words, 95 per cent. can be cared for in small hospitals. Whether we need parts of all district general hospitals to be areas dealing with plastic surgery, cardiac surgery, neuro surgery, radio-therapy, dialysis and renal transplants we do not know, but the OHE makes it plain that, in its view, there is no case to be made out for all these highly specialised departments to be put in all the hospitals we are building.
How will the reorganisation of the National Health Service bring in those VIPs, the occupational therapists and radiographers? We are falling down badly in many areas because of a lack of these vital people. I am concerned that we should do something positive to bring in more such people. I am not sure that the Bill makes that possible.
Many other points which I could raise are probably Committee points. For instance, Clause 2, which defines the duty of the Secretary of State, refers to aftercare for illness. We need after-care for accidents, too. I was glad to hear my right hon. Friend the Secretary of State say that later—I think he said this week —he will announce his decision regarding the medical social workers and the great dichotomy which is evident between the social workers as a whole and the medical social workers. There are, with reason, ruffled feelings in this area, and I await with great interest what is said about it.
I come, inevitably, to Clause 4. I was very glad to hear what my right hon. Friend the Secretary of State said today. I welcomed his statement at the end of last year that £17 million was to be spent on a new and expanded service for family 1000 planning. He has gone further today. In this area most of all, I am concerned about young people.
The argument about the population explosion has flaws. It is said " There is a population explosion; therefore, we must have a free planning service." I wonder whether there is a population explosion. I have a cutting from the Daily Mail of 28th February which is headlinedBirth-rate falls to its lowest ever.The article reads:The Government's latest figures are now confounding all previous estimates of the country's population by the end of the century. If the current trends continue the population will remain static at 56 million—and there is a strong possibility that it will begin to fall within 20 years.
§ Sir D. Renton
I am sure that my hon. Friend realises from her studies that the birth rate has always fluctuated. It probably always will. When the large number of girls born between 1959 and 1968 reach child-bearing age, it is virtually certain that the birth-rate will not only rise again but rise substantially.
§ Mrs. Knight
I have already heard my right hon. and learned Friend say that today. I listened to him extremely carefully. However, everything that he said about the population explosion falls down because it is based on hypothesis. He cannot possibly be sure about it. Yet not only does he adduce it as being fact when it is only supposition but he asks us to act on it in a way which none of us can be sure will affect the population in the way he states, anyway.
§ Dr. Stuttaford
Does my hon. Friend agree that there may have been a slight fluctuation in the last year or so due perhaps to the development of local authority clinics and an improved birth control service? It might therefore be a pity to go back on what has been done by the authorities and have a less good service in future.
§ Mrs. Knight
My hon. Friend has little faith in the good sense of the British people. Yet he has said that the propaganda—although he did not put it quite like that—about population has had its effect. People in this country are not stupid, and I am sorry if anyone thinks that they are. They do not do things only if those things are free. Many people do things which are extremely 1001 sensible and they are happy to pay for them. The idea that they are not is the flaw in the argument.
The case that the population explosion is dependent on the number of births has not been made out. The population in this country is at the figure that it is for a variety of reasons—for example, people are living longer; people are not dying after accidents as they used to do. Immigration figures have also possibly had something to do with it as well. It is quite extraordinary for anyone to try to put one across this House by saying the population is exploding so fast when the birth-rate is going down, and that we must make birth control free for everybody—for when girls get a little bit older.
§ Dr. Miller
If the hon. Lady looks at the report of the Population Panel, table 59, she will find that the 1955 birth-rate was 15.3 per 1,000 and it was lower in 1955 than last year. She is not suggesting is she, that because the birth-rate was low then the population of this country has not increased since 1955?
§ Mrs. Knight
I am sorry if I did not make it clear. I thought I was making it perfectly clear. I was saying that the birth-rate has fallen, is continuing to fall, and is falling very rapidly indeed. I have certainly read that report very carefully, but I wonder whether the hon. Member has read a gentleman named Malthus. People have been making wrong predictions about the birth-rate for hundreds of years, and this one is no more accurate than any of the others.
What seems to me so extraordinary, and I must repeat it because hon. Members do not seem to have grasped the point, is to suggest on the very shaky evidence which they advance we should thereby have a free birth control service. It is a great piece of nonsense. The population explosion argument for a totally free birth control service simply does not stand up.
So what are the other reasons? To prevent the unwanted child; but let us say "the unwanted pregnancies" instead of "the unwanted children". I can remember in this House not so very many years ago hon. Members saying that if only we were to pass the Abortion Act there would not be any more unwanted 1002 pregnancies. [HON. MEMBERS: "No."] They did. This has been proved absolutely inaccurate. Many people said that.
§ Mrs. Knight
Let hon. Members look up HANSARD at the time and they will see plenty of examples of hon. Members saying that.
Would free contraceptives cut down the number of unwanted pregnancies? Would they? Very many doctors believe it would be less likely to reduce unplanned pregnancies than to create a further impetus towards diminishing responsibilities in personal relationships among young people. This is a fact to which I draw attention, but I will quote a doctor well-known in the family planning field, Dr. Malcolm Potts, Medical Director of the International Planned Parenthood. Let no one think I am quoting somebody who necessarily entirely holds the views I do. He said:As people turn more and more to contraception there will be a rise not a fall in the abortion rate.What he is saying is that as people turn to contraception there will be a rise in the number of unplanned pregnancies. That is absolutely clear, and I do not think anyone would argue with it, because, of course, we are creating a climate, just as the Abortion Act created a climate and has led to far more abortions than anyone in this House believed to be possible.
§ Mrs. Knight
I am sorry, but I have been immensely patient and there are other Members who wish to speak.
The point is clearly made that if there are free family planning devices, free contraceptive devices, for everybody, a climate is created in which it is more likely that there will be more unplanned pregnancies and not fewer.
One of the things which worry me very much at the moment is that many young people think that if they do not sleep around there must be something wrong with them, because of the kind of pressure which is being put upon them.
§ Mrs. Knight
I am afraid that it is not nonsense. I wish it were, but I am afraid that it is not.
I would draw attention to another gentleman well-known in the family planning field, Mr. Caspar Brook, of the Family Planning Association. He says,The age of consent is not relevant".I would beg the House to realise that what we would be doing if we were to pass Clause 4 as it is at the moment would be to encourage people by giving free contraceptives to children of any age —well under the age of consent. Mr. Caspar Brook says the age of consent is not relevant. Heaven save us! He says that it is high time this were done away with. He goes on to say—this is the kind of advice he gives—If you are the sort of boy or girl who promises all and then says 'No', this sort of chastity is not very fair on the other person".What does this advice do to young people under pressure? I said that I am worried about young people, and the climate that is being created at the moment for young people. There are too many agencies today dishing out contraceptives without the slightest warning of the dangers which go along with them.
I do not think the case has been made out that free contraceptives will save on unwanted children, but will they save on the cost of children in care? That indeed is highly debatable, and we could have an interesting debate on that, but nowhere yet have we got clear evidence that the provision of a totally free family planning service gets rid of all the children in care. In fact, it does no such thing, and even were it to cut down the number of children in care, would that be a reason for having these things free on the rates or on the taxes?
The cost of car accidents is very high indeed. The individuals who are taken to hospital after accidents in this country cost us thousands and thousands of pounds, but is there any suggestion before this House that because that is undeniably the case we should provide seat belts free? There are many young people who tragically come off their motorcycle even at a very early age and are total wrecks for the rest of their natural lives. I have 1004 seen one of them, because we in Birmingham have one of the only two clinics in Britain for these people. These victims of motor cycle accidents cost the country heaven knows what before they die. Does anyone suggest for one moment that we have free crash helmets? Of course not. Yet expenditure on those things would be much more likely to save money than this.
What about VD? Does no one at all in this House worry about the rocketing VD figures? There are commercial pressures at work here. I would ask some of the hon. Members so keenly advocating free contraceptives to ask themselves whether or not they are being made a tool of by people who are anxious to sell more and more and more of these things.
Let us just look at the VD figures. Apparently they are not thought relevant. I think them highly relevant. In the last 20 years male VD has gone up by 122 per cent. and female VD by 485 per cent. and, of course, very steeply recently. In 1971 there were more than 300,000 registered cases of VD. Does nobody care about this appalling rate of rise?
If women are enabled through Clause 4 to go on the pill for free this House should realise that it has now been proved beyond all doubt that the chemical reaction on the body of a woman taking the pill creates a condition in which the gonococci thrive, escalating the chances of infection on a single exposure from 40 per cent. in a woman not taking the pill to 100 per cent. in a woman who is. The pill has undoubtedly been a factor in the rapid spread of VD, particularly in women—not, of course, all women. There are many thousands of married women who have one partner and who have been taking the pill perfectly safely. Not all of them are women who cannot afford to pay. How can we expect sick and suffering people to pay for their medicines if we make contraceptives free for the healthy and affluent? There is no possible moral case for doing so. I am strongly in favour of birth control, but that does not mean that I am strongly in favour of making it free. Nothing in this world is free. Someone has to pay, whether it be the ratepayers or the taxpayers. In Birmingham, £300,000 was spent last year on a free family planning service, and many ratepayers are grumbling because the rates are going up.
1005 I have four questions which I wish to put to the House. Only if an affirmative answer can be given to each should Clause 4 remain as it is. Will free contraceptives for all cut down unwanted pregnancies? Are we sure that there is no higher priority for the money? There are many things in the National Health Service which have a far higher priority than this. Is it right for the State to take responsibility? Do we know that provision of free contraceptives will not further increase VD? The answer to all those questions is "No".
§ Mr. Eric Ogden (Liverpool, West Derby)
From time to time the hon. Member for Birmingham, Edgbaston (Mrs. Knight) showed that she had stumbled over the truth but, like many other ladies, she managed to pick herself up and carry on as if nothing had happened. I confess that I like the hon. Lady, although I disagree with almost everything she says in the House—
§ Mr. Deputy Speaker
Order. I distinctly called Mr. Whitlock and I saw him rise. He has gone. Mr. Lamond.
§ Mr. Deputy Speaker
Order. I see that the hon. Member for Nottingham, North (Mr. Whitlock) has reappeared. Will he refresh my memory? Did I see him rise when I called him?
§ Mr. William Whitlock (Nottingham, North)
Yes, Mr. Deputy Speaker. I had the impression that you called my hon. Friend the Member for Liverpool, West Derby (Mr. Ogden), and I went outside the Chamber to make representations to you.
§ 7.34 p.m.
§ Mr. William Whitlock (Nottingham, North)
All hon. Members who have spoken from the Government back benches have dealt with family planning, birth control and population problems. I 1006 do not wish to do so, important though those issues are. I shall speak briefly later about population trends in the East Midlands, but I shall do so in a different context from that which has concerned hon. Gentlemen opposite.
Like all her colleagues on the back benches, the hon. Member for Birmingham, Edgbaston (Mrs. Knight) in her general remarks about the Bill spoke of it with some doubt—not small doubts but serious doubts about the broad sweep of the Bill. I began to think that we should welcome her with us in the Division Lobby tomorrow evening until she blotted her copybook by talking about the National Health Service taking us into the red. The figure showing the time lost in industry through strikes pales into insignificance when it is compared with the enormous loss to industry through illness. Without our wonderful National Health Service, the time lost through illness would be much greater.
In July 1971 we debated the Consultative Document, and I remember my hon. Friend the Member for Hitchin (Mrs. Shirley Williams), speaking from the Opposition Front Bench, referring to the phrase in the Consultative Document about the need for maximum delegation downwards matched by accountability upwards. My hon. Friend said that the document was much more about management than about accountability.
My right hon. Friend the Member for Deptford (Mr. John Silkin), speaking from the Opposition Front Bench this afternoon, said that the Bill showed that the fears that were aroused by the Consultative Document were justified. The Bill is much more concerned with management and administration than it is with people and accountability. We need managerial skills in the administration of our NHS but we need more than anything else humanity and effective local control. The administration of the health service is concerned not with a system of factory control but with people. We all agree that the service needs to be reorganised, but it needs reorganisation not with a target of productivity in mind but for the prevention and treatment of disease.
Any changes which we bring about in the NHS must ensure that the conscientiously mastered skills, the great 1007 kindness, the infinite care and the painstaking attention to which we have grown used in our health service, and which we tend to expect from the people who serve in it, are made available to the maximum possible extent to all those who need them. Whatever the complexities of the organisational set-up of the service, the patients and the staff are at the point in the whole scheme which matters most. The scheme breaks down or succeeds to the extent that the wonderful staff in the service are enabled to do the job that they are so well qualified to do.
A management study on the future reorganisation of the service was conducted in 1972, and a study group concerned with that management study came to Nottingham. I make no apology for dealing at some length with the hospital service in the Nottingham area, because that is the part of the service I know best.
Criticisms have been made by staff, officials and members of the hospital management committees that the management study group was largely in the hands of management consultants. Management consultants are the people whose whizz-kid ideas were so much in vogue a decade and a half ago and whose reputations are not nearly so glamorous these days, so they have moved to other fields. Unfortunately, the reverence that was once accorded to them by industry seems recently to have been extended to them by the Secretary of State and his Department.
These people came to Nottingham with their instructions about the kind of organisation the Government wanted to see. They came with preconceived ideas, and this meant that their minds were closed to much of what the staff in the Nottingham area had to say to them. They were concerned with management and administration and were only remotely concerned with people and with suffering humanity.
I have with me a copy of the report produced by the study group entitled "Realising the Objectives of the National Health Service Reorganisation in Nottingham". One part of the report is interesting since the group states thateffective management is constrained by four important handicaps".One of the handicaps is outlined under the heading "Uncertain delegation of authority by the Department of Health 1008 and Social Security and the Sheffield Regional Hospital Board". That part of the report reads as follows:At present, proposals for the development of health services in Nottingham are initiated by the Sheffield Regional Hospital Board and discussed with the Department of Health and Social Security before full consultations are undertaken locally. As a result, many management decisions are taken either in Sheffield or in London and there are many relatively minor administrative matters … that cannot be agreed locally. This is inconsistent with the Secretary of State's objective of maximum delegation; and it is inefficient. It is most unlikely that officers of Sheffield Regional Hospital Board, let alone the Department in London, will be better equipped than the local people to make these decisions.With that part of the report I wholeheartedly agree.
In the 13½ years I have been a Member of this House I have repeatedly drawn attention to the consequences of the fact that the offices of the Sheffield Regional Hospital Board and the Department of Health and Social Security in London are less well equipped to make decisions on the proper development of the health services in Nottingham than are local people. I wish to point to some of those consequences and I make no apology for doing so.
When the National Health Service was first set up in 1948 there was in the South of England better provision for hospital and medical services than in other parts of the country. Each successive Government, of whatever political colour, has had to continue to maintain and to extend the services in each of the areas. But the elimination of the imbalance and of the injustice between regions has taken far too long.
For too long the expenditure per head of population in the Sheffield region has been below the national average figure. This has meant that in the Sheffield region waiting lists for hospital beds and for out-patient appointments have been longer than those in the rest of the country, and this cannot be disputed. It has also meant that the number of doctors, specialists, professional and technical staff, nurses, midwives and ancillary staff per 100,000 population in the Sheffield region has been lower than the average figure—and in some cases lower than the lowest figure in some of the regions.
The Under-Secretary of State for the Department told me some time ago that it would take another 10 years to correct 1009 the imbalance between the Sheffield region and the rest of the country. In my view that is far too long a period to do away with that injustice. The new regional health authority must take steps to correct the situation much more speedily.
Bad though the position may be when we compare the Sheffield region with the rest of the country, if we break down the figures within the region we find the scandalous situation that the further south we go within the region, the smaller has been the expenditure per head of population on the National Health Service and the worse the staff position. Undoubtedly, cities such as Nottingham and Leicester have not had their fair share of the regional cake.
I believe that this situation could be speedily remedied if the headquarters of the new regional hospital authority were to be sited in Nottingham, which is in the centre of the region, instead of in Sheffield. The Secretary of State has come to the conclusion that logic, equity and good planning all point to Nottingham as the best centre for the regional hospital authority. I commend him on that decision and I hope that be will adhere to it.
§ Mr. Edwin Wainwright (Dearne Valley)
Will my hon. Friend explain why Nottingham will better serve the new district than does Sheffield which serves it at present? Does he or does he not feel that moving staff from Sheffield to Nottingham will be to the benefit of the employees in the National Health Service?
§ Mr. Whitlock
In moving the regional headquarters to Nottingham it is inevitable that people will be affected, but I suggest that the majority will be retained in the new administration offices to be set up under the provisions of the Bill in Sheffield and, therefore, only a small number will be affected, many of whom will be likely to wish to come to the fair city of Nottingham.
The headquarters of the old regional board were placed in the north-west corner of the region because Sheffield was the only place in the region which at that time had a teaching hospital. But now Nottingham and Leicester have medical 1010 schools and the region is the only provincial region with more than one medical school. The population growth predicted for the East Midlands will occur in the central and southern areas, and this is another reason for siting the headquarters of the new authority in Nottingham.
I have outlined the sorry state of affairs when one compares the Sheffield region with the rest of the country and when one looks at what has gone on within the region. I quote once again in explanation of all this the telling sentence from the study group's report:It is most unlikely that officers of the Sheffield Regional Hospital Board, let alone the Department in London, will be better equipped than the local people to make these decisions.But if the Sheffield Regional Hospital Board and the Department in London are less well equipped to make decisions about, for example, the closing of a casualty department, the siting of a health centre, or providing more district nurses in an area, and if, as I believe, a regional health authority with its headquarters centrally sited in Nottingham would be better equipped to do so than is the old regional hospital board situated in Sheffield, how much better that regional health authority would be if it were made up not of appointees of the Secretary of State, who will be remote and insensitive to public opinion, but of locally-elected representatives. I hope that during the passage of this Bill we shall see the Secretary of State give way a great deal on this point.
I have drawn attention to the state of affairs in the Sheffield region. Perhaps I might go further in underlining this by pointing to the fact that 48 per cent. of those on hospital waiting lists in the region during 1971 waited more than six months for a bed and many of the region's surgical specialisations struggled along with more than 30 per cent. fewer consultants per 100,000 population than the national average. What is more, all these problems are much worse in Nottingham and Leicester.
With that kind of information constantly in my mind, as it has been for a number of years now, I have been nauseated to receive from the secretary of the Nottingham branch of the British United Provident Association a letter in 1011 which I am invited to join that organisation with the offer of a 20 per cent. subscription rebate and immediate entitlement to benefit. By joining the organisation I could gain immediate admittance to the Nottingham General Hospital if I required it, and, with my doctor, so the BUPA literature tells me, I couldchoose a particular consultant who would carry out treatment personally.There are two standards of care in the National Health Service and they exist because professional medical organisations, whose strength makes that of the large industrial unions look like a kindergarten in comparison, compelled Aneurin Bevan to permit private treatment in our national health hospitals. I agree with my hon. Friend the Member for Wolver-hampton, North-East (Mrs. Renée Short) that it is high time we ended this abuse of our National Health Service. I hope that during our proceedings on this Bill we shall be able to effect that change.
§ 7.53 p.m.
§ Captain Walter Elliot (Carshalton)
I wish to raise two or three matters which have been put to me by people in my constituency who are concerned with the National Health Service and about which they have expressed some anxiety.
I refer first to the planning processes outlined in the Bill. The right hon. Member for Deptford (Mr. John Silkin) used the word "cumbersome" to describe the structure. Other hon. Members have suggested that it is a bit top heavy. The impression that I get is that there is a pretty hefty planning organisation. It is fair to say that with the main planning functions at three levels—area, region and central department—there will be no lack of planning, and it appears to me that a large proportion of the heavy guns will be concerned with it. Yet from my experience at the grass roots, with members of the public and with quite a large number of hospitals in my constituency, basically what the health service needs is greater resources at the level at which medical care is given; in other words, as the Minister said today, with the professional staffs.
We know that in modern developments, if we are to use efficiently all the implements of a profession, we have to build up a much bigger infrastructure or backing. We are told that one of the 1012 purposes of the proposed reorganisation is that it will enable the resources available to be put to better use. One of the results by which we shall judge the effects of the Bill is how much better a patient is treated.
I suppose that the area health authorities will be the key authorities in the new organisation. I presume that will be reflected in the persons who serve on the authorities. They will be of high calibre because they will have a great many hospitals to look after and a lot of work. As the function of the area health authorities is both planning and executive, care will have to be taken to ensure that they do not overwhelm the districts especially as the areas will be employers of staff in the districts.
The districts are not a formal tier of authority below the areas, we are told, and it is most important that they should not be overwhelmed or engulfed. If that happened I do not see how the community health councils could prove effective. If that was the case it would be very bad.
Anxiety has been expressed to me about the effect on the community health councils when the people who serve on them see the very big structure of organisation being built above them. It is most important that the community health councils should be effective.
I thought that the Minister moved rather quickly over the matter of coordination between the areas. Clause 10 requires health and local authorities to co-operate with one another and to establish area joint consultative committees. As I see it, that puts into operation paragraph 55 of the White Paper. I hope sincerely that there will be no misunderstanding here. In the White Paper paragraphs 58–60 contain the working party's recommendations. They imply that coordination is largely a matter of the efficient utilisation of hardware.
For example, paragraph 60 states:On day-to-day operations the arrangements for collaboration must cover the general sharing of goods and facilities … the bulk purchase of supplies; building and associated maintenance services".Paragraphs 58 and 59 refer to planning and investment. I hope that collaboration is not confined to that. It should go much further.
I have vivid recollections of serving on the Standing Committee on the 1013 London Government Bill when the lines of the new London boroughs were being drawn. We laid down, so we thought, absolutely firmly that education, the siting of schools and the passage of children across boundaries would not be affected in the slightest. I confess that one of the biggest thorns in my flesh in my constituency is to get my children into neighbouring schools which are much closer than schools within their own boundaries. The boroughs, quite naturally perhaps, undoubtedly try to serve their own children first. I hope that this will not apply to the hospitals in the areas.
To emphasise this point I should like to quote an example from my constituency. I could quote several examples, and I am sure there are many others throughout the country. I have in my constituency the Queen Mary's Hospital for Children, which is a famous establishment—famous world-wide. In the same group, the Fountain and Carshalton Hospital Group, there is the St. Ebba's Hospital which is sited in Epsom.
St. Ebba's Hospital was incorporated into the group in July 1962 and changed its r61e from that of a hospital for the mentally ill to that of a hospital for mentally sub-normal adolescents and adults. The purpose of incorporation was to provide a hospital within the group to which long-term mentally handicapped children from Queen's Mary's Hospital could be transferred when they reached the age of 16. That would enable their development and training to be followed through under the care of group consultants and staff.
St. Ebba's Hospital—I repeat, in Epsom—had, and still has, a prior commitment to take from the surrounding areas a defined quota of patients from other mentally subnormality hospitals. That commitment was fully met a year ago. Since then adolescent patients from Queen's Mary's Hospital have been admitted to St. Ebba's as and when vacancies occur. That is not only a benefit to the children concerned but is welcomed by the parents who are able to familiarise themselves with St. Ebba's prior to the transfer and know that there will be continuity of care for the children.
Since 1962 St. Ebba's and Queen Mary's hospitals have grown much closer 1014 together. But, after the reorganisation of the National Health Service, they may no longer be within the area of the same area health board, although they will remain under the same regional health boards. It would not help if they were separated as they form an entity which ensures the smooth transfer of adolescents from a children's to an adults' hospital. I sincerely hope, and it is my firm conviction, that Queen Mary's and St. Ebba's hospitals must not be separated, but that the links between them should be maintained and strengthened.
I went into that example in detail because this afternoon the Minister, when talking about the regional council, seemed to stress that it would have monitoring duties. However, I should think that, in a case such as I have mentioned between areas, it would be concerned to see that that kind of co-operation was carried out. I hope that it will be so.
I am glad to see the hon. Member for Wolverhampton, North-East (Mrs. Renée Short) in her place—I interrupted her during her speech—because my next point concerns the establishment of the Health Service Commissioner. Appendix II on page 55 states:The commissioner will be responsible for investigating actions taken by or on behalf of the Health Service authorities where it is claimed that an individual person has suffered injustice or hardship through maladministration, or through a failure to provide necessary treatment and care.I emphasisefailure to provide necessary treatment and care.I mention this particularly because I am a Member of the Select Committee on the Parliamentary Commissioner. Occasionally, perhaps rarely, the Parliamentary Commissioner, as well as examining complaints of maladministration, examines questions of the lightness of the decision by a Department. This is a very difficult matter. I do not believe that, even if he had an enormous staff, he could examine the Tightness of the decision as opposed to maladministration for anything like a reasonable proportion of the cases that come before him. He examines only very special cases. To suggest that the Health Service Commissioner could examine cases for correct diagnosis would be out of the question, even if the medical profession would accept it, which I do not think it would.
1015 Schedule 3, paragraph 1, rules out investigation by the Health Service Commissioner ofaction … taken solely in consequence of the exercise of clinical judgmentby a doctor. Sometimes it is difficult to separate necessary treatment and care from a clinical judgment. A doctor may prescribe certain treatment and care. I am not qualified to say whether that is a clinical judgment. There is a difficult distinction there. I hope that the wording will be considered very carefully in Committee in order that misunderstanding and disappointment will not occur in future.
§ Dr. Miller
Despite the difficulties and the circumstances that the hon. and gallant Gentleman is putting to the House, may I ask whether he agrees that there are areas where it might be a good thing if a patient had the opportunity of airing a grievance? I am thinking particularly of unnecessary operations. I am sure that the hon. and gallant Gentleman will agree that a lot of operations are carried out which are not entirely necessary. Would it not be a good thing to ensure that every operation carried out was necessary?
§ Captain Elliot
If we could establish some means by which that could be done, I am sure it would be an excellent thing. I am only saying here that the Health Service Commissioner is not the person to do it. I understand that the present Parliamentary Commissioner is to be appointed to that post, and I suppose his staff will be increased—if his work is to be comparable to that of the Parliamentary Commissioner. But he is not the person to re-examine whether an operation was necessary or effective or whether the diagnosis was right. That is what I am saying, but I doubt whether the medical profession will agree, willingly anyhow, to someone breathing over the necks of its members when they are making a diagnosis or after they have carried out an operation.
I come finally to the position of the medical social workers. As the Minister knows, many of these people are anxious about the effect on their work of being transferred from the authority of the National Health Service to local authorities, but his Department has written 1016 to me on this subject explaining that no decision has been taken and that all the arguments both ways will be carefully considered. I am grateful to my right hon. Friend for that, and I know that many of these people will be glad to hear it.
I hope that when the Bill, with whatever is necessary to correct certain facets of it, gets on to the statute book it will be another monument to the excellent work which is being carried out by my right hon. Friend.
§ 8.11 p.m.
§ Mr. James Lamond (Oldham, East)
One of the difficulties about listening to an interesting debate of this kind is that one's attention is diverted by a number of the points that are made and the speech for which one made notes tends to become a little different when one gets the opportunity of delivering it.
We have dwelt much more on Clause 4 than I thought we would because, from announcements that I had seen in the Press, I had hoped that the Government would be prepared to accept the amended clause. Before I came to the House to represent Oldham, East, I was a member of the health committee in Aberdeen which was responsible for the decision to provide free family planning supplies. I listened with great interest to the points made about it, and I was disappointed to hear the Secretary of State say that he did not accept some of the figures that had been provided and some of the conclusions that had been drawn. It is difficult to quantify the great advantages that have arisen in the city of Aberdeen because of this decision. Some attempt has been made to do so, but one must never forget the great advantages in the lessening of mental anguish that has occurred because of the availability of these supplies.
The hon. Lady the Member for Birmingham, Edgbaston (Mrs. Jill Knight) asked whether it was right to provide these supplies to people, without any warning of the dangers that might arise. Anyone who goes to any of the clinics in Aberdeen to receive free supplies is fully informed of all the advantages and disadvantages. The place where someone is not told of the disadvantages is the shop which he enters casually to buy these supplies. That is where young people get 1017 no advice or guidance. However, that is a diversion from the point that I wanted to make.
I propose to say something about the philosophy behind the appointment of people to hospital boards. We are all democrats here. We are all prepared to go on platforms all over the country to defend the method of election in this country as being as good as one can devise. I should be the last to deny that democracy is inefficient. The Bill is an attempt by the Government to make the National Health Service a little more efficient and a little more responsive to the feelings of the people who use it, but the search for efficiency is no reason for discarding a proper democratic method of appointing management committees for hospital boards.
It is interesting to examine the Governments' point of view. If one accepts what they are saying in the Bill then the decisions being made by hospital management committees are too important to be left to the electors through their elected representatives, that is, we cannot afford to have the fools and the unintelligent people who are sometimes thrown up by elections on hospital boards of management. If one looks closely one sees that that is the philosophy behind the Bill.
It is true that eccentrics, people whom we do not like and people who are a thorn in our flesh are thrown up by elections. It is interesting to look around the Chamber and wonder who would be here if it were not for the electors putting them here, if they were here at the whim of the Prime Minister. It is not just those on this side of the House who would find themselves without a seat. Some hon. Gentlemen opposite, too, might not find themselves so welcome if their election were entirely within the gift of the Prime Minister.
What the Government are saying here is that we should staff these committees with people whose wonderful attributes are outlined in paragraph 96 of the White Paper and they will provide us with all that the electors require—the electors, of course, being synonymous with the users of the service. I do not believe that for a moment.
The Secretary of State said that there is not sufficient money to develop the 1018 service as he would like it to be developed, and I agree with that, but there is nothing like pressure from the electors through their elected representatives to make sure that a proper share of the money goes where they want it to go. That is how this country works. That is why there is tremendous pressure here from some Members to spend less on defence and pressure from others to spend more. I do not disagree with that process. It is a good thing that the electors have this method of getting through to the people who are trying to govern them, but I do not see it happening through the proposals outlined in the White Paper.
I speak from the experience of 16 years not of a hospital board but a worm's eye view as a member of the staff of a regional hospital board. Many of the people who served on the committee were excellent, but many would not have been there had it not been for their appointment by the Secretary of State. I am sure that they would have never got there if they had to submit themselves for election. That is one of the major defects of the Bill, and for that reason I shall not support it.
§ 8.19 p.m.
§ Mr. Arthur Jones (Northants, South)
It is interesting to hear the hon. Member for Oldham, East (Mr. James Lamond) in the context of his experience as a member of the staff of a regional hospital board. That qualifies him to give us his views in this debate. From his close knowledge of the subject the hon. Gentleman is able to make deductions which are denied to those of us who have not had the close association with the service which he had before coming to the House.
From the contributions that have been made to this debate two issues arise in the context of Clause 4 and in the proposal at the root of the reformed administration from the point of view of local government representation. In opening the debate my right hon. Friend referred to the 10 years during which the matter has been under close consideration. It is well known, and it is almost a historical fact now, that the British Medical Association opposed the local authorities' control of the health service on the basis of administrative 1019 unsuitability in 1945, prior to the decisions which flowed from the implementation of the 1946 Act. Its opposition, as we have heard today from hon. Members who were engaged in those discussions, carried the day with the late Aneurin Bevan.
The right hon. Member for Deptford (Mr. John Silkin) emphasised the democratic basis upon which, as he saw it. the reorganisation of the National Health Service should rest. In 1946 it was generally recognised that, in the absence of local government reforms, both the objections of the BMA and perhaps the decisions of the Government of the day were valid.
A lot has happened since those days. The Redcliffe-Maud Commission pointed out that the unification of the existing tripartite structure of the National Health Service and its accountability under democratic control could best be achieved by its incorporation into the reformed structure of local government. Under last year's Act we now have the pattern of reform, its implementation to be coincident with the introduction of the reorganised health service. It is most regrettable that we are not to have a democratic basis for this great service.
The 1970 Green Paper rejected that solution, and in the debate on 23rd March 1970 the right hon. Member for Coventry, East (Mr. Crossman) gave as the principal reasons for that decision medical opposition, which was still current then, as he told us, and the financial weakness of local government. I do not think that either of those reasons is of the significance today that they were in 1970. Local democracy, as many hon. Members who have spoken today have reminded us, has a proud tradition in the United Kingdom and many of the great social advances of the nineteenth and twentieth centuries had their origin in local government.
I was particularly interested in what my hon. Friend the Member for Norwich, South (Dr. Stuttaford) said about the introduction of family planning by local government originally. Whatever the merits of that case, it does not detract from the point made by the hon. Member for Oldham, East that, Aberdeen, where he lived, was responsible for the 1020 introduction of a family planning service. One could quote a large number of examples of initiatives taken in local government leading to national adoption of the institution of priorities which they established; the pioneer work was done in local government services.
Local government, employing 2 million people and responsible for almost one-third of public expenditure, surely cannot be denied its right and proper place in services such as those we are discussing. The Government's proposals under this Bill, and equally under the Water Bill, which is in Committee and on which we are having some interesting discussions, remove substantial responsibilities from local government. Such policies inevitably give rise to the questioning of the Government's long-term proposals for local democracy.
It was my right hon. and learned Friend the Member for Huntingdonshire (Sir D. Renton)—I was surprised to hear him speak to this effect—who said that local government members would not be able to find the time that it was necessary to give to the Health Service. Although there is to be substantially more power for instruments of local government, we are at the same time, I hope, to have more effective local government members. That is the whole basis of reform—the greater responsibilities which should be there for locally-elected members to fulfil. So I do not accept my right hon. and learned Friend's argument.
This move, as with the Water Bill, begs the question of where the Government stand with regard to local democracy. Do they wish to see power and responsibility continue for elected members of cities and local communities? Do the Government wish to avoid political judgment and argument? That has been made an argument in the context of this Bill. Are our services to be determined by the technocrat, who may understandably place sufficiency before consumer interests and sensitivity to local opinion?
Present trends cannot be otherwise than a slur on local democracy, on local members and officers alike. When one considers the high standard of excellence which has been built up by our local government services, which, I think it will not be denied, are as high in standard as those anywhere in the world, it is a remarkable state of affairs that 1021 this Government are beginning to move away substantial powers from local government.
The proposals in the Bill are an undesirable erosion of local democratic control over essential services, whereas what is needed in the Health Service is increased sensitivity and responsiveness to local communities, whether in the individual's rôle as a patient or in his rôle as a member of the public prepared to play a positive part, either as a professional or as a member of one of the voluntary services interested in the work. In both categories, those who are interested are likely to be denied a really positive rôle.
I welcome the assurances given by the noble Lord, Lord Aberdare, speaking for the Government on 13th February in reply to the noble Lords, Lord Brooke and Lord Amory, when he said:… we believe in the need for the closest possible relationship between the local authorities and the National Health Service; but we believe this to be crucial at the Area Health Authority level."—[OFFICIAL REPORT, House of Lords, Tuesday 13th February 1973; Vol. 338, c. 1428.]My right hon. Friend emphasised that this afternoon. The noble Lord made certain assurances with regard to the appointment from local authorities to the area health authorities, and accepted the amendment of Lord Brooke, which called for four members.
Clause 9, dealing with the community health councils within each area, is also an introduction of consumer protection. I share the scepticism already raised in the debate about the influence which those councils will have. It is only where there is some executive capacity that there can possibly be any worthwhile influence on decision-taking. My right hon. Friend referred to the Health Service Commissioner; but this is really as a last resort. It is no constructive contribution to the problems which exist. However, even with those assurances, the representation of locally elected members will be indirect and in a small minority.
Both the County Councils Association and the Association of Municipal Corporations are of the opinion that an opportunity to introduce and maintain a democratic element in the organisation of the National Health Service is being lost. Those associations, on behalf of their very 1022 large membership, regret that this is so. It is significant that the English White Paper states at paragraph 8:There are very strong arguments for bringing health and social services under a single administration. This could be accomplished by putting the NHS within local government. But, for reasons accepted and fully explained by both the previous and the present Government, that is not attainable, at least in the foreseeable future.This is a major setback and misfortune for democratic local government when the paramount need is to provide a strong and comprehensive new structure and to reverse the established trend of local government services being lost to central government and, indeed, to ad hoc bodies.
The weakness of this solution under the Bill—and under the Water Bill—can be seen in the complicated arrangements required for collaboration between regional bodies being appointed in each case and local authorities. We had that also in the Local Government Act. We had the agency clause. In the Water Bill we have all sorts of arrangements to ensure co-ordination and an element of continuity. We shall have the same hybrid arrangements under this Bill, too.
I welcome the identity proposed between the health areas and the areas of local authorities responsible for the personal social services. This will provide at least some safeguard for the services for which health authorities and local authorities will be mutually dependent, such as the provision of medical, nursing and dental services for the school health service, and the provision of residential domiciliary services for patients on discharge from hospital.
I was interested to read an inquiry financed by the Joseph Rowntree Social Services Trust Limited and undertaken by the Department of Community Medicine at Guy's Hospital. It appears over the names of Peter Draper and Tony Smart. It draws attention particularly to the significant change taking place in the responsibilities of the medical officer of health. Traditionally, his security of tenure was guaranteed so that he could speak out in the public interest. In the new structure he becomes part of the management hierarchy. As the inquiry observesnothing here about a public watchdog whose bark must be protected.1023 The right hon. Member for Deptford used a similar reference to the duties of local government and its responsibilities in the proposed new arrangements. Dr. Draper and his colleague observe that one way of construing the Government's proposals is that they can be seen as an attempt to de-politicise health policies. It is clear, they say, thatthe way in which more than £2,000 million of taxes are spent is of great national concern and political interest …that health planning and policy decisions are inescapably political in that they vitally affect the quality of human life, that they raise fundamental questions of social justice and that the democratic method of dealing with issues like these is normally to provide representatives with adequate powers.I entirely agree with that summary of a great deal of information which is gathered together in that report.
Many hon. Members will remember with me the tremendous voluntary content that there was in earlier days between local communities and their hospitals. The hospital fête was the great occasion of the year for many communities, by which money was raised for this wonderful service. Although I in no way deny the tremendous voluntary content of the hospital services today, I do not think that they are to be compared in either volume or influence with those which we knew prior to the Act of 1946. I say that paying due regard to the tremendous work undertaken by the Friends of the Hospitals and other community-oriented organisations. During the present unrest in the service side of hospitals, many hospitals have called upon local organisations to help the hospitals out of their difficulties. But there is general recognition that since 1946 a gulf has appeared between the hospital boards, which are inescapably remote, and the community. This is a very unfortunate reflection of a trend which is now confirmed in these proposals.
Whereas in 1945 the British Medical Association tended to be very much against the National Health Service coming within the orbit of local government, I do not think that this is anything like as strong a feeling today as it was then. Attitudes have changed, and this applies particularly to the junior members of the profession. I think that my hon. Friend the Member for Norwich, South will agree with me in this respect, because he referred to it.
1024 I believe that public participation should not be denied and that health care organisations should be characterised by the existence of widespread public involvement in their decisions. The giving and sharing of information is an essential subject in the process of participation, and the community should not be denied the information and experience which will enable an increasing number of people in our society who are anxious to do so to develop the knowledge and skills to enable them to take wise decisions about the complex problems of health care.
There is a great contribution to be made by society as a whole. I regret the almost entirely technocrat approach within the Bill. I regret the marked absence of participation in terms of professional and lay opinion. I believe it to be a grave defect of the Bill.
§ 8.37 p.m.
§ Mr. Leo Abse (Pontypool)
I regret that I cannot follow the argument of the hon. Member for Northants, South (Mr. Arthur Jones). As he has sat through the entire debate so far, he will know that there has been a dissonance between two themes—the theme of reorganisation and the theme of family planning— both of which we have endeavoured, in an almost schizoid attempt, to bring together as a result of our proceedings.
It is not surprising that we should find, when dealing with problems of family planning, that much of our thinking appears to be at the very least tortuous. It is natural when such delicate subjects —life and death issues—are being discussed that there should be in some of the views advanced some impress of the internal conflict which must arise and be provoked. The Minister's circumambulatory apologia when he spelled out his muddled comments upon what would happen under Clause 4 revealed that conflict.
Where, indeed, is the rationale behind the Secretary of State's new proposals? It is certainly out of keeping with his temperament. Has he suddenly turned misogynist? As to family planning he declared this afternoon, as I understood him, that every man shall have his sheath free and every woman must pay for her pills—[Interruption.] As I understood the intervention, and I see that the right 1025 hon. Member for Wolverhampton, South-West (Mr. Powell) agrees with me, the Secretary of State clearly indicated that for the sheath no prescription would be required whereas, as the Secretary of State explained to the right hon. Gentleman, a prescription would be required for medical reasons in respect of the pill. I willingly give way to the Secretary of State if he wishes to clarify the matter.
§ Sir K. Joseph
I am dismayed to think that anything I said to my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) should have given rise to such a misapprehension. I am grateful to the hon. Member for Pontypool (Mr. Abse) for allowing me to intervene. If a man seeks through a doctor at a clinic, hospital or general practice a form of contraception, it is up to the doctor whether he will prescribe. It is up to the doctor what he will prescribe. If he prescribes a sheath, the sheath will be available on prescription charge. That is not necessarily for a medical reason. In future, a doctor will be free to prescribe what is appropriate by way of contraception for the man, woman or couple. It does not follow that most men, who now buy sheaths for themselves, will want to get a prescription for their sheaths.
§ Mr. Abse
It was partly because of the ambiguity of the right hon. Gentleman's statement and his reply to the right hon. Member for Wolverhampton, South-West that I and many other hon. Members were left with that impression. I am left even more dismayed if the situation is that a man can obtain a sheath without a prescription neither at a clinic nor from a doctor—
§ Dr. Stuttaford rose—
§ Dr. Stuttafordrose—
§ Mr. Abse
I am indicating what I think the House will want to know. Under the scheme which the Secretary of State is proposing, will it be possible for a man to obtain his supply of sheaths freely without a prescription? If the right hon. Gentleman is saying that a man cannot do as he is now able to do in local authority 1026 clinics in certain areas, where he is able to obtain his sheaths free, he is re-emphasising the retrograde steps which he is taking in the Bill.
§ Sir K. Joseph
It is true that the population in the areas where there is at present a free service for males or females will have to pay a prescription charge after April 1974 unless they are in an exempt group. It is my understanding that there is a relatively small take-up in those free zones. It is further my understanding that most men, unless they have a medical preference for sheaths which the doctor validates, will buy their sheaths commercially or will obtain them through clinics at wholesale rates, which will still be possible after April 1974—that is, wholesale sheaths not on prescription.
§ Dr. Stuttafordrose—
§ Mr. Abse
They will have to pay for the prescription for their pills. It is to such absurdities that the Secretary of State is reduced because of a spurious attempt to save public expenditure. It is spurious because in the long run the failure to give a full and free family planning and counselling service to the community will cost the nation dearly.
It is understandable that the right hon. Gentleman should resist the population doomsday men, of whom we have heard quite a number today. They seem to revel in their gloomy jeremiads and cling to their extravagant projections. They seem to love to give the most terrifying admonitions, all of which lack authenticity.
We will each extrapolate what we will from the Population Panel Report. Having read it, I still find no reason to doubt the view of the distinguished Welshman who is the editor of Nature who stated, much to the fury of those who are doomsday men, that it is not necessarily credible that our population will have materially increased by the end of the century as they believe it will. The projections that have been arrived at from the Government's statisticians are constantly plunging.
1027 Although I disagree in many ways with the hon. Member for Birmingham, Edg-baston (Mrs. Knight), I am bound to say that when she talks about guesswork of this nature and in this respect—
§ Dr. Millerrose—
§ Mr. Abse
I am not giving way as there are other hon. Members who wish to speak. The hon. Member for Edgbaston is in that respect correct. I say to those stereotyped hon. Members who expect everybody to have the conventional avant garde view that they must get accustomed to the fact that each matter should be considered on its merits, and they should free themselves from their prejudices and their ideologies.
§ Dr. Millerrose—
§ Dr. Miller
My hon. Friend the Member for Pontypool (Mr. Abse) is attempting to show that no projections can be made. How does he account for the fact that there has been a steady increase in the population all through the years and, indeed, all through the centuries? What makes him think that it will stop now?
§ Mr. Abse
Having been a little longer in this Labour movement than the hon. Member, perhaps, I have very clear recollections of other fashionable views on the population. I am sorry to see that my party should be infected with such views. I can recall how in the immediate pre-war years, in a document which had a lot of influence on Conservative thinking, the present Lord Chancellor prophesied the same sort of gloom and doom which is being prophesied now, and his prophecy which influenced Conservative thinking was that this country would have a declining population and that it was going to the dogs because we were not going to have men.
§ Sir K. Josephindicated assent.
§ Mr. Abse
That was the view, as the Minister acknowledges, which was propounded then. When I see these extravagant oscillations—[Interruption.] 1028 I wish hon. Members would be quiet. I pay them some respect when they speak, and they should get used to hearing different views from others. When I hear these extravagant oscillations of view— when at one moment we are told that the population will be excessive and at the next moment we are told that it is declining—I ask myself what is the unconscious motivation behind those views. Is it that the people who express those views are so sexually confident, or is it that they lack some personal sexual confidence, that at one moment they exaggerate the propensities of other people to proliferate and at another moment they have to deny it? I feel bound to say that when such curious views are put forward I hesitate to draw conclusions such as some hon. Members evidently do.
When people put forward the view that there should be a full and comprehensive family planning service, the Secretary of State is bound to be sceptical when that view is put forward on population grounds. But although he may feel that he can shrug off the doomsday men, he cannot shrug off the question of the mounting figure of abortions. Certainly we in Wales cannot. In the league table of abortions within the National Health Service we have the miserable and unfortunate fact that we are second of all the 14 regions in the proportionate number of abortions taking place. I ask the Secretary of State whether he has considered the cost to the community of those abortions. I do not believe we can quantify the total cost to the National Health Service merely by multiplying the number of abortions by the cost of £80 to £120 per head.
All of us who have read the report of Margaret and Arthur Wynne on the physical consequences of induced abortion will once again be grateful to that lady in particular, because once again, as in her work on fatherless families and social security, she has supplied us with objective assessments which have proved invaluable.
It should therefore be known, not only by the House but by young men, including those who shirk their responsibilities, that the evidence gathered by the Wynnes from all over Europe makes it overwhelmingly clear that a man is more likely to have a sterile wife or a stillborn or premature or defective child 1029 if he marries a girl, particularly a young girl, whose first pregnancy has been terminated by an induced abortion. This probability is undoubtedly documented within the report.
Every woman who has had one or more abortions is made less eligible for motherhood and therefore, surely, less well equipped for marriage. After all, a man insures his house against a fire risk a hundred times smaller than the risk of sterility in a young woman who has had an induced abortion. The nation that rightly and vigilantly expresses, as has been expressed in recent debates in the House, compassion for the thalidomide children should know that in tolerating an increased proportion of terminated first pregnancies it is tolerating a situation which can lead to a harvest of premature and defective children. Confronted with such facts, we would want to take action which might contribute to minimising the harm.
I do not put the view to the House that if everyone had a free family planning service it would mean that the number of abortions would dramatically fall. It is only the naïve who do not understand that, no matter what one does very many unmarried mothers, because of their early upbringing, desperately need a child even while protesting that they do not. Our teaching hospitals today are full of women who have had one child taken away from them by abortion, undoubtedly under the pressure which surrounds them and the opinion that has been brought into existence, but who feel deprived of that one child and before long come back preferring another. It would be naive to believe that there would be a dramatic fall in the numbers, but I believe that it would be a contribution that would help a little.
What troubles me very greatly in the way that the Secretary of State has drawn back from the final hurdle of allowing contraceptives to be free without prescription is that quite clearly it will be the least responsible members of the community who will regard themselves as debarred from taking up these contraceptives because they have to pay a prescription charge. It is the most feckless section of the community which will find this an obstruction. It is those who would have the least responsibility.
1030 Therefore, what possible rationale can there be, when we know already from our experience in family planning that our domiciliary visits, which by and large mean that we go to the least responsible members of the community, are proving so successful and getting good results, in drawing back from taking the most obvious step and making certain that we help those who are in obvious need and whose inadequacies make them just the sort of people who would be burdening the community with abortions and perhaps causing—as I am already finding in my divorce practice—marital stresses to arise? I say that because many a young man is, after marriage, finding his wife sterile as a consequence of an abortion she had before marriage. Such a situation adds materially to the marital stresses within the community.
I believe that the figures we now have as a result of the reckless Abortion Act will be radically modified only when the Secretary of State modifies the Act itself. We cannot do it simply by providing family planning services. We cannot succeed that way. I know not what the Lane Committee will recommend, but of one thing I am sure. Whether that committee vacillates, or whether it is bold enough to put forward proposals which will radically amend the Act, it is certain that, if matters remains as they are, we shall have in this country exactly what has happened and is happening in Eastern Europe. As we coarsen our sensibility through this type of law, and as the community becomes increasingly indifferent to the carnage, we shall burden the National Health Service not with 100,000 abortions a year but with 1 million. Let all those who regard that as extravagant look at what is happening in Eastern Europe, and let them watch the figures mounting year by year under our unfortunate Abortion Act.
I urge the Secretary of State, therefore, to take every step, including holding on to Clause 4 as it stands, so that we may attempt to contain some of the effects of the mood which has been induced and the facilities which have been created by that wretched Act.
We can deal in many ways with family planning. Family planning can be life-enhancing. It can lead to planned parenthood. It can give people the boon and blessing of parenthood when they want it. 1031 Family planning has strengthened, and can still further strengthen, our family life in this country. Abortion is life-denying. Abortion is the negation of life. Its physical and psychological consequences are already causing havoc and are likely to cause more.
I hope that the Secretary of State will pause before, in this illogical manner, giving three-quarters and not giving the one-quarter. He advances all the arguments to justify giving as much as he does—I acknowledge that it is a great deal—and then, suddenly, his argument falls short at the prescription charge. He is a logical man, and the House knows him to be so. He must know that there is no argument in logic to support what he is doing. He may imagine that there is a financial argument, but there is no logic in not following to its conclusion the path which was opened up when, with Edwin Brooks, I put through the original Family Planning Act. There is no way out now. If we really want to strengthen family stability in Britain and to minimise abortion, there is no way out, in my judgment, except to have a full, free comprehensive family planning and guidance service throughout the country.
§ 8.59 p.m.
§ Mr. John Stokes (Oldbury and Halesowen)
I agree with much of what was said by the hon. Member for Ponty-pool (Mr. Abse) about abortion, but in the few minutes at my disposal I shall discuss the family planning proposals. I am one of those in the House who believe that the State should not make contraceptives universally available, even on prescription charges, save where there is special need. On the contrary, I believe that people should be responsible for their actions and should pay for what they require.
After listening to this earnest and serious debate, I am surprised there has been so little mention of the moral problems that must be involved when the State intervenes in this massive way. I fear that these proposals have come about because of the unprecedented propaganda not only by the population lobby, in which I do not believe, but by some of the birth control pressure groups. I believe that some of the activities of some of these bodies require careful scrutiny. This is a matter which should be dealt 1032 with by the individual couple. The further the State keeps away from it the better.
Surely the prime duty of the House—it should involve all that we do—is to maintain intact the fabric of our society. To me, and I suppose to most others in this Chamber, the family is the foundation of our society. The uncontrolled massive availability of State-provided contraceptives may in time, without the Government wishing or even knowing it, gradually but imperceptibly undermine family life as well as the whole Christian ideal of chastity before marriage and faithfulness between married partners.
Making contraceptives available to all and sundry cheapens the sexual act. It makes it a thing of no account, and that is what some of the enemies of traditional morality want. The so-called educational activities of certain bodies in trying to indoctrinate our children with immoral ideas are simply frightening.
I do not believe the subject of birth control can be dealt with by the State in the simple mechanistic way in which it has been discussed in this debate, as if the State was simply selling packets of potato crisps. Surely greater issues than that are involved. But that is what the materialists would like. Others believe that serious matters of conscience and morals are involved. I was very sorry that in the debates in the other place the voices of the bishops were faint on this subject. I believe that many who hear me now or who may read this tomorrow will secretly agree with me, even if they are afraid to disagree with the liberals and the progessives and the avant-garde of whom we have heard so much.
The time has come for those who believe in traditional morality to make a stand. The irony is that Clause 4 not only condones what may become mass promiscuity and immorality but ensures that they will be paid for by the unfortunate ratepayers and taxpayers.
I read yesterday in a newspaper this comment by the Secretary of The Responsible Society, and I thought it summed up the point of view of millions of people whose voices have not been heard:The more you give in the way of contraceptives the more hedonistic the climate you 1033 create. There is a tendency today for everything to be disposable—even babies.I believe that that comment is profoundly true, and I am extremely sad and sorry that the Government should appear by this clause to make matters even worse.
§ 9.5 p.m.
§ Dr. Shirley Summerskill (Halifax)
It is a tragic irony that this debate on the future of the National Health Service is being held under the shadow of an unprecedented strike of the hospital ancillary workers. The dedicated men and women who staff the service have become angry and bitter over inadequate pay, and yet over £2,000 million a year is now spent on the service and the Secretary of State boasted in his opening speech that this is a larger share of the national income than ever before. This can be no consolation to those on strike. Against this sorry background of crisis we have to decide on the future of the National Health Service as presented in the Bill before us.
I start on a note of agreement. On this side of the House we welcome the basic aims of this long-awaited Bill, and even hon. Members opposite could agree on that matter, although their support for other matters in the Bill was distinctly qualified, particularly the excellent speech of the hon. Member for Northants, South (Mr. Arthur Jones). The concept of integrating the service, of abolishing the tripartite system, has general support.
The establishment of the service was one of Labour's greatest achievements, and our proudest, in 1948, but there was a gap in the Act: the division of responsibility for health care between the three sections did not bring about a unified service. The quality and standard of care varies greatly in different parts of the country. We need to see greater liaison between the curative and preventive sides of medicine, greater emphasis on community and health centre care.
Never before has proposed legislation been discussed for so long by so many with such an ignoble end. The Bill is the result of 10 years' public debate, two Green Papers, one Consultative Document, one White Paper, one Grey Book, and one Circular. I recently read a profile of the Secretary of State in a medical journal. Its title was "The Enigmatic Administrator". This was an apt descrip- 1034 tion, because we have before us a dangerously enigmatic Bill. We have been debating a skeleton of a Bill which lacks both flesh and teeth. It is as dangerous for what is left out as for what is in it. To further its regressive, bureaucratic, undemocratic proposals it is intentionally, perhaps, vague and imprecise on important matters, matters which can be brought before Parliament at a later date in the form of orders.
I come to a major criticism of the Bill, the inclusion of the private practice sector within the reorganised service. Let us look at some facts. There are at present no fewer than 4,527 beds within the health service exclusively retained for private fee-paying patients, and this is in England alone. These beds have about a 60 per cent. occupancy at any one time. Two-thirds of health service consultants give part of their time to private practice; only one-third are full time in the service. There is notorious evidence of queue jumping by those who can pay, us my hon. Friend the Member for Nottingham, North (Mr. Whitlock) illustrated; queue jumping for consultation, queue jumping for a bed, queue jumping for a place at the top of the operating list. This is socially unjust and medically indefensible.
I have received a letter which reads as follows:A relative of mine, a pensioner, has recently had an operation and I would like to draw your attention to the circumstances. Her doctor told her that there would be some months' delay in procuring a bed although she was in great pain. On seeing a consultant privately she received a letter by return with instructions to attend the hospital as an in-patient and was operated on the following day. The patient is a woman of slender means, and the whole episode seems to be a gross abuse of the system. What the cost will be I do not know, but I have no doubt that it will cause hardship, and I write to inquire whether this could be investigated.All that was within the law. The instance of "two nations" among patients, those who pay and those who do not, casts a shadow over the health service. It leads to a conflict of loyalties and a resentment among staff—technicians, nurses, junior hospital doctors and ancillary hospital doctors—who, incidentally, receive no additional fee for their services to private patients. These are the people who resent the system. Their morale and dedication are undenied.
1035 Abuses in the system were clearly revealed in the long report of the Select Committee chaired by my hon. Friend the Member for Wolverhampton, North-East (Mrs. Renée Short). Yet the report ended up as a simple statement of the political faith of the Conservative majority, and a clear party division prevailed throughout the Committee's proceedings, ending in a minority statement and recommendations from the Labour members. Ever since its creation by a Labour Government, when it was bitterly opposed by the Conservatives, the National Health Service has been at the centre of party politics.
The Select Committee reported to the House a year ago this month. It shows a disgraceful disregard for the House that the Secretary of State has failed to make a statement on the report. He has been repeatedly asked to do so, and a statement from him was necessary for a debate to be held on the report before consideration of the Bill. A further statement on 3rd April and a White Paper are not good enough.
The Government's long-term attitude to the private sector within the health service is mentioned only once in the Bill under the general heading "Miscellaneous functions of the Secretary of State". In a subsection of eight lines the Minister is given wide power to provide facilities and accommodation for private patients. The White Paper assures us that continued facilities in health service hospitals for private patients will be made available—… without prejudice to the needs of those … who wish to be treated as National Health Service patients and who are the hospitals' primary concern".The Opposition believe that the National Health Service patient should not just be the primary concern but should be the only concern of National Health Service hospitals. In justifying the private sector, the White Paper claims that it is right for people to have an opportunity to exercise a personal choice to seek treatment privately. We have heard this freedom of choice argument before in the context of retaining grammar schools, although the fact that 75 per cent. of pupils who fail the 11-plus never had a choice is conveniently overlooked. Within the health service it is the power of the purse that determines 1036 whether or not one has a choice. Most patients are excluded from the right to choose, so why should beds and staff be set aside for a privileged minority?
The White Paper goes on to claim that the private sector within the health service not only does no harm but has a part to play in acting as a stimulus to enterprise, development and high standards of service—but it does nothing to reduce the waiting list or staff shortages. In fact, it monopolises more than 4,000 beds.
The White Paper admits the existence of double standards of service—one for the health service and a higher one for private patients. The private sector should need no justification. There would be no queue jumping if there were no queues to jump. There would be no staff shortage if there were adequate pay and conditions of work. If this happened, the private sector would lose its fascination for patients and staff. The solution lies in improvement in the public sector.
§ Dr. Summerskill
I should like to discuss that topic at length with the hon. Lady, but I cannot do so in the time I have available. If the Minister feels that the private sector has a part to play, will he explain why only 4,527 beds are playing it? Why not have fewer full-time and more part-time consultants? If part-time consultancy is not to be discouraged or discontinued, at what level is it to be maintained in future? We see nothing about this in the Bill. I suspect that the Secretary of State has no answers to this question because he regards the private sector as one of his "miscellaneous functions". His policy is one of laissez-faire inertia.
§ Sir K. Joseph
The Labour Government when in office allowed the private sector to continue virtually unchanged. The hon. Lady has devoted 10 minutes of her winding up speech to the private sector. Will she tell the House whether it is Labour Party policy to forbid National Health Service consultants to carry out any private practice?
§ Dr. Summerskill
That is the climax of the first section of my speech. There 1037 is a clear and fundamental division of opinion on this matter to which it is important to devote a quarter of an hour or 20 minutes of my speech—if I had the time. This revealed itself in the report of the Select Committee, and it is present between Government and Opposition, as shown by this debate. It is increasingly evident that many patients and staff are becoming intolerant of a privileged sector within the health service. The Labour Government reduced the number of private beds within the health service as a positive act of policy. The next Labour Government will ensure that private beds are no longer provided in new hospitals, that existing ones are phased out, and that part-time consultant appointments within the health service will also be phased out.
I now turn to family planning. This is a part of the Bill which has had the benefit of most public discussion and which has occupied most of the time in this debate. The Opposition support the Lords Amendment to Clause 4. I said only a few weeks ago that the only fair and effective scheme of family planning within the health service is one that is free of charge and freely available to everybody—married or unmarried, healthy or sick, somebody with no children or somebody with six children. Only in this way can every child born be a planned child. In 1972 there were 106,000 legal abortions performed on British residents. This House would need to spend less time on the subject of abortion if it spent more time legislating for family planning.
I congratulate the Secretary of State on an explicable, but only partial, conversion since his last statement on family planning a few weeks ago. But, despite his surrender to the blandishments and backstairs wooing of his right hon. and hon. Friends, and to a lesser extent to the Women's Institute, his present policy is as full of anomalies, complications and injustices as was the last one, It seems that inside the Secretary of State there is a civil servant struggling to get out. If I may borrow from the Daily Telegraph, in this BillSir Keith Jekyll, the civil servant, has triumphed over Mr. Joseph Hyde, the politician.Family planning is essentially a preventive service. It is not a form of 1038 treatment. It should be put on an equal basis with other preventive services which are free at the time of use, like mass X -ray, vaccination, immunisation and cytology services. Prescription charges act as a deterrent to the seeking of advice. For a 12-months' supply of contraceptive pills a woman will have to pay at least £3.50 if she uses a prepayment certificate. This can deter a woman struggling to bring up a family.
What is the point of health education and the publicity for family planning now partly financed by the Government if the service is to be at a price? To encourage its use while putting up barriers of cost is the height of illogicality. Local authorities with totally free services report 30, 50 and sometimes 100 per cent. increases in attendance.
We come then to the whole mix-up on exemptions. Who will be exempt under the Government's plan? Who can receive free contraceptive supplies? They include children under 15, people over 65 and, last but not least, expectant mothers. A further group for exemption are women, for some unknown reason, during the 12 months after the birth of a baby—not before the birth of a baby and not when the baby is over one year old. If anyone can explain the logic of that I shall be obliged.
§ Sir K. Joseph
The hon. Lady may have confused some people. Normally, a prescription for an oral contraceptive would be for about three months. Assuming that a doctor provides a woman with four prescriptions for oral contraceptives during the year the cost will be 80p—unless her income is so low that she is exempt on income grounds. That will happen in only a minority of cases.
§ Dr. Summerskill
But if she obtains her prescriptions on a prepayment certificate, my point is that it will be more expensive.
Does this make economic sense? Have the Government considered the administrative costs? Have they considered what the cost will be of all the exemptions? For a completely free service such as that envisaged in the Bill as amended by the other place, the cost would be only £3 million more than the service proposed by the Government.
§ Dr. Miller
Does my hon. Friend agree that the Secretary of State has indicated quite clearly that he knows nothing about the prescribing of contraceptive pills if he says that a woman needs only four prescriptions a year? My own experience in a family planning clinic shows clearly that very often a woman has to have a number of different pills before the exact one which suits her is found. In such a case there will be many more than four prescriptions a year.
§ Dr. Summerskill
I am sure that the Secretary of State takes the point. I ask him seriously whether he cannot find another £3 million to introduce a totally free scheme.
The final anomaly is that of the 20 or so progressive local authorities which at the moment are implementing a totally free scheme. There are others which have planned to introduce one within the next year. The most famous of these is Aberdeen, with the results about which we all know. Although the Population Panel has said that one should not generalise, it is an extremely interesting experiment.
After the Government's scheme is introduced some people in these progressive boroughs will no longer receive a free contraceptive scheme. The Bill for them is regressive, as my hon. Friend the Member for Willesden, West (Mr. Pavitt) pointed out. The local authorities have been realistic and humane in their attitude, and the Bill rejects local authority control over the wisdom of the Secretary of State.
The report of the Population Panel, which endorses the Lords Amendment, makes the Government's attitude look positively antediluvian. We trust that the Committee will retain the Lords Amendment.
I now come to Part III of the Bill, which deals with the establishment of health service commissioners for England and Wales, which we welcome. The opportunity to complain about a failure in a service provided or about a failure to provide that service increases the sense of involvement among patients, their relatives, and staff. For too long many of them have felt like helpless and voiceless cogs in a machine. In particular, the succession of reports of mal- 1040 administration in long-stay hospitals has revealed the powerless situation in which some patients and staff find themselves. But it was premature of the Government to appoint the Commissioner over Parliament's head as long ago as last November, before the Bill had been passed. Perhaps, as a matter of principle, that will not happen again.
Sir Alan Marre, the Parliamentary Commissioner for Administration, has now been given the additional rôles of Health Service Commissioner for England, Wales and Scotland. Surely this is too much responsibility for one person. Is not the precise function of the Parliamentary Commissioner different from that of the Health Service Commissioner? The health service, which employs more people than any other Government Department, merits a totally separate ombudsman, or even two. I have nothing personal against Sir Alan Marre, but until recently he was second permanent secretary at the Department of Health and Social Security. Is not this like appointing as referee of a football cup final a man who had been playing for one of the two teams only a week before?
More important, the Bill will create an edentulous ombudsman with severely limited powers. One of the list of conditions laid down is that before the commissioner will investigate a complaint the health authority concerned must have had an opportunity to investigate it and reply to the complainant. This will certainly act as a deterrent to many patients and their relatives from complaining for fear of victimisation or intimidation by the authorities. That this can occur has been shown by the Payne Report and the Farleigh Report. Because the commissioner will need to investigate not only individual incidents but allegations of continuous neglect or intimidation of patients in long-stay hospitals direct access to him, bypassing those about whom a complaint is made, is therefore essential.
Complaints which can be pursued through the courts or before a tribunal are excluded.
A further glaring and serious condition in the Bill is that the commissioner will not be allowed to look at anything whatever to do with general practitioners, 1041 dentists, opticians or pharmacists. A key sector of the health service dealing with at least 90 per cent, of all episodes of illness is thus exempt from investigation The commissioner will be primarily a hospital commissioner, not a Health Service Commissioner.
It is proposed that the commissioner should be precluded from investigating complaints relating to the exercise of clinical judgment, as these are already subject to other sanctions. He should, however, be obliged to give advice to complainants on the legal and other procedures open to them in connection with complaints. We will pursue all these matters in Committee to create a really effective form of external investigation of the health service.
Of a variety of possible sub-titles to the Bill, one could say that it is the Bill of missed opportunities because there is one especially shameful omission. The reorganisation of the health service should include the establishment, within the service, of an occupational health service. This would concern itself with safety and health at work, and with the treatment and prevention of accidents and disease. This was admittedly the great gap in Labour's 1946 Health Service Act, but the necessity for such a service is now accepted by trade unions, by all sensible management, by the United Nations International Labour Organisation, by all Common Market countries, by the British Medical Association, by those who work in industrial and preventive medicine and by the Opposition. But not by the Government.
The White Paper states that responsibility for the health of persons in relation to their employment lies with the Department of Employment, and it merely urgesimproved co-operation between the National Health Service and the Employment Medical Advisory Servicebut in the long term this arrangement is totally inadequate to care for 23 million wage and salary earners.
I remind the Minister of the speech of his colleague the Under-Secretary of State for Employment during the Second Reading of the Employment Medical Advisory Service Bill. The hon. Gentleman admitted that the new service was 1042 not intended to be a comprehensive industrial health service and that responsibility for it remained with the Department of Employment, but he assured the House that when the health service was reorganisedthe proper home for the Employment Medical Advisory Service will undoubtedly have to be looked at again by the Departments concerned."—[OFFICIAL REPORT, 13th December 1971; Vol. 828, c. 126.]Have the Departments looked again? If not, will they be looking again? Meanwhile, the Bill is deafeningly silent on the subject of an occupational health service. As the Secretary of State has refused to include it in the Bill the House can be assured of its introduction by the next Labour Government.
I have been speaking of serious omissions and defects in the Bill. My right hon. Friend the Member for Deptford (Mr. John Silkin) voiced our fundamental and major criticisms. We are opposed to the excessive power relegated to the Secretary of State. We are opposed to the sacrifice of election in favour of selection, to the sacrifice of democracy at the altar of management ability. Are these characteristics incompatible? Is not this a reflection on the efficiency and administrative competence of every councillor in the land, and even of Members in this House?
The health service is about the care of the sick, not the management of the sick. It is a public service, and not a factory, and its patients are not employees to be manipulated by a managing director and his board. The theme running through the Bill is "The Minister knows best. Leave it to him." We do not intend to leave it to him, and we shall vote against the Bill tomorrow.
§ 9.34 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)
We have been debating proposals for the most far-reaching changes in the organisation of health care to have been considered in Britain for a quarter of a century. The scope of these changes —that is to say, the integration of the local authority health services on the one hand and the family practitioner services on the other into a single unified National Health Service—is on no less a scale than the nationalisation of the hospital side of the service in 1948. They 1043 are fundamental and sweeping changes which we propose in the Bill.
Indeed, the changes that we propose might be considered almost too daunting, for all that they involve in adaptation and upheaval for the men and women who work in the service, if we do not look at them in the context of the needs which they are designed to meet.
I want to accept the invitation of the right hon. Member for Deptford (Mr. John Silkin) to look for a moment at the wood as opposed to the trees. Changes far more radical than any we propose have occurred in the health needs of our people. Over the last 100 years, and dramatically in the last 25 years or so, since the end of the last war, a combination of modern drugs and, incidentally, modern sanitation, ushered in by earlier pioneers in public health has virtually eliminated the traditional killer infectious diseases. One can illustrate this by pointing out that as recently as 1930 mortality from the five main infectious diseases affecting children was 100 times the present scale.
We have virtually, in two generations, created for the first time for many thousands of people the possibility of surviving into old age. The staggering fact is that in the fantastically short space of about 100 years we have added 25 years to the life expectation of the ordinary citizen, an increase of virtually 50 per cent.
By a paradox, it is this very survival which has created the problems of delivering health care today. The House knows only too well that half our hospital beds are occupied by the mentally ill and the mentally handicapped and another quarter by patients over 65. These are the symptoms of physical survival in an age of stress—three-quarters of hospital beds occupied by the mentally infirm or the elderly infirm.
What the House appreciates less readily, I think, is how real and how strong are the natural ties which today link home life for the family and hospital life—no longer as isolated segments but as part of a continuous whole. As never before, the terms and conditions of life for hundreds of thousands of families in the outside community are governed by the availability or otherwise of hospital beds and treatment for their elderly infirm 1044 or handicapped members—not just for short episodes of acute illness but, because they are of these long-term characters, over a long period of time.
Conversely, the hopes and prospects of thousands in hospital beds turn upon the existence or absence, as the case may be, of services of help and support in the community to which they are, in health terms, ready to return if those facilities were available. So the two, home life for the family and hospital life, are in reality interlinked and interdependent in the real world.
Indeed, the more successful we are in curing acute illness, where, on the whole, patients take the initiative in coming to their doctors for treatment, the more we shall depend for progress in the National Health Service upon preventive medicine —as my right hon. and learned Friend the Member for Huntingdonshire (Sir D. Renton) pointed out—which is precisely the sort of medicine about which the doctor, be he general practitioner or hospital doctor, has himself to go into the community and take the initiative, because patients will not take it in the way that they clearly do if they are acutely ill.
But if, in the real world, the hospital environment and the community are interlinked and interdependent, we simply do not recognise this in the organisational structure which the health service features at present. The falseness of the division between community care and hospital care is perhaps most dramatically illustrated in the relationship between family planning and abortion—indissolubly linked in human reality, rigorously separated in service organisation at present between hospitals and local authorities.
It is in response to present contemporary human realities that we have presented a Bill designed to match with modern organisation the dimensions of modern need. My hon. Friend the Member for Norwich, South (Dr. Stuttaford) is wrong at least in this respect. We have taken into account the changing pattern of disease in the community, and it is precisely for this reason that we seek in an organisational system now to link together the community with the hospital world.
The Government do not dispute that changes as radical as the Bill proposes involve us in some difficult choices. The 1045 terms of the Opposition's amendment make clear where they think we have erred. But, before dealing with their criticisms, I want to remind the House how much common ground we share.
First and foremost, we all seek to pinpoint the human needs of the individual citizen as the focus of all our reforms. I hope that no one will be so superficial as to complain that because the Bill, or the Grey Book that lay behind it, is a complex document, nothing good can emerge from it from the point of view of the patient. The House has considered in the past many documents, including the Briggs Report on Nursing, which have been very complex, and in some ways rather turgid in their style; but that does not prevent them from having real benefits in prospect for the individual patient.
It is because we are concentrating upon the patient above all that we have given the greatest thought and care to our plans for the district organisation; that is, the lowest level—roughly equivalent to a district hospital catchment area—for which we have drawn up a specific organisational structure. It is at this level that the modern successor to that great and familiar figure, the old medical officer of health, will operate. Called "the district physician", he will have even greater scope than the medical officer of health, because for the first time he will straddle the worlds of both the hospital and the local community outside, and will play a key rôle in planning and managing the services of both.
Some people may suspect that the district physician will not be as accessible as the old medical officer of health. But I have every reason to believe that the community physician will be at least as accessible. He may lack something, as right hon. and hon. Members may suspect, of the autonomy of the old medical officer of health, but this will at least be compensated for by the extra scale of responsibility he will have, stretching right across the spectrum of hospital to community, and the very much larger budget that will in the event be backing him up.
It is at this level that, alongside the community physician, we have welded together, again for the first time, general practitioners, hospital consultants, and 1046 nurses as well as lay administrators—the key people from the patients' point of view—into a single management team. It is at this level for the first time that special teams of people from all the necessary disciplines—the health care teams to which my right hon. Friend referred— will be set up to look, with a single eye, at all the ramifications of need of particular groups, such as the elderly, children, maternity cases, the mentally ill and the mentally handicapped. Finally, it is at this level that our new community health councils will operate. My right hon. Friend has elaborated the changes we have made to improve upon them.
These are just a few of the pointers to the improvements to which the individual patient can look forward from reorganisation; a system at district level very much more elaborated to bring together into an effective organisational team those individuals most intimately concerned with patients' care. There will be not far short of the same number of district management teams as the existing HMCs—about 200 as opposed to 275 HMCs—but they will be immeasurably better adapted by their structure and membership to deal with the comprehensive health needs of a given community.
§ Dr. Stuttaford
Does my hon. Friend agree that the new district physician will have no power to initiate any programme and will have no command? He will be only an adviser. An adviser is only as good as those who will listen to his advice or reject it.
§ Mr. Alison
The district physician will have assistant community physicians under him who will be subject to his authority. The new philosophy, which I am sure is a wise one, is that as far as possible this kind of initiative should take place in the context of a consensus discussion amongst people who will all have responsibility within a complex of services in which it is better to do things on a coordinated and collaborative basis rather than the great white chief deciding things and everybody else falling into step behind.
§ Mr. Arthur Jones
Does my hon. Friend see the new district physician having the same independence and same responsibility to the public as the present medical officers of health?
§ Mr. Alison
Clearly the new district physician will have the same responsibility to the public, though not through a democratically elected local assembly. His powers, as always, will be determined by the amount of money available and will be backed up by any policies which he can put into operation.
I freely admit that our proposals owe a great deal to the work done by the last Government in their two Green Papers. We largely accepted the three firm proposals put forward in the second Green Paper, which were as follows. The first proposal was that the National Health Service should be administered not by local government but by area health authorities responsible to the Secretary of State and closely associated with local authorities. Secondly, the administrative boundaries which have as a consequence to be drawn between the National Health Service and the local authority services are the same as those proposed by our predecessors in office. Their proposals, like ours, included transfer of the school health service and the ambulance service but did not at that time include the occupational health services, about which the Opposition appear now to have adopted a different position. Thirdly, we also agree in general that the number and areas of the new health authorities should match those of the new local authorities outside London.
On other matters our proposals are a development of ideas that were provisionally put forward in the second Green Paper, examples of which are as follows. The first is the establishment of a separate statutory family practitioner committee to administer the contracts of the professions providing family practitioner services. The second is the need for detailed machinery for collaboration with local government, including arrangements for exchange of services. The third is the emphasis on the importance of voluntary organisations and voluntary work. Those three are common ground. There is in fact a great deal of common ground in the Bill, in spite of the differences expressed by some right hon. and hon. Members.
In the context of voluntary work I wish now to refer to the speech of my hon. Friend the Member for Dorking (Sir G. Sinclair) about the need to encourage 1048 volunteers. We share my hon. Friend's concern about this and I warmly echo the tribute paid by the hon. Member for Norwich, North (Mr. Wallace) to the immensely valuable contribution that volunteers have made throughout the history of the National Health Service. It is worth reminding the House that with 200 community health councils, each with 30 members, 90 area health authorities, each with 15 members appointed as members, and more volunteers on the family practitioner committees, and with 15 regions, we shall have just about the same number of volunteers engaged and involved in the new National Health Service as there were in the old set-up.
The hon. Member for Norwich, North spoke also about the need for consultation between management and staff at local level. The staff and management sides of the Joint Whitley Council are reviewing the present arrangements, which are non-statutory, and considering how they can best be improved and developed in the reorganised service. We have not made mention of them in the Bill, though we are as concerned about staff relations as is the hon. Gentleman, only because it is unnecessary to make provision in the Bill for a topic about which both sides of the non-statutory Whitley Councils are themselves deeply concerned.
I want to refer also to the distinguished speech made by the hon. Member for Woolwich, East (Mr. Mayhew), who suggested that we consider the possibility of bringing consumer health councils up to a pyramid and establishing a national community health council. There is no reason why the system should not evolve in this way. Many of the existing national organisations representing a whole distribution of local organisations and voluntary bodies have evolved in precisely this way to establish a national set-up, such as the National Association of Leagues of Hospital Friends.
§ Mr. Mayhew
It will be necessary, for example, for there to be a grant by the Secretary of State. Should not that appear in the Bill?
§ Mr. Alison
There is no need for such provision in the Bill for the development of the system of community health councils. We shall have plenty of powers in the regulations to determine how they 1049 should evolve. If it seems that they should come to a pinnacle in a central organisation, that can be done within the scope of the Bill.
I now turn briefly to the extensive comments which have been made about family planning. The right hon. Member for Deptford made a witty remark about "tiers". I suspect that Clause 4 will be our vale of tears. I hope that he will help us to wipe them away. I shall clear up a point which arose in the course of an interjection during my right hon. Friend's opening speech about the provision of sheaths, which may have arisen out of some confusion between medical and non-medical methods. We do not envisage that we will make the sheath available in an uncontrolled or irresponsible way. If the sheath is the appropriate method of contraception it will be available on prescription.
Some hon. Members raised the question of vasectomy. Area health authorities will have the power to provide vasec-tomies for non-medical reasons. That is covered in Clause 4 by the words "or treatment". Guidance will be issued to health authorities encouraging them to make provision for vasectomy as part of the family planning programme. Area health authorities will be asked to provide this service to the extent that their resources permit. It will be for the authority to determine how these will best be allocated between different parts of the service. The method of contraception which is prescribed will be the result of the advice of the doctor and the wishes of the patient. The ultimate choice will clearly be for the patient.
The hon. Member for Willesden, West (Mr. Pavitt) spoke about the effect that the introduction of prescription charges might have upon the general practitioner's load as distinct from that of the existing clinics. My right hon. Friend made clear that we are negotiating with general practioners on their involvement in family planning. We do not know what the outcome of the negotiations will be.
There is no reason why the introduction of prescription charges should affect the pattern of take-up between the different kinds of service—namely, the general practitioners and the clinics. The service to which patients go will be largely determined by the preference of the individual. 1050 Some are a little shy about going to their general practitioner and prefer to go to a slightly more anonymous clinic. Others prefer to go to a clinic. There is no reason for the matter not to be decided entirely on the merits of the services and the individual.
The other main point that seems to have disturbed a great many of my right hon. and hon. Friends—
§ Mr. Pavitt rose—
§ Mr. Alison
—and also Opposition right hon. and hon. Members is the extent to which by not going the whole way which another place would have wished us to take we have fallen short of the ideal service which may be provided. I remind the House of the scale of expenditure for which my right hon. Friend has provided. Even in the first set of proposals which he announced to the House on 12th December there was represented an increase of an astronomical scale on what was proposed by the last Labour Government before we came into power. We inherited a scale of family planning expenditure of about £750,000. My right hon. Friend's first set of proposals raised that to about £12 million. He has increased that to substantially more. The only difference between my right hon. Friend and myself and some of our right hon. Friends on the back benches is whether it will make a great deal of difference that some consumers should pay the basic prescription charge of 20p perhaps two or three times a year. That will not reduce the scale comparatively of the service that we envisage.
I now turn to the areas where we disagree and to the specific Opposition criticisms made both in speeches and in the terms of their amendment. The first stricture in their amendment is that our proposals are too managerial. At first sight that sounds a damaging criticism. However, if we consider carefully the proper meaning of words it proves to be thoroughly superficial and misleading criticism.
The Opposition depend entirely for the impact of their criticism upon importing into the words "management" and "managerial" a set of meanings and undertones which belongs to quite a different world—a world which the hon. Member for Willesden, West described as high Tory managerial tycoonism. If it 1051 was management in that narrow and specific sense which was to be imported into a health organisation, the prospects for the patients would not be as good as we propose. But this is a travesty of what we seek.
There is another version of "management". Let me remind the House of the views of the Briggs Committee on Nursing. The Briggs Committee said this about management:The collected reports we have received from the National Nursing Staff Committee demonstrate beyond doubt that good management can prevent 'dehumanisation' and 'depersonalisation.' By its nature it is not bureaucratic, but the reverse…. We do not see nursing management as something distinct from nursing practice. All nurses and mid-wives are managers of their own time and skills and … nowhere is this more true than when they are providing care directly to the patient.I may add that the report goes on to applaud the scope offered by our new management structure at area and district level for promoting better standards of service.
It is impossible to avoid devoting great attention to management in the health service. It is a body that employs 850,000 staff—virtually the whole of the Army, Navy and Royal Air Force rolled into one from the managerial point of view, with an infinite number of professions, grades and so on.
I refute the allegation that our structure is old-fashioned and clumsy. We have devised a method of recognising in management clinical independence in the medical profession and its vital managerial rôle. We brought them together and the system will work.
The Opposition are on even weaker grounds when they get on to a plea for greater democracy. The inherent contradiction in the approach of the right hon. Member for Deptford is that local government is the appropriate democratic body to be deployed in a unified and integrated National Health Service. On any common interpretation, the words "democracy" and "democratic representation" must be associated with supply. It is my right hon. Friend who disposes of the whole of the financing of the National Health Service and it is quite proper, therefore, 1052 that the representation should be in Parliament. I may add that the right hon. Gentleman and his colleagues, who have laid such stress on the scope of local democracy, are belying themselves when we consider some of the things they have said about local democrats in the operation of the health service.
Let me remind the House of what the hon. Lady the Member for Halifax (Dr. Summerskill) said. This is in the context of criticism of the Chronically Sick and Disabled Persons Act, a health measure, which the House deliberately laid on local authorities:We are concerned with the lazy local authorities, the under-staffed local authorities, the mean local authorities. Every hon. Member knows that there are many such authorities.That is the sort of authority to which the hon. Member wants to hand the National Health Service.
§ Mr. John Silkin rose—
§ Mr. Alison
I have only about a minute left. I quote again from the same debate:Many of us said at that time that it"—and Chronically Sick and Disabled Persons Act—would revolutionise the provision for the disabled of Britain. However, its implementation depends largely on local authorities, among which we find the very good and the appallingly bad."—[OFFICIAL REPORT, 21st February, 1972; Vol. 831, cc. 915, 939.]That is the Opposition's view. The qualities of local government hardly befit it to be the paragon of virtue to which we should hand over the whole of the local health administration.
The Opposition amendment in its reference to democracy and management is superficial, unthought-out and entirely bogus, and I hope that when the time comes we shall have no hesitation in disposing of it with a massive vote.
I apologise for not giving way to the right hon. Member for Deptford but I have had five minutes less in which to speak than is customary.
§ Debate adjourned.—[Mr. Paul Hawkins.]
§ Debate to be resumed tomorrow.