HC Deb 27 March 1973 vol 853 cc1101-232


Order read for resuming adjourned debate on amendment to Question [26th March], That the Bill be now read a Second time.— [Sir K. Joseph.]

Which Amendment was, to leave out from "That" to the end of the Question and to add instead thereof: 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.—[Mr. John Silkin.]

Question again proposed, That the amendment be made.

Mr. Speaker

Before I call the right hon. and learned Gentleman the Secretary of State for Wales, I have to announce that I have a very long list of speakers for today. Yesterday speakers from the back benches took 28 minutes, 24 minutes, 20 minutes and so on. This is not being quite fair to other hon. Members. I ask for reasonable brevity.

3.43 p.m.

The Secretary of State for Wales (Mr. Peter Thomas)

I am very glad that it has been possible to arrange that this Second Reading debate should have a second day in which there can be particular emphasis on the Welsh interests in the Bill.

We have had two full debates in Welsh Grand Committee on the proposed reorganisation of the Welsh health service. There were differences between the Government and the Opposition, but there was a large measure of agreement. We agreed, for instance, that our joint aim is to make better provision for the needs of the patient and the community through a well organised and truly national health service.

I do not intend to take up the time of the House by repeating in any detail the general theme discussed yesterday, but it is right to emphasise again that the Government's proposals in the Bill and in the arrangements to be made under it have this aim: a better deal for the patient and better protection for every member of the community. Everything else flows from this.

Inevitably in a measure to reorganise the administration of the service much of the immediate attention has to be focussed on matters of efficiency. This is no more than the necessary means to the end, for without sound management—I use that word in the sense in which it was used yesterday by my hon. Friend the Under-Secretary of State for Health and Social Security in his winding-up speech—we cannot produce a better service, we cannot use our available resources more effectively for patients' benefit. We want their needs to be better understood, and we want better planning to meet those needs. We want particularly to make sure that those who are elderly and those who suffer from mental handicap or mental illness, or from chronic illness—what my right hon. Friend the Secretary of State for Social Services described yesterday as the "Cinderella groups"—are not overlooked.

That is what we want a well-managed service to achieve. I think that we are all agreed on that. There is also wide agreement on the measures to secure the necessary close collaboration between the health service and other related services.

I know that there have been claims that the health service could somehow have been put under local government. As my right hon. Friend said yesterday, in a perfect world this may be the solution. But neither Government have found it a practicable one. The Opposition, when in office, could not discover a realistic means and none has been discovered since. I am sure that reorganisation of the health service can only be on the basis of separate health authorities as proposed in the Bill.

The differences between us are how best to secure a well-managed service and at the same time ensure that it is sensitive to local needs and wishes and responsive to them. We attach as much importance to this as do the Opposition. But we are concerned that the kind of arrangement which hon. Members appear to suggest would put the effectiveness of the service at risk and would not be in the true interests of the people.

We must be sure that health authorities contain a proper balance of personal skills and experience for this work—and this means selecting members, in the main, for their personal qualities and for their contributions to the tasks of management rather than for representational purposes.

Local community influence on the planning and running of the service is best and most effectively secured by the independent community health councils we propose in the Bill.

Having said that on the general theme, I now propose to concentrate specifically on Welsh matters. First, there is the one major difference in the Bill between the provisions for England and Wales: the proposal to set no intermediate tier of authority between the eight Welsh area health authorities and the Secretary of State for Wales. We have debated this at some length in the Welsh Grand Committee on two occasions.

The right hon. Member for Deptford (Mr. John Silkin) would agree that it is always desirable, in any organisation, to keep the links in the chain of responsibility as few as possible. It is particularly desirable that in the health service the greatest possible responsibility should lie close to the communities being served.

If at all possible, the area health authorities should be in direct relationship with the Secretary of State. In England my right hon. Friend recognises the hard fact that the sheer number of AHAs—90— makes this impossible; they must be grouped under regional authorities.

In Wales we do not have this problem. The right hon. Member for Deptford will be glad to know that this is a "tier" which we shall be happy to shed. Obviously eight AHAs do not require to be sub-grouped under intermediate authorities; and Welsh Ministers and the Welsh Office are no more remote from any area health authority than an all-Wales health authority would be.

The people of Wales expect Ministers to concern themselves closely with the health needs of every part of the country, and this must mean direct responsibility for the allocation of resources, the coordination of area plans, and oversight of how the service is run.

The Government accept the arguments of the former administration that the people of Wales will best be served by concentrating the greatest possible measure of responsibility and authority upon the people who know the needs and circumstances of their areas. We agree with them that to make the eight area health authorities subordinate to an intermediate authority would be bound to work against this aim. In Wales our smaller scale is an advantage which we must not throw away.

I recognise the dilemma of Welsh hon. and right hon. Members opposite. When in office they said, forcibly, just what I have said, and nothing, so far as I can see, has happened to explain any change of mind. I think their problem, judging from the debates we have had, is how this might fit in with what they anticipate or hope the report of the Royal Commission on the Constitution may say.

To set up a Welsh regional health authority on these grounds would, I am bound to say, be to prejudge the report of the Royal Commission—which is precisely what the former administration in its Green Paper said must not be done.

We do not yet know what the Royal Commission may say. Certainly the constitutional issues with which it has to grapple are intensely difficult and complex. It would be unwise to work on guesses but from the statement of the right hon. Member for Sowerby (Mr. Houghton), which he published yesterday, it is clear that the Crowther-Kilbrandon Report will undoubtedly need most careful consideration before final decisions can be taken. It is bound to take time. But the reform of the health service—which we are all agreed is necessary—cannot wait, and we must do what is right in the circumstances as they are now.

Of course, we must be prepared to review the matter again fully in the context of the Royal Commission's report. This is what the previous administration said it would do. This is what we also propose to do.

Mr. Cledwyn Hughes (Anglesey)

The right hon. and learned Gentleman has really evaded the central issue. Does he agree with the principle that if there is an elected council for Wales these functions should be given to such an elected council?

Mr. Thomas

I know that the Labour Party has said that if it got into office there would be an elected council for Wales which would have certain responsibilities, including health. But, as that is a very remote thing and is quite some distance away, it is clear that we cannot possibly hold up the reorganisation of the National Health Service in order to cater for that eventuality. The position is that this Government propose that there should be the area health authorities in Wales, of which there are only eight, in a direct relationship to the Secretary of State, without the intermediate and suffocating tier which was proposed.

Mr. Ted Rowlands (Merthyr Tydvil)

Why is the right hon. and learned Gentleman not singing the same tune when it comes to the reorganisation of water? In fact, on the Water Bill the whole argument is that the Government cannot publish the constitution of the regional water authority because they are expecting Crowther to report in such a way.

Mr. Thomas

That is a totally different set-up. It is not proposed that in the reorganisation of water there should be area authorities. It is proposed that there should be one national authority with powers covering the whole of Wales. What I have said is that, as it has been decided to have one national authority for Wales, it is only right that the composition of that authority should not be finally defined until the Crowther-Kilbrandon Commission has reported. Therefore the constitution which is proposed is merely an interim one. The proposals for a Welsh National Water Development Authority cannot possibly be compared with the proposals for eight area health authorities in Wales.

I know that some hon. Members have expressed the fear that without the Welsh Hospital Board—to whose excellent work I again pay tribute—there may be a fall-ing-off in matters like the surveys of hospital services for the elderly and for children and the inquiry into waiting times in hospitals. But I do not think it has been generally appreciated how many of these surveys have sprung from advice, often detailed advice, given through my Department. The right hon. Member for Cardiff, West (Mr. George Thomas) will certainly appreciate it because several of the relevant notes were issued in his time. It is our firm intention that surveys and inquiries of this kind shall be pressed forward on the broader basis of the integrated health service.

Added momentum will come from putting direct responsibility for planning and operating the service where the needs and difficulties, along with the salutary pressure of the community health councils, will be directly felt. I have no doubt that initiatives in these matters, and in inquiries into how to run particular aspects of the service more efficiently and economically, will come increasingly from area health authorities.

Full co-ordination and any necessary all-Wales coverage will be secured through the regular consultations between area health authorities and the Welsh Office. The Welsh Office will be strengthened: it will promote operational research and the increasing use of management intelligence. Experienced staff of the Welsh Hospital Board will be moving into it, and it will recruit appropriate officers to enable it to give guidance and advice in relation to special matters such as the scientific, ambulance, pharmaceutical and catering services.

I see a very real partnership developing with the area health authorities, and they will share very fully in the processes of central decision. The Welsh Secretary of State will also have the support of expert advice from all-Wales professional advisory committees, as provided for in the Bill, and strategic advice from the Welsh Council. Good progress has been made informally in discussion with the professions on the constitution of professional committees not only at central but also at area and district level.

As hon. and right hon. Members know, a Welsh Health Technical Services Organisation will be set up as a special health authority under the powers proposed in Clause 5(6) of the Bill to carry out the design and execution of major capital works, central supplies functions and the running of central computer services and to provide general support to area health authorities and to the Welsh Office in the fields in which it is expert. Adjustments in the precise range of its work will be made as appropriate in the light of experience, after consultation with area health authorities.

The technical services organisation is another expression of the partnership between area health authorities and the Welsh Office, for both of which it will be providing specialised supporting services. I propose that the composition of the small board to head the organisation should be balanced to reflect this partnership, with the majority of its members being drawn from area health authorities and the Welsh Office.

I want now to speak of the staff of the service, many of whom are, I know, going through a period of uncertainty, and of the arrangements being made to look after their interests. The Welsh National Health Service Staff Advisory Committee —which, given statutory authority, will become a staff commission—has been set up specifically to ensure fair and equitable treatment. It has already done much valuable work and has established close contact with staff interests throughout the Principality. On transfer to the new health authorities, staff will have the protection of Clause 19. I expect that in practice virtually all who work in local health authorities, executive councils or hospital management committees will be transferred to the new health authorities on duties reasonably comparable to those they were doing before.

I have referred previously to the fact that staff of the Welsh Hospital Board are faced with more uncertainty than most about where they may go. A large proportion of them will be able to judge pretty well what changes the Bill's proposals will bring. Nearly half the staff are engaged on building work or on running computer services, and these could expect to transfer to the technical services organisation. Another large group will be transferred to the South Glamorgan Area Health Authority with its work in the blood transfusion service. For others their personal position is not yet so clear but we are fully aware of their difficulties. We have had discussions already and we will continue full consultation with them with a view to resolving the uncertainties as soon as possible.

As for staff coming into the Welsh Office, I have said already that it would be important to ensure that their terms and conditions of service were not less favourable, taken as a whole, than they are now. I fully understand their concern about superannuation rights, age of retire- ment and protection of personal salaries. Discussions are proceeding, and I see no reason to doubt that we shall reach an amicable agreement.

I now turn to the work being done to prepare the way for the new health authorities. Joint liaison committees of existing authorities have been set up and are hard at work preparing detailed information about current arrangements ready for the new area health authorities. I have emphasised that staff interests must be kept fully in the picture. There is also an all-Wales joint liaison committee to co-ordinate at that level. It has established a link with representatives of the staff organisations. Hon. and right hon. Members representing Welsh constituencies have received copies of the circular which I issued last week setting out my views on the central features of the organisations within area health authorities subject, of course, to the passing of the Bill.

I have recommended that the pattern of health districts proposed in the management arrangements steering committee's report, though I recognise that area health authorities may need to reconsider that later in the light of experience. I have endorsed the recommendation in the report for teams of officers at area and health district level. These arrangements are practical examples of how within a sound management structure we shall try to bring day-to-day decision-making closer to the local community.

I refer lastly to the community health councils. I hope that on reflection Labour Members will accept the importance and great value of this new feature of the service. These councils can contain a much broader spectrum of people representing local interests than could possibly have been expected within the area health authority itself. Their will and freedom to criticise fearlessly will not be inhibited by problems of divided loyalty. They will have the means and the right to make their views known publicly, and they can expect to receive consideration and reasoned response from the area health authority. It will be my responsibility to ensure that their work is not hampered in any way.

My hon. and right hon. Friends yesterday referred to the significant improvements made through the provisions of the Bill as a result of the consideration in another place, and I gladly acknowledge the contribution made by Baroness White.

I am satisfied that particularly in Wales, with our tradition of service to the community, we shall have active community health councils exerting a strong influence on the development and standards of the health service in Wales. If hon. Members have other suggestions designed to improve still further the effectiveness of the community health councils and suggestions designed to take into account our particular Welsh circumstances, we shall be ready to consider them fairly and sympathetically.

As to the pattern of community health councils, our general view is that it would be best normally to have one for each health district. It is at this level that the most meaningful influence can be exercised on the planning and running of an integrated service. We are ready, particularly in rural Wales, to consider sympathetically the creation of more if this is the wish of the people concerned.

We shall certainly consider claims for a unified community health council in the operational health divisions of Gwynedd and Powys, but there must be the general proviso that community health councils should not be so numerous and represent such small populations that they impair their effectiveness.

I know that all of us are deeply concerned to ensure that we acquire the best health service in Wales that we can possibly have. There is no doubt that in Wales the best way to serve our people is through a single-tier system in which the greatest possible responsibility is put close to the communities being served. I believe that the voice of those communities will be heard powerfully through the new community health councils. Out of the unification and re-organisation of the service will come new strength and vigour and a better service to the people of Wales, and I commend the Bill to the House.

4.8 p.m.

Mr. George Thomas (Cardiff, West)

The House will have noticed that the Secretary of State for Wales is not supported this afternoon by the Secretary of State for Social Services. I can understand that. The right hon. Gentleman has said to himself, "It is none of my business. It is the business of the Secretary of State for Wales to deal with Welsh matters". That is an issue to which I shall return later.

Yesterday my right hon. Friend the Member for Deptford (Mr. John Silkin) and my hon. Friend the Member for Halifax (Dr. Summerskill) outlined our deep anxieties about this measure. My right hon. Friend told me today that he felt as though he had intervened with a contribution on the health service in a debate on family planning and abortion. Like the Secretary of State for Wales, I shall not seek to pursue that subject today. I am one of the dwindling number of Members in the House who were here in the 1945 Parliament when the Labour Government put the National Health Service into operation. It was a far-sighted Act and it has been justified a million times. I have been here long enough, Mr. Speaker, like you, to have the ineffable—

Mr. Speaker

Is the right hon. Gentleman suggesting that I have been here long enough?

Mr. Thomas

I withdraw, Mr. Speaker. May you be here as long in the future as you have been here in the past. But I hope I shall not be here with you! I have been here long enough to have had the ineffable pleasure of watching the Conservative Party reverse its judgment on the principle of a National Health Service. The service has saved countless lives, but the time to restructure it is here" and both sides of the House recognise the need to unify the service.

The National Health Service removed the nightmare of hospital bills from the life of our working people. I hope the House will forgive me this brief personal word, but in my early years in this House one of my most frequent duties was to call upon hospital almoners on behalf of old people who could not meet the hospital bills with which they were presented. As late as 1946, breadwinners in this country were refusing to go into hospital when they should have done because they could not afford the bill. No wonder we on this side are so proud of the National Health Service. It was our creation and we keep a jealous eye on what is done to it.

Before turning to the Welsh Bill that is cocooned within this English measure, I have one comment to make. This is a major measure. It affects every family in the land and I believe it should have come to this House before it went to another place. I hope that the Government do not regard this as a precedent for the other major Bills which from time to time they bring before the House. We believe there should have been a separate measure proposed for Wales. When the previous administration published its Green Paper, referred to in felicitous terms by the Secretary of State this afternoon, we firmly intended that Wales would have its own Health Service Reorganisation Bill. The Department was geared to this end. Wales was to be treated as Scotland is being treated.

Now the whole significance of giving the Secretary of State for Wales executive responsibility over the National Health Service in the Principality is being undermined by this administration. In health matters the Secretary of State gives Wales separate Green Papers, separate statistical returns, separate consultative documents, separate management papers, a separate White Paper, separate circulars about management and a separate Staff Commission. But in the Bill itself the Welsh proposals are tied like a tin can to the tail of another measure—and the reason advanced by the Government in defence of their attitude, by both the noble Lord, Lord Aberdare, in another place and by the Secretary of State in the Welsh Grand Committee, was that they have acted in this way to save parliamentary time. That is their alibi.

The true reason is that any measure brought before this House that deals mainly with Welsh affairs has, by the Standing Orders of the House, to be submitted to a Committee composed of all the Welsh Members of Parliament, and everyone knows that the Welsh Committee would consist of 28 Labour Members out of 36. I understand the Government's difficulty. If they sent any Bill there it would come in as a Tory Bill and go out as a Labour Bill. But why do not they "come clean" and say the reason why every Welsh measure has to be submerged in an English measure is that they dare not deal with the Welsh Members of Parliament who are gathered there in strength? Quite clearly, for the rest of this Parliament only agreed measures will be Welsh Bills.

I turn to deal with the question of the regional board in Wales. The Secretary of State again took shelter behind our Green Paper, but he makes two major mistakes. He forgets our insistence throughout that Any proposals for health service reorganisation for Wales put forward at the present time must not pre-empt the outcome of the work upon which the Commission on the Constitution was engaged.

That is a quotation from the foreword of my own Green Paper. The Secretary of State referred to this but he did not indicate that these proposals that he is now submitting to Wales he regards as binding and long term. In our proposals we created representative area health authorities on which I made provision for the ancillary workers in the industry, as well as the professions, to be represented. Our current hospital difficulties have reminded the whole country that the ancillary workers are an essential and vital part of our National Health Service. The fact that they do the unglamorous and the dirty work of the Service has only led to them being treated shabbily.

We believe in all the workers being represented. The Secretary of State dealt with our proposal for an elected Council for Wales in which health will figure largely, but the Secretary of State himself assumes all the powers that are given in England to the regional boards without giving any added power at all to the area health authorities in Wales, as compared with those in England. He argued in the Welsh Grand Committee, If there are area authorities which are in direct contact with the Secretary of State, inevitably those area health authorities are more powerful."—[OFFICIAL REPORT. Welsh Grand Committee, 21st November, 1972, c. 13.] They are said to be more powerful because the Chairman will have access to the Minister. This is the most phoney argument that I have heard advanced in the House—and that is saying something.

Mr. Peter Thomas

How does the right hon. Gentleman reconcile what he has just said with what he said in the Welsh Grand Committee on 28th July 1971: It is right that area health boards should be directly responsible to the Secretary of State. That will give them much more power provided that real power is vested in the localities. A body in between could be just an impediment."—[OFFICIAL REPORT, Welsh Grand Committee, 28th July 1971; c. 19.]

Mr. George Thomas

We are talking about two different bodies. I am talking about a democratic area health authority, and the Secretary of State knows that he has produced a very different creature from that which I proposed. We shall give the powers enjoyed by the English regional boards to an All-Wales Council representative of the people of Wales. The cold, managerial system so attractive to the Government will go. It does not provide for one elected representative of the Welsh people to have a say in the broad sweep of health policy throughout Wales.

We intend to democratise the service. We give this assurance to Wales. We shall restore lay representation. We shall ensure that those who administer our health service have been elected by the people. All experience proves that elected representatives are more conscious of public pressure than are professional managers of the type so attractive to the Secretary of State.

Opportunities for public service in Wales are being eroded by this Government. First we saw the numbers serving in local government reduced. Now the numbers serving in the National Health Service are to be reduced. The paper-thin defence of the Secretary of State hitherto has been that the Welsh Hospital Board was a nominated body and that I and my predecessors as Secretary of State for Wales nominated people to it. That is true. But though I salute the courage with which Mr. Gwilym Prys Davies has gone out of his way to meet the people as though he were answerable to the people, nonetheless we are now planning for the health service in the next 20 years. We refuse to accept the managerial concept. We put all our faith in local democracy.

Nominated bodies proliferate in Wales and they are resented. The Tourist Board, the new Water Resources Board, the Welsh Council, the Welsh Development Corporation, the Mid-Wales Industrial Corporation, and the consultative committees of the nationalised industries—all are nominated bodies. If the Secretary of State for Wales represented a Welsh constituency he would be sensitive to the rising tide of public anger against Ministers' men managing our affairs. The truth is that change is in the air. People are demanding a greater say in their own affairs. The Government's mistake is to take the philosophy of long ago and to seek to apply it in an age which simply will not accept it.

Nominated bodies tempt political nepotism. I remember what Nye Bevan wrote in "In Place of Fear". It is respectable to quote that because we on the Opposition benches speak with great affection of Nye Bevan. Referring to these political appointments he said that he acquitted the Conservative Party of nepotism because there was no money involved. That is no longer true. The chairmen will be paid.

I confess that when I bore the responsibility now carried by the right hon. and learned Gentleman, all other things being equal I always preferred the nomination of a good Labour man or woman. That is natural enough. It is not an offence for a Labour Minister. The Secretary of State has shown how vulnerable he is on this score.

I recall the case of Oliver James, a distinguished public servant in Pontypool and leader of the Cwmbran Labour group. He was thrown out by the Secretary of State. He was Labour. I think of Philip Squires, one of Glamorgan's most able and distinguished public servants. He was chairman of the Welsh Sports Council. The Secretary of State could see only a vacancy for a Tory. Of course, we all tend to be a bit biassed when it comes to nominations to bodies of this kind. But my charge is that this system is bad for democracy. It is time that it was changed. An elected man is better every time than a nominee whose very existence depends on the good will of the Minister.

I turn to the community health councils, the guardians of the people's rights. Referring to them earlier today the Secretary of State spoke of the salutary pressure of the community health councils. The original proposals of the Secretary of State are with us no longer. Even the non-elected House of Lords could not stomach these undemocratic proposals. We have reached a sorry pitch when even the dukes, earls, viscounts and barons feel it necessary to tell the Government that they are not giving enough protection to the man in the street.

The Secretary of State said that the community health councils would have no divided loyalty now and that they would be independent and strong. That was his general theme. But the Government insist that the staff of the community health councils are the creatures of the Minister. The staff will have divided loyalties. The staff will be answerable to the Minister. He pays their salaries, not the community health councils. Everyone knows that the quality of the advisers whom the community health councils have will decide the degree of independence that ultimately they are able to exert. I see no reason why the community health councils should not be staffed, housed and financed by the local authorities.

That is what the Welsh Counties Committee asked for when its representatives met the Minister of State a little while ago. The committee said: The proposal for the membership and servicing of the Community Health Councils is criticised by the Committee. The Committee consider that not only should the Council be serviced by the corresponding local authorities, to give the necessary independence from the body which the Council may from time to time be called to criticise, but also that County Council members should be included in the membership of the Community Health Council to enable the Social Service viewpoint to be clearly expressed. These proposals are not likely to improve the quality of the service to the patient. But they are certain to create an army of bureaucrats answerable to bureaucrats. The Secretary of State for Wales has let the cat out of the bag. He issued a circular to which he referred earlier giving guidance to the new health authorities in Wales and outlining his lines of accountability. It looks as though we shall have as many officials as we have doctors. We shall have more and more people doing less and less for the patient.

Let us consider the advice of the Secretary of State to the authorities. I am reminded of the way in which the number of officials has multiplied in some of the nationalised industries—[Interruption.] Those who work in the nationalised industries and are anxious for them to succeed resent it more than anyone. The Secretary of State says in his circular that each area health authority will appoint an area medical officer, an area nursing officer, an area treasurer and an area administrator, each with his chain of command. In other words, empire building on a mammoth scale will go on. There will also be an area dental officer, an area pharmaceutical officer and an area works officer. Then we get the administrator for the family practitioner services. Responsible to him will be the chief ambulance officer, the area personnel officer, and the area supplies officer. Then comes the area medical officer, who in turn will have his little empire. In paragraph 10 we are told: Other posts may be established at the discretion of Area Health Authorities. That is at area level.

I turn to the district level. There we repeat the performance. There will be a district community physician, a district nursing officer, instead of the old matron running the hospital, a district finance officer, and a district administrator. Then we come to the Welsh Health Technical Services Organisation. It would take too long to read out all the names. Never will there have been such empire-building since Alexander.

I turn to the question of the Ombudsman, of the Parliamentary Commissioner. Six Alan Marre is a very distinguished and able public servant. All of us who know him respect him. But I am sure that in his wildest dreams he never expected to be exalted into a trinity, three in one and one in three—Sir Alan Marre, Parliamentary Commissioner for Scotland, Parliamentary Commissioner for England and Parliamentary Commissioner for Wales—in addition to his other duties.

His powers, however, are those of a poodle whose claws have been cut. He cannot deal with major grievances. The list of negatives which the Government laid down for him reads like the Ten Commandments: thou shalt not deal with grievances about general practitioners; thou shalt not deal with any grievances that can be taken to a tribunal; thou shalt not deal with any grievances that could be taken to a court; thou shalt not deal with any grievances to do with dentistry; thou shalt not deal with any grievances to do with pharmacy; thou shalt not deal with any grievances to do with appointments, with discipline or with superannuation. I could continue the list.

The office of Parliamentary Commissioner is a sop to keep the people quiet. They have given us the shadow hoping that we shall mistake is for the substance. The Parliamentary Commissioner will have about as much influence in dealing with the real grievances of the people as my respected Aunt Maria, and not much more.

The Secretary of State will know that the Welsh counties waited upon him— at least they tried to wait upon him, but, like everybody else in Wales who wants to deal with health matters, they found that the Secretary of State was an invisible man and they had to see the Minister of State. The Welsh counties saw him on 21st January. They made representations on the question of the Ombudsman. They suggested that the best method of dealing with the situation would be to have a commissioner of administration for Wales covering all aspects of public administration. They said that would give them one commissioner to deal with complaints arising from local government, the health services and the water service.

They waited for a while and on 23rd March—exactly two months later—they had a letter, a shabby letter from the Welsh Office. It was in typical Civil Service jargon, if I may say so—and I have had my share of that. I acquit the Minister of State of any blame for this letter. His only contribution was to write in, "Dear Mr. Rees" and "Yours sincerely, David Gibson-Watt". That is the only part of this letter that is in the language that the Minister of State would use. This ponderous heavy style is all used to cover up the fact that it is saying "No" to every request that the Welsh counties made.

Having received their rebuff, the Welsh counties quite properly addressed themselves to every Welsh Member of Parliament. They are unhappy about the question of the joint consultative committees which are dealt with in Clause 10. They want to know—and so do we—to whom are these joint consultative committees to be responsible? Who will resolve the disagreements—again the great man? How many members are to sit on these consultative committees? Will the division be on a 50-50 basis, area health authority and local authority? Who will provide the secretarial services? I hope that the Minister of State, who failed to answer the County Councils Association on these questions, will answer us tonight. Since he was engaged when I was relating the questions to which I hope we shall have a reply, I will give them to him later in the day.

This Bill is anaemic. It shies from faith in elected representatives. It puts power that belongs to the people into the wrong places. It fails to tackle the real issues. The structure proposed for our health service is just not good enough and we shall vote against it tonight.

4.36 p.m.

Mr. J. Enoch Powell (Wolverhampton, South-West)

After the characteristically good-humoured and entertaining speech of the right hon. Member for Cardiff, West (Mr. George Thomas), I hope that hon. Members from Welsh constituencies will not think it amiss if even on the second day of this debate upon the first major reorganisation in the National Health Service since its foundation 27 years ago there are contributions relating to the whole of England and Wales and to the general policy underlying the Bill —even if some of those contributions should come from former Ministers of Health themselves.

I often think that former Ministers of Health find themselves in very much the same relationship to the present incumbent as the saints in Paradise to the Church Militant here on earth. With a mixture of compassion and benevolence they watch him toiling along the hard and stony road which they themselves once trod. I express to my right hon. Friend the Secretary of State for Social Services my admiration for his energy and my envy of his optimism. May neither years nor experience nor reflection lessen the infectious and impressive character of that optimism.

As has already been observed, a crosscurrent has been stirred up in this debate by Clause 4. I do not intend to be diverted by that clause except to say simply this, which I think is a point that perhaps has not yet been made. It is a perilous line we cross when we invite the medical profession in the National Health Service to issue prescriptions not upon their clinical judgment of medical need but in pursuance of a social policy. I cannot believe that that erratic element introduced into the health service by the way in which Clause 4, as my right hon. Friend has explained it, will be administered, will be found to be successful or long-lasting.

Turning at once to the organisational changes, I note some directions in which I feel a definite gain has been achieved. The system of regional health authorities and area health authorities seems to me decidedly superior to the present structure of regional hospital boards and hospital management committees. Not only is the balance between the two geographically better, but I notice that in the terms of the statute my right hon. Friend has given himself much greater flexibility in his relationships with these two tiers than was permitted by the theory underlying the organisation in the 1946 Act.

I hope that this change will more and more lead the Department and the Secretary of State to deal directly and intimately with the area health authorities. I am in agreement here with the hon. Member for Norwich, North (Mr. Wallace), who spoke yesterday. Indeed, the hon. Member was repeating what has been an aspiration of mine since before I became Minister of Health; namely, that the regional hospital boards, instead of being the dominant element in the administration of the service, should more and more be restricted to a planning and advisory function—which was perhaps the orginal concept—and that the genuine administrative and living link between the responsible Minister and the service should go direct to the administering authorities which are now to be the area health boards.

I do not think there is anything really impracticable in a Department of State keeping the necessary contact with the number of area health authorities that there are to be. I am aware of aphorisms about the structure of an army, to the effect that a commander cannot have more than six subordinates; but it is a common experience, with, for example, the old Department of Housing and Local Government, that a central department can deal effectively with quite large numbers of administering authorities. This contact is to the benefit of both ends of the line of communication: it gives the Minister a much closer and more direct insight into what is happening on the ground; and it eliminates the sense of frustration and dissatisfaction on the part of those administering the service, who constantly feel they are separated from the Minister by an opaque screen. I would not go quite so far as did my right hon. and learned Friend the Secretary of State for Wales this afternoon in referring to the tier in between as "suffocating", but I know what he means; I know the sense of frustration which largely justifies that epithet. My right hon. Friend the Secretary of State for Social Services has provided himself with a more flexible and lively structure of administration, particularly of the hospital service.

It is right, too, to recognise that the time had come for the teaching hospitals to be fully absorbed into the administrative structure of the National Health Service. No doubt 25 years ago it was right that they should have almost a separate organisation of their own; but during the quarter century that has passed they have seen the advantage in much closer links with the rest of the hospital service and the National Health Service, and I hope they will accept the place in it which is assigned to them by the Bill.

I am afraid, however, that I cannot say the same of my right hon. Friend's attempt to solve his central dilemma—a problem which was created when the National Health Service came into being. Administratively viewed—although, of course, this does not exhaust the whole description—the creation of the National Health Service represented substantially the nationalisation of the hospitals. That was the essence, the big thing that happened in 1946: all the hospitals were taken out of the previous diverse ownership and administration and vested in the Minister of Health, to be entirely financed by him and administered by agencies acting in his name.

This act of nationalisation inevitably opened a gap—what would have been called, if the jargon had been invented at that time, an interface—between the National Health Service and nationalised hospital service on the one hand and the community health services on the other. That separation in the administrative organisation has become more and not less perceptible in the course of the last 25 years.

In a distinguished speech last night my hon. Friend the Under-Secretary of State, in an eloquent passage, illustrated the growth of the community health services in importance and in ramification. The health services administered by the local authorities, although they were in some ways the pioneers of the National Health Service, have changed and become more important relatively to the National Health Service and to the totality of health care in the course of the last 25 years. There is no point in attempting to deny that we are here confronted with a built-in problem, basic and serious, that of the administrative division between the community health services on the one hand and the rest of the National Health Service, particularly the hospital service, on the other. If it is to be solved at all by administrative means, the problem can be dealt with only in one of two ways, which follow of their own accord. One is to denationalise—by which I mean, municipalise—the National Health Service. The other is to nationalise the community health services also. There is no third method whereby administratively this gulf can be bridged or this gap filled.

Let me look at these two alternatives. I look first at the municipalisation of the National Health Service, whereby the administering authorities—in this case the area health authorities—would be local authorities, directly or indirectly elected authorities.

The reform of local government has not improved the prospects for this solution; and in that I take issue with what my hon. Friend the Member for North-ants, South (Mr. Arthur Jones) said yesterday. It is a fallacy to suppose that the creation of larger local government units has increased the financial resources of local government. The taxable capacity of a given area of land and population is no different whether that area is divided into 20 administrative units or covered by a single administrative unit. The fact remains that there is a limit, not precise but practical and political, to the finance which can be raised by means of taxation available to local authorities from any conceivable area of local administration. The idea that even half the £2,000 million a year spent at present upon the National Health Service could be added to the expenditure of local government in this country—could be added not only to what local authorities spend at present on the community health services but to all the rest of their expenditure, particularly education expenditure —appears to me to be inconceivable.

This is the heart of the matter. It is simply impracticable, so long as the National Health Service is publicly financed, for even half the financing of the service to be made the responsibility of local authorities. That is the central reason why one Government after another have looked at this solution and turned away from it. It is not because of the capability or incapability of local representatives or elected councillors or anything of that sort. It is simply because nothing short of the total range of national taxation is capable of bearing fairly the cost of the National Health Service.

Of course, right hon. and hon. Gentlemen opposite know that perfectly well. Therefore, although one sympathises with the sentiments glowingly expressed just now, for example, by the right hon. Member for Cardiff, West, the Opposition amendment—and surely hon. Members opposite must accept this—is really spoof. They are humbugging either other people or themselves if they pretend, and seek to persuade the House, that there can be representative and democratic administration of a National Health Service unless the representative and democratic bodies which they imagine are to administer it will be responsible for at least the lion's share of the cost of the service.

Mr. George Thomas

In education the local authority raises a proportion, not the lion's share. The lion's share is raised by the taxpayer. It could be lower in the case of health.

Mr. Powell

If the right hon. Gentleman is willing to write into the policy of his party and to proclaim in the country that he and his colleagues intend to place upon local authorities and upon local taxation, in addition to everything else, the same proportion of the cost of the National Health Service as they bear at present of the cost of school education—

Mr. Thomas

I did not say that.


If the right hon. Gentleman did not say that, and is not prepared to say that, then he cannot appeal to the precedent of education.

I do not believe there is any difference between the two sides of the House that the essence of democracy and of representation is financial responsibility. That is what this House is about. Our representative nature, which was being dilated upon in many speeches yesterday, does not arise simply from the fact that we are elected; it arises from the fact that we grant supply and that, having granted supply, we hold to account those who spend it and answer to our electors for the way in which it is spent. That is the only meaning of representative democracy: to raise a substantial proportion of the cost of a service—and I do not say even a "decisive proportion" but a really substantial proportion—and to be responsible for the way in which it is spent.

Unless that is what we mean by democratic and representative administration of the National Health Service, we are talking about nothing. This is not achieved just by putting members of local authorities on to the administering health authorities. It is not done by co-option. It can happen only when the representatives bear the responsibility for taxation as well as for expenditure and policy and where, therefore, their election is not the election of a number of ladies and gentlemen on the ground that they appear to the electorate admirably qualified to administer the health service. Election means that the electors have the opportunity to vote for one policy rather than for another policy. Therefore, the administration must be in the hands of those who are elected.

Mr. Richard Crossman (Coventry, East)

Is not the right hon. Member for Wolverhampton, South-West (Mr. Powell) merely saying that, under the existing system of local finance, transfer is impossible? If we were to transfer from the centre to the local authority certain forms of taxation which at present go to the Treasury and say they should go to the local authority, would we not then provide the local authority with sufficient finance to be able to bear the fair proportion. Is not the criticism of the Government that their reform of local government finance simply has not taken place, without which such a reform cannot be contemplated?

Mr. Powell

I suppose it is possible to imagine that Parliament could endow local authorities with virtually the full range of major taxation which this House exercises. But I chose my formulation carefully before, when I said I could not imagine that the major burden of the cost of the health service could be fairly or practicably borne other than by the whole range of taxation imposed upon the public of this country.

This is obviously a matter of opinion, but I would think it fantastic to imagine that local authorities, which can be responsible only if the sources of their finance are recognisably and definably local, could ever exercise a sufficiently wide range of taxing powers to fulfil the condition which I have stated and which I believe lies in the nature of things.

This difficulty, on which not only the amendment of the Opposition founders but also the alternative to which it points, is not altered or reduced by any community health councils or by any health service commissioners. It is in the very nature of the inter-connection of representation with taxation and with responsibility for what is actually done.

Thus if my right hon. Friend was going to resolve the problem, he was, in fact, obliged to take the other alternative, as he has done, that of nationalising the community health services. That is the essence of this Bill: we have completed in the Bill the process of nationalisation of health care in this country which commenced with the National Health Service Act 1946.

I fear that in doing so we shall be found to have lost more than we have gained. The gain is obvious, such as it is. We have brought under one administrative umbrella—a word that I believe was used more than once yesterday afternoon by my right hon. Friend—all the health services operating or available in an area. As to administrative logic and tidiness, there can be no criticism and nothing left to desire. But I believe that for the sake of the shadow we have lost a great deal of substance.

In the first place, we have lost the only sources of independent policy, initiative and decision which existed outside the central Government in the whole range of health services. After drawing up the first hospital plan, I well remember, when, in 1962,I moved on to attempt a similar plan for community health services, how astonished and delighted I was to find that there was not one Minister of Health but 145 Ministers of Health: one Minister of Health and—at that time—144 local health authorities. I realised there were potentially 144 separate and independent sources of initiative, experiment, variation and adaptation to local conditions. I saw how rich were the sources of experience available to the health service under such a system compared with those that were still possible in the monolithic structure of the nationalised hospital service.

From now on there will only be one sort of policy and initiative in the community health services as in the rest of the National Health Service. There will be sources of information and opinion but this is something quite different from an authority which, having formed a view, can act upon it and be responsible for the consequences. That will have disappeared.

With it will go the independent status of the local officials. I do not know whether that is not just as important as the independence of local authorities. There one had men equal to any in the national Civil Service who enjoyed an independence and an independent responsibility which nothing can replace. They had an immediacy of contact with the people of their area. Every hon. Member, in assisting his constituents with their problems, has hitherto had reason to bless the existence of independent local authority officials of high calibre with whom he could deal directly and between whom and himself there could be completely unrestricted exchange of opinion and advice.

The Secretary of State for Social Services (Sir Keith Joseph)

I am grateful to my right hon. Friend. I am agreeing with almost everything he is saying in what is a beautifully analysed speech. However, I do ask him to consider that the area health authorities, which he has just recognised will be agencies of infinitely greater potential and power than either hospital management committees or local health authorities will be able to pursue national policies by way of a wide range of initiatives. Any sensible Minister in any sensible Government will encourage the diversity and initiative which my right hon. Friend so rightly recognises are riches of the community.

Mr. Powell

I am sure that my right hon. Friend and most of his successors would exercise their powers and duties in that way. But he has had to pronounce the fateful word "agency". They are the agents of the Secretary of State, who will be answerable to this House and the public for everything which is done or not done, not only as hitherto in the hospital service but in the whole range of community services. That means that even the most powerful community physician will be in a quite different position from the old medical officer of health, responsible to a local authority and to a local electorate.

The second great loss which I think there will be is through the growth of bureaucracy. It is inevitable that in bringing together under one umbrella, with the professed aim of co-ordinating them, services so subtle and diverse as the community health services, the family practitioner services, and the hospital services we shall find that one tier after another of administration will be erected in an effort to bring that co-ordination about.

A word about this concept of co-ordination. It is a delusion to suppose that in a department such as medicine and health care, which progresses by specialisation and by the growth of specialisation—I guarantee that every advance in health has come about as a result of a refinement of specialisation—co-ordination in the interests of the patient is produced by an administrative structure which will throw a roof over all those who ought to be co-ordinated. Co-ordination will come about, whatever is the administrative structure, only by direct links between one professional and another, one speciality and another, one function and the other. We may well find that we have impeded rather than facilitated that communication by this attempt to throw an umbrella over the whole.

The third, and perhaps most serious, loss is that we shall have taken away from local government, in the very period when we purport to be seeking to strengthen it, one of its most valuable and valued functions. We shall have removed from it services which attracted to local government some of the most dedicated people. We shall have taken away from it the functions, many of them functions upon which local government was built, which make local government respected by the electorate and central government.

These, then, are the three major losses —the growth of bureaucracy, the loss of independent sources of initiative and authority in the health services, and the removal of a major function from local government. This is the price that has to be paid for my right hon. Friend's solution to the dilemma of administrative division between the National Health Service and the community health services. I will not seek to deny my right hon. Friend his Bill tonight; but I am afraid that when we give it a Second Reading we shall be sealing the loss of things which once destroyed cannot easily be restored.

5.6 p.m.

Mr. Cledwyn Hughes (Anglesey)

I will seek to obey Mr. Speaker's injunction and be brief. I do not propose to follow the speech the right hon. Member for Wolverhamption, South-West (Mr. Powell) in detail. At the start of his speech he likened himself to one of the saints in Paradise. It occurred to me that many of his hon. and right hon. Friends would be very happy to see him achieve that elevation. There were points in the right hon. Gentleman's speech with which I agreed. It was a thoughtful contribution and I respect his knowledge and experience. His criticisms will bear careful study. My immediate reaction however, is that it was destructive speech. He criticised the Bill but did not say what he thought would be the right structure to put in its place. To that extent it was a disappointment.

I want to deal rather more with the Welsh aspect of the Bill. We can all summarise our objectives and aspirations by saying that the National Health Service exists or should exist to ensure that the poorest and most vulnerable member in the community, whether he lives in Cardiff or a remote village in Anglesey, should, if he is taken ill, receive the best medical attention it is possible to obtain. All of the administrative structure, the committees, the councils, the doctors and nurses, the ancillary workers, exist or should exist to achieve that simple but profoundly important end. There should be equality of treatment and of opportunity for treatment. Health is the one thing that money should not be able to buy. That was Aneurin's Bevan's objective and vision.

There are, of course, certain physical and geographical constraints. If a person lives in a remote Welsh village he will be a considerable distance from a modern teaching hospital in Cardiff or Liverpool, where all the facilities of science and technology are concentrated. That makes it all the more important for our GP services and our administrative machinery to be efficient. I take this opportunity to pay tribute to the contributions which the hospitals of Liverpool have made to the population of North Wales. I am sure that the residents of Liverpool will allow me to pay tribute to the Welsh surgeons, physicians and nurses who have served in the Liverpool area.

As the Secretary of State for Wales knows, I have been deeply concerned for a long time about the inadequacy of the Caernarvon and Anglesey Hospital at Bangor, a concern shared by my right hon. Friend the Member for Caernarvon (Mr. Goronwy Roberts), the hon. Member for Conway (Mr. Wyn Roberts) and by my hon. Friend the Member for Merioneth (Mr. William Edwards). When I say inadequacy, I refer to the building, because the medical and nursing staffs have worked like trojans under difficult conditions to serve the patients' needs. The small hospitals of Anglesey are old and unsuitable, although their staffs work with dedication. In Bangor there are long waiting lists and beds sometimes have to be put in the corridors of the hospitals. There has been inadequate financial provision to meet the increased demand. These things must be put right very soon.

That brings me to one of the main themes in the debate, and to a point with which the right hon. Member for Wolverhampton, South-West dealt— namely, that the people who pay for the National Health Service should have and should be seen to have some say in its running. The further we are away from the centres of administration and decision, as is the case in my constituency, the greater the care which should be taken to ensure that people obtain the best service.

The Bill provides the Government with a golden opportunity to place the service on a democratic base. Unhappily, instead of making it more democratic it is to be less representative than before. It is reprehensible that Wales should be less well served than England. The Secretary of State for Wales is to be the great panjandrum, the final arbiter and the master of the service in the Principality.

I thought that the right hon. Gentleman's justification for all this was rather contrived. It is strange how little confidence he and his colleagues have in men and women elected by the community. They talk about freedom but they do not practise it. I cannot accept the argument of the right hon. Member for Wolverhampton, South-West. For even if the members elected to district and county councils do not raise the major part of the finance, they are more responsible than the nominees of the Secretary of State. That is the point which the right hon. Gentleman has failed to grasp. The Secretary of State has had representations from various Welsh local authorities and from the County Councils Association. As my right hon. Friend said, they have been unanimous in their criticism. I also read the letter of 9th February which the Minister of State sent to the Secretary of the Committee, Mr. Haydn Rees, and I found it unconvincing.

The attitude of the County Councils Association is clear. It describes the Government's plan as a major set-back and misfortune for local government.

Then there is the proposal to enlarge yet again the empire of the Parliamentary Commissioner for Administration. We shall shortly need a commissioner to investigate the Parliamentary Commissioner ! I confess that when I read Clause 31 I understood that there would be a Welsh Health Commissioner stationed in Wales. That would have been both prac- ticable and right. However, it is to be Whitehall again, and the Secretary of State and the Minister of State have surrendered yet another piece of ground.

So we have it in a nutshell. There is to be totally inadequate local authority representation and the power of appointments and administration is reserved to the Secretary of State. The court of appeal is to be in London. That is not good enough. We cannot ride roughshod over the reasonable demands of local authorities and people generally without inviting cynicism and damaging the trust which people should have in the Service. I hope that the Government will have second thoughts in Committee. The right hon. Gentleman has enough on his hands as it is. I am not sure that it is a good thing that officials in his Department should be given the work and the power which will come to them as a result of the Bill.

My right hon. and hon. Friends believe that accountability should be to an elected Welsh body. I was disappointed that the Secretary of State did not develop that theme. He fobbed it off. He is refusing to deal with it. He knows perfectly well what the point is. Like us, he has considered it over many years. Perhaps the Minister of State will consult his right hon. and hon. Friends and give us a better reply. If an elected council is set up to perform certain functions in Wales, do the Government believe that the National Health Service should be one of them? It is a simple question and I think that the Minister can give a straight reply. The inference, if there is no reply, is that they do not believe in further devolution. The principle of this Bill is anti-devolution and it is so regarded in the Principality.

Mr. Raymond Gower (Barry)

I am listening with interest to what the right hon. Member for Anglesey (Mr. Cledwyn Hughes) says. Would he favour giving such a council the right to levy taxation of any kind, or would it have a certain amount of money provided from funds from Westminster? I am merely asking for information.

Mr. Hughes

I know that the hon. Member for Barry (Mr. Gower) has given a good deal of attention to this matter. I have no objection in principle to giving an elected council for Wales the right to levy taxation in certain matters but this depends on the functions. The position could be the same as that of county councils—that part could come from local rates and taxes and part from the Exchequer.

I have three more points, which I will summarise in the interests of brevity. First, the North Wales branch of the National Health Service Social Workers is opposed to a mandatory contractual relationship between area health boards and the local authority social service departments, and the provision of social care to patients under the area health board. It takes the view that this will lead to great diminution of the care of patients and the polarisation of medical and social work. Will the Minister of State please comment?

Secondly, what is the position regarding the appointment of a regional pharmacist in Wales on the lines of similar appointments in England and Scotland? I understand that there has been considerable delay in the Welsh Office on this matter. Perhaps the Minister of State will give us the latest information.

Finally, on reading the Bill it could be concluded that the nursing service does not exist, or that it is not in the least important. In one sense it can be described as the most vital element in the whole of the National Health Service. Will the Minister of State say what representations he has received on the Bill from the nurses' representatives? They have a strong claim to be well represented at all levels in the structure. The position of the nursing profession should be taken into account, and I hope that the Minister of State will recognise this in his reply.

Finally, I pay tribute to those who have served on the Welsh Hospital Board, on the hospital management committees and on the health executive committees in Wales over the last 27 years. They deserve our gratitude for their devoted voluntary work. I have strong reservations about the Bill and I shall be voting against it tonight.

5.18 p.m.

Mr. Marcus Worsley (Chelsea)

I hope that the right hon. Member for Anglesey (Mr. Cledwyn Hughes) will forgive me if on this occasison I do not follow what he said. Perhaps the fact that I had a Welsh great-grandmother gives me no entitlement to do so.

Mr. Cledwyn Hughes

That is not quite close enough.

Mr. Powell

Not patrial.

Mr. Worsley

Thanks to my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell), not patrial. Nor do I intend to follow those hon. Members who have spoken on Clause 4. Of course, family planning is a critically important matter. However, it is peripheral to the Bill. We are here to discuss how health care should be administered. I hope that I shall be forgiven if I do not talk on Clause 4.

We are unlikely to take a more important decision during the course of this Parliament about our domestic affairs than to decide how we are to tackle health care. This Bill is not something that my right hon. Friend has dreamed up. It is the result of a whole process of negotiation, discussion and debate which goes right back into the time of the previous Government. It was one of the many things that they left unfinished after six years of office, and I hope that we shall finish it tonight.

I listened with the greatest attention to my right hon. Friend the Member for Wolverhampton, South-West. Those of us who have thought about the health service over recent years have been enormously aware of the dilemma that he presented to us, although I do not think that I have ever heard it presented as crisply and as clearly as he did today. But what he did not tell the House was what he would do to solve the dilemma. He said that there were two ways in which it could be solved, and he rejected both. So I take it that he would wish to preserve the existing situation—

Mr. Powell indicated assent.

Mr. Worsley

—of a division between a nationalised hospital service and a municipalised service for community care.

I do not agree with my right hon. Friend on this. While completely accepting the disadvantages of either solution of the dilemma, the time has come when we must consider the health needs of the citizens of an area together. This is pre-eminent. It is now 11 years since the Porritt Report and the hon. Member for Willesden, West (Mr. Pavitt), apparently at the same time, put this idea forward. This is the time to carry it out, and, in spite of the vote of the Opposition, I hope that we shall do so tonight.

A new and comprehensive look at the needs of an area, in health or anything else, has profound and often disquieting results. We have just done this with social work. The local authority social services have been asked for the first time to look at the whole range of social needs in their areas and to produce a plan to cope with them.

Such a new look has often shown up new areas of need. Therefore, I believe that the new look that we need in health will produce a clearer idea of new areas of need, but it will also—this is why I disagree with my right hon. Friend— bring a new emphasis to health care in the community and outside the hospital. I simply do not believe that, in the present state of medicine, one can sensibly consider health as if there were a boundary at the hospital wall.

In such a transformed set-up, the general practitioner will find himself again the centre of the service. One of the ill effects of the hospital-centred service has been to some extent to eclipse the GP. The new health service, I believe, will restore him to his proper importance.

But there is a danger in such a comprehensive look. I should like to quote again the precedent of the social service reorganisation. The danger is that, by trying to do too many things, by trying to cover the whole field, we may cease to do as well the things that formerly we did best. In the social services, there is proper concern about some of the services for children, which, under the old arrangements, were well cared for and which have sometimes suffered.

In the health field, one is obviously afraid for the acute hospitals. One is afraid that the centres of excellence which are built up there, and above all in the teaching hospitals, may be at risk. It seems to me, as a layman, that doctors have such a special feeling towards the teaching hospitals where they were trained —the only comparable thing is the alle- giance of soldiers to their regiments— that we must look carefully in Committee to see whether we have yet got this right.

I do not wish the present situation to continue. I am sure that it is right for the teaching hospitals to be more directly associated with the community, but I am not certain whether, in an area like the one in which my constituency lies, where there are two teaching hospitals, it is right that there will be no board of governors or representative body for the individual hospitals.

As for relations with local authorities, I have long taken the view that our objective should be a National Health Service responsible to the local community. The local community can be represented only by its elected local authorities. In that way only can one have a health service that is truly responsive. Only in that way can we end the anomaly of considering the health needs and the social service needs of an area as if they were wholly separate.

But, like the last Government and this Government, and like my right hon. Friend the Member for Wolverhampton, South-West, I do not believe that this is now possible. My right hon. Friend was absolutely right to remind the House of the financial problem, which cannot be glossed over. Unless there can be found for local government a massive new source of finance, the thing cannot be done. We had much better face up to that. Hon. Members opposite know it perfectly well. They are misleading the country and the House when they suggest that this thing can be done without a radical alteration of local government finance.

But even if that were not so, it is ruled out at the moment by the doctors' obsessive fears about local authorities. I call them obsessive because I suggest that they are not wholly rational. Therefore, the Government are absolutely right at this stage in not seeking to put the National Health Service under local authorities.

But—this has not been stressed enough in this debate yet—the Bill will lead, I am sure, to a period of growing together of the local authorities and the health service. A word has been coined to describe this—"coterminosity". I am delighted that no one on the Government Front Bench used that monstrous word, but it expresses the important concept that these services should be administered in the same areas. The extent of joint plans, cross-membership of committees and the rest is considerable. These authorities will be encouraged to work together.

May I say something which I hope will contribute in a minor way to the solution of the dilemma that my right hon. Friend has posed? I do not think that the National Health Service should be run by the local authorities. That was not my phrase. Instead I used the phrase "responsible to" about its relationship to local authorities. It is an unhappy fact that there is a tradition in this country of local councillors interfering in the detailed administration of local affairs, which is deplorable and discouraging to those who have to administer. It is that fear of the detailed interruption of their own clinical programme which is at the root of the doctors' fears. Therefore, our objective should be a health service responsible in general terms, and not in detail, to the local authority.

Perhaps I may instance one example which might possibly help towards a solution in future. I refer to the relationship of London Transport to the Greater London Council. London Transport is not run by a GLC committee, it is run by a distinguished and high-powered board, but on overall policy it is responsible to the GLC. That precedent should be brought more widely into local government in other ways.

I have always felt that central government services tend to be more efficiently run than are local government services. One reason is that we in this House do not try to run the services of central government as a local authority tries to run its services. We in this House leave it to Ministers, although we may challenge Ministers and give them overriding directions. I wish to advance the idea that there could in local government be responsibility without directly running the services.

We must not be afraid of management in the health service. The Opposition speak as though management in itself is a bad thing, but the health service is a complex organisation. I see that the hon. Member for Cardigan (Mr. Elystan Morgan) disagrees with that view, but I am sure that he would agree that a teaching hospital is complex and needs detailed administration. There is no real conflict between the good management which ought to exist—and we must not be afraid of good management—and a responsible service. I see that the hon. Member for Cardigan agrees with me on that.

I conclude by saying that the House must appreciate the real concern in local government at the loss of powers. For example, the Greater London Council is concerned at the fact that the Bill takes away from it the London Ambulance Service. I do not think the council is right in that view, and I believe that the ambulance service must be an essential part of the National Health Service. But it is the gradual piece-by-piece erosion of the council's powers on one issue or another, perhaps even more than consideration of the merits of the particular case, which leads it to take this view.

We must not see the Bill as an anti local government measure or as something which seeks to draw the health service away from local government. We must see the Bill as a measure which seeks to bring local authorities and the health services together as bodies working in the same area for the same ends. If it is to be seen as the beginning of their working and growing together, then I believe that the Bill will be seen as a landmark in the National Health Service.

5.35 p.m.

Mr. Arthur Blenkinsop (South Shields)

I am glad to have the opportunity of intervening, partly because I am one of the dwindling number of Members of the House who were involved in the early stages of the National Health Service, and also because, over the years, I have seen a large number of major changes. I believe it is absolutely right that we should now be considering the need for change—indeed the time for change is overripe. Therefore, I am more willing to accept the comment by the hon. Member for Chelsea (Mr. Worsley) in this respect than those points made by the right hon. Member for Wolverhamp-ton, South-West (Mr. Powell). Both raised very important issues. Some of these points should be followed up rather more fully.

The right hon. Member for Wolver-hampton, South-West was wrong to say at the opening of his speech that "the big thing which happened on the introduction of the National Health Service was the nationalisation of the hospitals". This was a big thing administratively, but I believe—and I think the country also believed—that the really big thing was that it enshrined acceptance of the principle that health was the concern of the whole community. That was the overwhelming issue at that time.

The health service expressed our interdependence in a way in which no other legislation had done previously. The administrative forms then set up were no more than the best we could achieve at that time. They enshrined various compromises some of which we were unhappy about at the time and have become increasingly unhappy about since. Many of these compromises were enshrined because of the narrow views of the main professional bodies at the time. It is a misfortune that a great deal of misleading advice has come from the main professions and the leaders of those professions. They have not played a very healthy part in the development of the health service in the sense that one might have hoped.

Any criticisms of this Bill should be shared between the Minister and the leaders of some of these professions, who are still rejecting the possibility of further advances which are now needed on broad social grounds. We must take account of the great changes which have occurred and which, above all, have emphasised more and more and day by day the close link between health problems and social problems.

The great issues that have to be tackled by our health service cannot be tackled by the health service in isolation, even when widening it to the broader community health service as comprehended in the new set-up. This relates not only to the question of mental health, a topic which was raised yesterday by my hon. Friend the Member for Woolwich, East (Mr. Mayhew). The answers to our problems cannot come from the National Health Service by itself but require, above all, the concern of the organisation of the whole range of our social services. It is wrong to say that this is true only of mental health. It is true also of most of the problems that confront us in health matters today. Perhaps it is something of an anomaly at a time when many in our community are expressing their faith more completely in scientific and technical answers to problems. The reality is going the other way.

The answers are more and more to be found in a wider social understanding than in narrow, technical terms. It is because of this dilemma that I am so worried about the structure proposed in the Bill. I said a moment ago that it was not only in our concern about the needs of the mental health service that we had to see a close connection between health and social services. Whatever subject one takes is of concern in the House and outside. Some of us have been particularly concerned about the misuse of drugs. There may be no clearer case than this where an answer cannot be found in legal impositions or through ordinary channels of the health service, but by a close linking together of the inspired judgment and concern in the whole social field with the co-operation of those working in the health service.

We talk about the care of the elderly. This theme comes through clearly again. Any efforts which can be made effectively through our National Health Service can be vitiated by the general social policies that are followed nationally in this country and by particular communities. We are increasingly beginning to realise the great gap that was left in our health service in the preventive and occupational spheres. Many other countries have done more than we have. Alas, the Bill makes no adequate provision for or takes no step towards new development. The new administration must take account of these facts.

I accept the view expressed by some hon. Members yesterday that the regional approach must essentially be the broad one of planning of fairly wide resources and their distribution at regional level. It should be our concern to try to bring health within the concept of wider planning and under democratic control. That is why many hon. Members regret that the opportunity was not taken with local government reform of establishing or at least making possible the development of a regional level of elected authority. We must face this necessity. Had we done so earlier, we might have seen more clearly how to bring the National Health Service at that planning level within the democratic control of an elected body.

I believe that contact and reality come at district rather than at area level. I am doubtful about what has been said concerning the functions at area level. There is a great element of artificiality at that level. It is at district level where the real working contacts will come.

Mr. John Silkin (Deptford)

There is a great deal of force in what my hon. Friend is saying. Is not the dilemma that he has posed, which was perhaps posed at the time of the Green Paper of 1970, that it is at area level where we have the social services and that the attempt to create a parallel level, as it were, between the two has created the difficulty? Were the social services at district level, presumably the district level would be the level in the health service.

Mr. Blenkinsop

I think that we ought to be looking towards some development of that kind. I am not necessarily seeking to try to impose some new pattern; I simply wish to see something new emerge and develop. Above all, I do not want to prevent the growth of the health service in a rational and clear way.

I think that Aneurin Bevan, with others, saw the health service as a living thing with opportunities to grow and to change as it grew. I believe that some of that growth can most easily take place at the district and health centre level. After all, the health centre was initially seen as one of the focal points of the development of the health service. Many people saw it as the point at which the closest link could come with the community and the whole range of social services around it. Of course, others rejected it. Aneurin Bevan was uncertain about the possibilities of experiments like the Peckham Health Centre. He certainly did not favour it as an example for the future. But a great deal has happened since then. I believe that the health centre, certainly the district hospital, and the wide range of new social services, can gather together at that point.

The right hon. Member for Wolver-hampton, South-West ruled out the pos- sibility of democratic control through the health service on financial grounds. Finance has always played a major part in discussions and consideration of the health service. But the right hon. Gentleman is wrong in suggesting that we are therefore completely prevented from seeing a growth of local authority influence and, indeed, responsibility. The idea put forward by the hon. Member for Chelsea was interesting. I do not assume, as the right hon. Member for Wolverhampton, South-West seemed to assume, that if a local authority is obtaining the greater part of its financial resources from outside its immediate area, if it is relying upon large national subventions, that completely prohibits the possibility of the independence of local administration by that authority.

We have a wide range of experience today at different levels. Education and a figure of about 60 per cent. national support has been mentioned. No one suggests that that has destroyed the possibility of independent action by local authorities. Indeed, there are many highly independent authorities—they have demonstrated their independence under all Governments —which rely upon large proportions of funds from national quarters. Experience abroad suggests that we cannot draw his close parallel between responsibility and the source of funds that the right hon. Gentleman seeks to draw. It is a common assumption, but one which can no longer be accepted automatically at face value.

Our concern is that the Bill fails to recognise the vast change which has taken place over the last 25 years and that it does not enable that close working of health and social services to be carried out which it should be our duty to ensure is carried out. For that reason and our desire to provide a new and steadily developing link between local authorities and the health service, I believe that the Bill must be rejected.

5.48 p.m.

Dr. Gerard Vaughan (Reading)

I hope that the hon. Member for South Shields (Mr. Blenkinsop) will understand if I do not follow exactly the line that he has taken. Rather, I follow a line similar to that taken by my hon. Friend the Member for Chelsea (Mr. Worsley), even to the extent of defending myself a little by pointing out that I have a good Welsh name and good Welsh origins although I do not represent a Welsh constituency.

I should like to comment only on the reorganisation side of the Bill. I do not wish to comment on Clause 4, although I share some of the anxiety felt by my right hon. Friend the Member for Wol-verhampton, South-West (Mr. Powell) about asking general practitioners and medical practitioners generally to take on this new kind of service.

I recall clearly, from experiences during the war, when general practitioners were asked to prescribe—to authorise, I suppose, is the right word—a whole range of equipment—hot water bottles, and things of that kind—and the difficulties which that led to between doctors and patients. But I am afraid that I cannot go along with the rest of my right hon. Friend's characteristically well-reasoned but rather gloomy and destructive speech.

Listening to the debate I could not help thinking of Aneurin Bevan's words in 1946—it seems fashionable to quote him today—that there is a danger of forgetting why these proposals are brought forward at all. The danger in this case is of losing sight of the many very necessary and good features of the Bill.

It seems a simple and unarguable fact that the National Health Service in its present form does not match up to the present-day needs of medicine. It is just those needs that we have been talking about—the community needs. Today even a surgeon—I suppose that he is the sharpest, white-hot end of technical skill in medicine—very frequently has to bring a patient's relatives into the full care of his patient. That applies more to other specialities, such as psychiatry and geriatrics, and in paediatrics, for example, where the paediatrician will frequently bring in the mother or father of a patient as part of his therapeutic team. When one realises how much medicines has changed on these lines, one begins to realise that the present structure does not match up to what is needed.

I accept that the Bill is aimed at improving patient care. I have some worries as to how far it will achieve its object, but I accept it. I accept entirely that a closer working link with local authorities and a take-over of some of their services can operate only in the way of improving our community services. The unification of the health service is essential. The Bill, however, offers a very large dose of line management. It offers a major tightening of executive authority. This is logical when one considers the difficulties of the National Health Service. But it is logical only provided that we realise that it will not solve a whole range of other problems which must be solved.

Only today there was a leader in the Daily Telegraph talking about the comments of the Parents Association—

Sir K. Joseph

The Patients Association.

Dr. Vaughan

The Patients Associa-titon—which has been investigating peoples' attitudes towards their general practitioners. It asked for good and bad comments. There were five times as many bad comments and complaints as there were good comments. The bad comments were mainly centred around bad receptionists, brusque, disinterested service and difficulties in getting general practitioners to go to people's homes in the way that they used to.

The Bill will do nothing to solve that side of our problems. But at the same time we are running a multi-million pound organisation employing over 800,000 staff, hence the need for better management. There is no general clash between most doctors and the administrators. In a few instances doctors make good administrators, but generally they are not interested in this on a big scale, and are only too pleased to work beside competent, well-trained administrators. We have some excellent individual administrators today, but not enough of the calibre we need. I see no reason why we should not have a centrally run, standardised structure for the health service within which the medical profession can exercise all its skills, variety and individuality, and meet individual patients' needs—secure in the knowledge that its financial, technical and building base is run by a competent authority.

In winding up the debate yesterday, my hon. Friend the Under-Secretary of State for Health and Social Security said that the community physician would be a vital part of the district management team. I agree. But in Committee we should look very carefully at some of the bases on which the recommendations have been made.

Yesterday the hon. Member for Willesden, West (Mr. Pavitt)gave us a very amusing rundown on the Grey Book. I should like to read a small part from it. If the work of the DMT"— district management team— is found unacceptable by the AHA"— area health authority— the DMT will not be held corporately accountable, but the AHA, with the assistance of the Area officers, will assess the performance of each team member to determine the source of the difficulty This smacks very strongly of a sort of Big Brother sending his investigators into the district management team to eliminate the individual who does not conform. If I am fortunate enough to be selected to serve on the Committee, I shall wish to have a very close look at that kind of thing.

Are we happy to read in the Brunei Report, on which much of the Grey Book is based, that patients were not studied because patients are not part of the organisation. I cannot go along with that.

In Committee I would suggest that we shall need to examine very closely whether the Welsh pattern should not be applied to England as well; whether we need a regional tier, except as, perhaps, a planning and advisory authority; whether, for example, the area health boards should not have representatives on the regional tier, if we have to have a regional tier, so that it is merely a coordinating centre for the area health authorities.

I get a little worried that we are putting in a system in which the policy decisions run from the top downwards, leaving very little discretion for the lower levels, whereas we would all like to see a district level with lots of discretion.

I should like to see much more authority given to the community health councils. We have to look very closely again at how they are constituted, and perhaps give them some financial backing and some teeth. Even at this late stage, is it possible to let the people who provide health care, including ancillary workers, and those who use the health care, the patients, have a real say in how the service is run?

The Committee must look very closely at the question of the teaching hospitals. My hon. Friend the Member for Norwich, South (Dr. Stuttaford) says that we are denigrating the teaching hospitals. I do not agree. We are modernising them by bringing them into the general system. But there are special difficulties in London. The teaching hospitals simply do not fit in with the geographical structure proposed. We need to look very carefully at the boundaries and to change them.

We heard a good deal of comment yesterday about the position of private practice. I hope that Clause 43 will enable private practice to be extended.

Mr. Leslie Huckfield (Nuneaton)

Does the hon. Member have an interest?

Dr. Vaughan

I say that because in medicine we have good medicine from individuals. I have a vested interest in teaching hospitals.

Mr. Huckfield

Hear, hear.

Dr. Vaughan

I have a vested interest in private practice. The reason for this is that it allows myself and my colleagues—

Mr. Huckfield

To make more money.

Dr. Vaughan

No. We have to work a great deal harder in our National Health Service sessions.

Mr. Huckfield

I am in tears.

Dr. Vaughan

I sat on the Expenditure Committee and heard the evidence about the corruption and abuses in private practice. They do not exist on a large scale. I assure hon. Members that if they read the evidence they will find that only a few isolated instances could be quoted and most of the evidence that we heard was on the excellence of the service, the long hours that part-time people work and the absence of large-scale abuses. What we did hear was a good deal about the difficulties of the waiting lists, and these are something which we must do something about.

Mr. Huckfield

Having read most of the evidence which was presented to that Committee and having been a member of one of the boards which presented evidence to it, I can assure the hon. Gentleman that if he reads it himself he will find that board after board and witness after witness said that there was no standardised procedure whatsoever laid down through a hospital group or region for the accounting or monitoring of private practice. I call that abuse.

Dr. Vaughan

I accept the point which the hon. Gentleman has just made, that the accounting as at present practised should be looked into, and that was one of the recommendations of the Committee. We made no secret of it. But I object strongly to the suggestion that there is widespread corruption and abuse of the kind that we heard about yesterday.

There are a number of aspects that will need looking into by the Committee, but in general I think that we should recognise the good features of this Bill, we should see the advantages of it, and I recommend it very strongly to the House.

6.1 p.m.

Mr. Richard Crossman (Coventry, East)

I start by apologising through you, Mr. Speaker, to the House for the fact that I was away yesterday, and I have sought to catch your eye today. It was only because I was unavoidably detained overseas that I was away, and I am grateful for a minute or two to put one or two points. I am not going to waste time on replying. I want to get on to essential matters.

First, about family planning, I would only add to the debate that as the Minister who had to operate the Abortion Act I became an irrevocable supporter of free family planning, if only for the reason that it is intolerable to have a free health service giving abortions free and not giving family planning free as well. I would have preferred it to be completely free, but I will say to the Secretary of State that he made a point in urging us to remember that if one has to pay 20p for life-saving drugs it is difficult to say that a special advantage should be given to drugs or appliances for family planning. Therefore I do not feel strongly about that.

If I could venture a suggestion through him to the Chief Government Whip, would it not be sensible to have a free vote on this clause, because there are very strong feelings about it and there is no great financial or other issue involved?

Mr. John Silkin

I should be perfectly happy on this side of the House to recommend to my hon. Friends that there should be a free vote. I hope the Secretary of State will recommend it to the Patronage Secretary, too.

Mr. Crossman

I want now to return to the central issue, which was argued so powerfully by the right hon. Member for Wolverhampton, South-West (Mr. Powell). I must say that I differ from him profoundly on two issues, only one of which I will discuss. He expressed— which he does not often do—extreme optimism. He is optimistic that the area boards are to be the pivotal centre of the scheme. If the Bill is judged solely by the speech of the Secretary of State, that can be believed, for there are columns about the area boards and only one paragraph about the regional authorities. That gave the impression that it was the area boards that mattered, but those of us who know the Health Service a bit from the inside are careful not to accept that kind of treatment. I look at the text of the few words he attributed to the regional boards. He said, strangely: …. we need a mechanism for ensuring that they"— the area boards— follow the general strategy …". So we need 14 boards to supervise other boards and make sure they follow a general strategy. Is it just an accident that we have 14 regions today with large bureaucracies, self-perpetuating oligarchies? I strongly suspect they will stay where they are and be renamed. I find it difficult to believe that, since these regional authorities are told to be responsible to the Secretary of State for long-term planning, hospital building, regional services, and the allocation of resources … there is very much they are not responsible for! Moreover, these boards are wholly nominated by him. I suggest that the right hon. Member for Wolverhampton, South-West is being a little complacent when he thinks that, by putting in a new tier of area health authorities below the regional authorities, the regional authorities are going to be weakened. The rule of the Health Service is "the higher, the more powerful". The higher you go, the greater the power, and if the area is put in below, it will be below. True, it will have a budget, but it will be submitted to the region, which is the authority for all these key issues. The Secretary of State added: There will no doubt be a continuing dialogue between area health authorities and regional health authorities."—[OFFICIAL REPORT, 26th March 1973; Vol. 853, c. 932.] I will translate this into a continuous mass interchange of bumf, endless official discussions, endless passing of papers, while the regional board smashes down any authority the area possesses.

Anybody who looks at it carefully must be seriously alarmed to find five tiers and to see the strength of the line which has been created between the Minister right at the top and the patient in the hospital or the doctor's clinic below.

I want not to be purely destructive but to make a number of suggestions. It would be tolerable—and I follow a point made by the hon. Member for Reading (Dr. Vaughan)—if the regional authorities were, for instance, nominated by the areas. If the areas set up their regional co-ordinating authorities, if they were clearly seen to be created by the areas in order to co-ordinate the services between them, we would really feel a great sense of relief.

Secondly, if the budgets of the area authorities were submitted direct to the Secretary of State and not to the regional authorities, then again I would have confidence that the region was not the effective authority between the Secretary of State and the area authority.

The third thing we need is to have the majority of the members of the area authorities not nominated by him but nominated from below by people in the region.

I have to repeat something I said in the White Paper debate. We are faced by vast satrapies in these self-perpetuating oligarchies, which are there and are difficult to remove. Are we really going to keep the fiction of the Secretary of State nominating all the members of the regional authorities—which means that they nominate themselves? Because he does not nominate them; he does not have time to. Year after year they build their power and their vested interest. All this, which is the most unsatisfactory part of our present service, will be strengthened, not weakened, by the changes proposed in this Bill.

So I beg the hon. Gentleman to consider the possibility of a regional authority created as a confederation of area authorities—working together, bringing members together—who will look at it from the point of view of the region rather than the area.

The other major deficiency of the new structure is that the responsibility goes upwards and not downwards. This was already so. When someone is appointed from above he feels responsible to the people who appoint him. What we need is an authority or a service which feels itself responsible to people below and not above. The Bill actually overwhelmingly strengthens the sense that responsibility goes up, and the sense of remoteness in the people below.

We therefore come to the community health councils. There are some minor changes in the Bill but I agree with those who have urged the Secretary of State to see that a mere consultative council is absolutely impotent against the kind of bulk authority that he has built up against it. I do not merely want the councils to be given money, I want them to be given jobs and to be endowed with a sense of management. Here I agree with those who say that the areas, far from being splendidly close to the community, are gigantic and miles away from it. Even a district under the new local authority is far removed from the community and to talk as though the creation of the areas is democratising or is enabling people to participate in the services is to fly in the face of the size of these areas and their nature. What we have to consider is how to improve the Bill in this respect. Clearly the first thing is to provide that the community health councils are elected. People below must be able to choose the people who will represent them up above and express their point of view. There must be a large elected element and I entirely agree with my hon. Friend the Member for Woolwich, East (Mr. Mayhew) that it would help a good deal if there was at least a central community council with authority to go direct to the Minister.

But above all the councils should have some power. There is a particular power in which I am interested. It is my conviction that there are areas of the service where care is more important than cure. That applies in over half the hospitals. In all the long-stay hospitals care is just as important as professional skill. The right hon. Member for Wolverhampton, South-West must realise that the service does not consist wholly of consultants and specialists and that the work of the service is not only concerned with professional medical activities. The work is also of caring for people, and caring is not done best by professional nurses or doctors. For the 8,000 disabled children in the long-stay hospitals, care and love, and being made to feel at home, depends on the rôle of the professional being matched by the outside voluntary organisation with a passion, a conviction and a dedication to the cause.

I know that the Secretary of State believes in the rôle of voluntary participation. At the community level it is of the highest importance to organise voluntary work effectively. Every long-stay hospital should have as many volunteers as it has professionals, actively participating and bringing in the community so that the evils cannot take place. The evils occur when professionals are isolated from the community and are doing a repetitive job which does not have a high cure quotient in it. The professionals get into routines and they are only woken up by volunteers from outside who have an idealism the professionals cannot have. That integration of the volunteer and the professional can be organised only at a level far below the area, far below the district, at the level of the genuine neighbourhood community council which should exist in local government as well as in the health service.

Another major omission from the Bill is more striking because the Secretary of State is a great devotee of professionalism. In view of his belief in professionalism and managerialism there is an extraordinary omission from the Bill of attention to active participation in policy-making by professions other than doctors. There should be a recognition of all the other professions in the service, of all the other skills and of the trade unions representing those who are semi-skilled. They all have a right to participate in policy at all levels. If there is a denial of the electoral principle in the selection of people who run the system, surely there must be recognition of the need for this vast service to have all the people who are organised, people in unions or professional organisations, in a position where they can participate actively so that policy making is not a monopoly of the consultants and top level appointees by the Minister. Sound policy can be made only in close relationship with care. Representation of the hospital workers' trade unions should be written into the Bill so that they have a say in policy making from the top of the service to the bottom.

My last point relates to the basic flaw in the Bill which is the split between community services and health services. I agree that it is doubtful whether transference of certain specific health services from the local authority to the health service will automatically improve the quality of the service. To do so would certainly reduce the level of democratic participation. People do not feel the same about a local authority service as they do about the health service. They feel that they can exercise some control over the local authority service since it is democratically organised. We must exercise the greatest care here. There were powerful reasons for the transfer. But we must be careful that by the transfer we do not bureaucratise all those areas of the Health Service. On balance I believe the transfer was right but it leaves an even bigger gulf than before between prevention and cure.

Take the simple example of home helps. We left the home helps with the local authorities but the doctors passionately wanted them on their side. There were powerful arguments both ways. But as long as the home help is financed out of the rates, we will not get a community service for the aged coordinated with the health services for the aged. That is what results from this basic and disastrous division.

I do not want to waste time discussing local authority finance except to say that if we had a local income tax we could perfectly well raise the money for local authorities—many other countries do it— and retain local independence. But that is an abstract thought because we cannot get such a provision into the Bill. However, we should admit to ourselves that this is an appalling flaw and all the speeches in the world about good intentions will not get over that. In considering getting people out of long-stay hospitals it must be remembered that they cannot be got out unless the local authority it willing to take them on and pay for them.

Sir K. Joseph

Both the right hon. Gentleman and my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) are hiding behind the illusion if they think that only finance stands between the Government of the day and putting the National Health Service under local government. There is a second reality—the medical attitude. It is surely true that doctors on the whole are not ready to be run by the party politics of local authorities.

Mr. Crossman

I had not forgotten this. It was the point to which I was coming. It could be overcome if we were prepared drastically to reform local government finance and compel the Treasury to hand over some part of a health tax to the local authority. If that were done—and it could be done—that would get over the difficulty. I was emphasising that we shall not cure many of the worst problems about getting people out of hospitals, which is one of our main requirements, as long as we have the situation where it depends on the local authority building and paying for the hostel. There are those who think that putting people in local authority hostels can solve all hospital problems, but a hostel may be just as bad as a hospital from the point of view of the patient.

We are to have fairly soon the report of the Royal Commission on Government, and recommendations. If by any chance, as I feel is quite likely, there is a proposition for provincial government then the last excuse of the doctors would be removed. It really would be impossible for a doctor to say, "I refuse that authority". It is worth considering whether we should hold our thoughts about the final reform of the Health Service until we know this shape. My view is that it would be far healthier to have provincial control of the National Health Service as well as of local government services, because thus we would be uniting the two sides, than not to have unity at all. Then, once we have unity at the provincial level we can knock out the terrible regional tier and see a relationship emerging which was not so devastatingly bureaucratic, since there would be some basic democratic control as well as a single health-community service budget. A single budget could be made at regional level.

Meanwhile, I say to the Secretary of State that his managerialism is terrifying to me. I repeat something I have said before; the job of management should be done by managers, by paid officials; and the members of the authority should not be good at management, they should be good at telling managers about local needs. But these people we will appoint according to the qualifications I see given are not the kind of people that are needed. The kind of people we need are not necessarily expert or experienced people. They are people who can speak for the patient, and expound local needs—people who go about the place and understand, exactly like elected councillors. They are the people who know about these things.

In my view it is a mistake to let the service—and here I agree with the right hon. Member for Wolverhampton, South-West—become a co-ordinated committee of bureaucrats. I am appalled by the prospect of a tremendous block of bureaucrats desiccating every original proposal and being difficult over every case. This was the danger when the Health Service was created. It was an over-professional, over-managerial service, with too many tiers. Under the managerialism of this plan the split with community service are aggravated. I pray God we shall not think that this Bill is any more than a patch-up measure worthy to stand alongside the local government reform of this Government.

6.25 p.m.

Dame Joan Vickers (Plymouth, Devonport)

I hope the right hon. Gentleman will not mind if I do not follow his speech. I would like to follow the comments of the hon. Member for South Shields (Mr. Blenkinsop), in regard to health centres. I hope that we shall have more health centres and less elaborate hospitals. Hospitals are becoming rather over-elaborate these days. The English White Paper says, in paragraph 8, that there are very striking arguments for bringing the health and social services under a single administration. Those services are not brought under one administration. Our region extends from Gloucester to Penzance, with its headquarters at Bristol, which is very inconvenient and means that most people have no contact with Bristol. I am speaking only because I had the great honour of being trained under Sir Frederick Menzies one of the great hospital administrators of the LCC. The service was taken over from the Metropolitan area board, then it was changed under the 1948 Act, and now there is to be this further change. We have gradually become less democratic over the organisation's future. It was rather unfair of the Secretary of State to say that democracy is not an instrument of efficient management. I gather he said it to justify the proposal that area health authorities should not be primarily representative but that members should be chosen for their capacity to judge. I am glad he is present, for I would like to ask him how they will judge and how they will know which people are capable of judging.

Sir K. Joseph

These are areas.

Dame Joan Vickers

But we have to find the people, and I am worried about how we are to find them. We are already seeing over 13,000 volunteers go down to about 1,600.

Sir K. Joseph

I hope my hon. Friend will justify those figures. According to my calculations about the same number of volunteers will be manning the new services as are manning these services now.

Dame Joan Vickers

In the debate in the House of Lords which I read carefully those were the figures given. I believe my hon. Friend the Member for Canterbury (Mr. Crouch) will support me in that. The White Paper emphasises the duties of management in treatment and care. I am wondering how we can divide treatment from care. I hope when people are chosen in the various areas they will be people who are fairly well-known, because the good thing about local government representation is that people know where to go and to whom to complain.

Nurses have hardly been mentioned, and I will concentrate now on the nursing situation. In the White Paper, Cmnd. 5057, it is promised that each area health authority will always include doctors and at least one nurse or midwife; but it is stated that for this staff must not be drawn from those accountable to the authority's chief professional officers. I understand that there is no problem here for doctors, consultants, or general practitioners, but that this would create difficulties for nurses. They are accountable to the area chief nursing officer. I know that the Royal College of Nursing has been in touch with my right hon. Friend on this. The College says the situation is not acceptable because it might mean having a retired representative or a nurse working in another area. When the Minister concludes the debate he may be able to say something about these consultations.

We speak of health care in the community. I was very interested in what was said by my hon. Friend the Member for Chelsea (Mr. Worsley). I would like to know what is to be the future role of health visitors and health inspectors. There are over 6,000 health visitors who have been neglected in the previous report and the White Paper. Health visitors are the only representative organisation concerned with the community nursing service, which is important; and they provide a whole range of community nursing services. They have directors of nursing services right down to clinic nurses. They are to be transferred to the area health authority or to become responsible for the geographical area in which the staff has its existing working base at the present time, or in which the larger part of its present working district is situated. There are a few health visitors who spend their entire time in the school nursing service. I would like to know what rôle they are to play in the future, because they do not seem to come into the Bill in any particular way. The rôle and work of the health inspectors may be considerably changed as a result of the reorganisation of local government as well as of our entry into the EEC.

I feel that Clause 41 should contain powers for the transfer to the National Health Service of responsibility for the licensing and inspection of nursing agencies under the Nurses Agencies Act 1957. This is extremely important. For example, the Director of Nursing Service for Croydon states that when a new agency is established—and they can be set up quite easily—she visits it initially every three months and then yearly. Her inspection involves checking the qualifications of the nurses employed, ensuring that they are adequate for the work they are allocated, and also the pay scales. I hope that this work will be transferred to the National Health Service. I am sure my right hon. Friend will agree that this would be to the protection of the general public.

I turn now to the question of representation on the family practitioner committees. I understand that dentists will have three representatives at that level but none at area level. Is my right hon. Friend considering having osteopaths on the family practitioner committees?

I want to mention Clause 19, because of its tie-up with local government in Relation to the transfer of staff. Line 44 contains the words "taken as a whole" which are causing anxiety as they do not appear in the parallel provisions in Section 255 of the Local Government Act 1972. As changes are coming about in both the National Health Service and in local government, I believe it is important to keep similar changes in line.

Hospitals for the Army, Navy and Air Force take in civilians. How are they to tie up with the area health authorities? Will they have their own organisation, or will they be completely independent?

Finally, I wish to ask about child guidance services. They are to be divided into three sections—child guidance psychiatry based on the local hospital, social work for children based on the local authority social services department, and educational psychology based on the local education committee. I hope that these three aspects of the work will be tied up together.

6.33 p.m.

Mr. Emlyn Hooson (Montgomery)

The hon. Member for Plymouth, Devonport (Dame Joan Vickers) devoted much of her speech to the nursing service, and was right to do so. Like patients, the nurses seem to have been forgotten in the Bill. The greatest criticism I hear of the National Health Service is of its remoteness from the people and this has been a matter of concern for a number of years. My impression of the Bill is that it tends to create an enormous administrative superstructure and that the result is likely to make the people feel even more remote than they do now.

I represent a sparsely populated county and I know that people there feel deeply that the administration of the NHS has been too remote. For example, we see hospitals in Cardiff built over-elaborately with a great deal of money wasted. Yet the money wasted would provide us with all the services we need. The hon. Member for Cardigan (Mr. Elystan Morgan) and I have been pressing for a long time for additional specialists to be appointed to the General Hospital at Aberystwyth. There is not a child specialist or an ear, nose and throat surgeon there. But we are obstructed by the powers that be in Cardiff. There is a constant feeling that the regional-tier body is already too remote and that in England, where it is to be retained, is liable to become even more remote under the new scheme.

The right hon. Member for Wolver-hampton, South-West (Mr. Powell) posed the dilemma facing any Secretary of State for Health and Social Services as perhaps no one else in the House could have posed it. Then he proceeded effectively to demolish the case for the nationalisation of the community health services. He advanced three reasons— and I agreed with all three—why community health services, which are already much closer to the people and are subject to democratic accountability, should not be nationalised in this way. When he had turned his attention to the National Health Service, he had argued in the other direction. He did not argue that this process would democratise a nationalised service, but argued against the case for municipalising it.

The right hon. Gentleman did not deal, however, with the question of having a provincial democratically elected assembly to which the National Health Service could be responsible. That was dealt with by the right hon. Member for Coventry, East (Mr. Crossman). The right hon. Member for Wolverhampton, South-West, laid great emphasis on the fact that democratic control depends on financial responsibility. I have always thought that to be a half-truth. Ultimate control depends on financial responsibility, but that does not mean to say that one cannot get effective although not ultimate control without the degree of financial responsibility which he implied.

It is very important that we should have much greater accountability for the National Health Service than we have today. I thought that the right hon. Member for Cardiff, West (Mr. George Thomas) was right in suggesting that eventually in Wales these functions should be in the hands of an elected Welsh assembly. I am glad to see his conversion to the idea of an elected assembly. For years he was against it. But it is fair to point out, in view of his effective criticisms of nominated bodies and their proliferation in the Principality and elsewhere, that it was the late Aneurin Bevan who introduced the nominated bodies at all levels in the National Health Service. Nye Bevan may have thought it necessary then, although the Liberal Party did not agree. No doubt the right hon. Member for Cardiff, West supported him, but now he has learnt the error of his ways.

Mr. George Thomas

Nye Bevan was fighting the medical profession, which had the full support of the Tory Party, which did not want a National Health Service at all.

Mr. Hooson

There is considerable validity in that point. The medical profession took a stupid view in 1946 and 1947, but the error could be put right now. Where I disagree with the right hon. Member for Cardiff, West is in my belief that it is better for the moment that the Welsh Hospital Board or a board at regional level should disappear and that the ultimate control should be in the hands of the Secretary of State for Wales. If we do have an elected Parliament or Council for Wales, the authority of the Secretary of State could then be transferred to that elected body. That is why I support the present proposal.

I share the criticism made by English Members of the regional bodies for England. I do not think they are necessary. It is important to realise that the National Health Service basically exists for the patients, that the patients live in a community and that therefore the community health councils are of the utmost importance. What is a community in this context? I think of it as the community which surrounds a hospital to which the local people are taken when they are ill. It is a community in which the doctors themselves live. It is a community interest which has to be represented at a level very close to the people.

I agree that care is very important. I live a few miles away from a hospital for incurable children, and the voluntary help it gets is very important, to the children, to the parents and to the medical and nursing staff.

I reiterate the plea that the Government should look again at the powers which they intend to give to the community health councils. They should allow them to have much more power of decision. It is not merely a matter of observing and reporting. They need teeth so that they can make their views known in their communities and in their hospitals.

I turn finally to the area health authorities, and in this connection I refer to my own area which I shall share with the hon. Member for Brecon and Radnor (Mr. Roderick); the new administrative county of Powys. We shall be an area health authority under the Government scheme yet we do not have even a district hospital. What control shall we have over the hospital services available to us? We shall not have representation on the bodies which provide us with district hospital services. Therefore our area health authority will be concerned only with the community hospitals and the community health functions at present carried out by local government. I should have thought that in Wales especially there was a first-class case for putting the area health authorities under local government. I am not satisfied and have never been that it is impracticable to do so.

I agree with the view expressed by the Secretary of State that there has been objection from the medical profession to being controlled by local authorities. I can understand that to a degree. But if there was a provincial or, as we would describe it in Wales, a national body having ultimate control, we could easily change the system so as to have accountability at county level as well.

6.42 p.m.

Mr. David Crouch (Canterbury)

The hon. and learned Member for Montgomery (Mr. Hooson) said that there was no district hospital in his new county. May I point out to him that there is provision in the Bill for an overlap of responsibilities from one AHA to another where such a situation arises?

In his eloquent way, the right hon. Member for Cardiff, West (Mr. George Thomas) spoke about the Bill's offering a cold managerial system. He said that he preferred elected men, and that elected men were better every time. I know that a remark like that is always popular in this House. But is the right hon. Gentleman right to say that in terms of the management and implementation of the National Health Service across the country?

My right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell) touched on this question of where responsibility lies for a national service. I speak as one who is a nominated man. I sit on a regional board. I feel the responsibility of being a nominated man, as do my colleagues on the board. Among them there are trade unionists. There are businessmen who give up time from business management to help manage the business of the hospital service. There are people nominated from the local authorities and others recommended from the county and district authorities. Among the members of the regional board there is a sense of dedication and a feeling of great responsibility.

I do not defend the position of a regional board in terms of the thinking of today. Regional boards are already in the past. They have lost their real place. But if we adopted the Opposition's view and transferred this responsibility to the local authorities, I wonder how we should find elected men in local authorities with the time to discharge their local government responsibilities and to serve the local administration of the National Health Service. A local government representative finds it very hard to give enough time to the vast administrative and budgetary controls about which he has to worry in local government. To add the further burden of the full administration of the National Health Service would be too much.

The right hon. Member for Coventry, East (Mr. Crossman) and other Opposition Members have said that officials in the area of local government health service administration will feel saddened to be transferred to a nationalised control from what was their previous control under local government. I can understand that. We have to watch the changed position of all those who have served under local government and enjoyed that responsibility. I have in mind medical officers of health, those engaged in the ambulance service, the midwives and all the other areas of local government health provision. We must not neglect to take account of their views in a changed position.

The overall object of the Bill, which I welcome, is to achieve a better administration and organisation of our health service. According to the original White Paper, the objective is … a better and more sensible service to the public". I hope that my right hon. Friend the Secretary of State for Social Services will not forget that. It could be forgotten very easily as we went into a Standing Committee and considered the great panopoly of bureaucratic administrative procedures, controls and set-ups with which the Bill is concerned.

The Bill caters for professionals in the medical administration service. A bureaucrat does not sit only in Whitehall or in the town hall. Many of those whom I meet are medical bureaucrats. It has been pointed out by a number of hon. Members who are associated with the medical profession that medical practitioners welcome working under good management. Nevertheless, the Bill seems to lean over backwards to involve the professional man in the National Health Service in the better management of the new administration of the service.

We are assured by my right hon. Friend that some laymen will continue to be involved in this management problem, as they are at present. But I am concerned that the bureaucrat may win and that the patient may lose. This again must be watched as we consider the Bill in Committee.

The crux of the problem that the Bill presents to the House, to the public, to patients and to the service is where the voice of the patient should be heard. Is it best heard after the event when there is a complaint and when a problem has arisen because a service in a hospital or from a general practitioner or a midwife, or an ambulance service has not been good enough, effective enough or quick enough? Alternatively, should it be heard at the point of planning and decision?

I serve as a layman on a regional board. We are a mixture of professionals, bureaucrats and amateurs. We have a voice at the point of planning and decision. We like to think that that voice sometimes speaks for the patient. There is a strong need for responsible laymen in addition to responsible local government representatives in the area health authorities to help make these decisions in the future about the structure of the new National Health Service administration. I hope that there will also be a place for those responsible laymen and responsible amateurs in the regional health authorities.

My own experience as one of those laymen attempting to be responsible in this job is that I want to ask questions. I am not afraid to ask them. I am determined to get answers. But to be able to ask questions I have to know the job at which I am looking. I have to visit the hospital to ask about the food, the general sanitary conditions, the decoration and a great many other matters which are all part and parcel of any hospital visitor's work. I see my job not as trying to replace the medical bureaucrats running the hospital but rather as equipping myself with a knowledge of what is going on and trying to see it from the patients' point of view so that I can ask questions at the management stage.

I am concerned that we may be departing from the position we have at present where the layman can take part in planning and decision by the institution of the community health council. I am not against the community health council, but I have seen and had experience, as all of us have, of the other consultative councils which already exist to keep a check on the nationalised industries. The Select Committee on Nationalised Industries, of which I am a member, has reported pretty adversely on the effectiveness of those consultative councils. It appeared to the Select Committee that there is some window-dressing and little effectiveness. I say to the Secretary of State about the new community health councils that we must be sure that they are given appropriate weight. He said yesterday, and the Under-Secretary indicated in answer to an intervention, that he was prepared to see them grow into something bigger than what is written in the Bill. I support that.

The Minister of State, Welsh Office (Mr. David Gibson-Watt)

Certainly concerning Wales this is very much in our minds. It is very much our view.

Mr. Crouch

I am grateful to my hon. Friend the Minister of State for saying that.

I wish to say something about the regional health authority versus the area authority. The Secretary of State properly laid emphasis on the area health authority as the most important sector of the new National Health Service administration. The regional health authorities are to be agencies of the central department of the Secretary of State. I do not say that is wrong. We are talking about national control and I have seen under the present system how a regional hospital board can sometimes step in and assist a hospital group when the group is facing perhaps almost insurmountable problems. I have also seen a regional board step in and redirect priorities in money allocation to correct a bad situation. I have also seen the board step in where it has seen inefficient management, sack the lot and replace them. The regional hospital authorities should be seen in that light, a more generous light, and not as an agency which would be breathing down the necks of area health authorities and spoiling all their initiative.

Where I differ from my right hon. Friend the Member for Wolverhampton, South-West is that I am concerned at the continued separation between the National Health Service and the health services provided by the local authorities. The Secretary of State provides the money for the majority of health provision for the general practitioner service, for hospitals and now, in the new plan, he has to take over many of the personal health services formerly provided by local authorities. But the provision of homes and hostels is to remain with the local authorities.

If the National Health Service could be empowered to provide such homes I maintain that a big frustration in the effort to provide a complete health service would be removed. I think in particular of our psychiatric hospitals and hospitals built 120 years ago as mental hospitals, which are now quite monstrous. They could be largely emptied of patients if we had these homes and hostels with today's medical knowledge and drug therapy. There is frustration about them because, on the one hand, the National Health Service, through boards and various groups is saying that it wants to do this, and, on the other, local authorities say they cannot afford it and have not the budget for it.

This massive reform of the National Health Service must go further than just providing a better management structure and a better bureaucracy. I am not against that, but I believe it must also provide attractive conditions for employment of all who work in this service, in the medical and nursing professions and all the ancillary professions as well. We must bear in mind that it is job satisfaction in looking after the sick at which we should be aiming, not just job satisfaction in providing better budget control and management planning alone.

6.57 p.m.

Dr. M. S. Miller (Glasgow, Kelvingrove)

It is always a pleasure to speak following the hon. Member for Canterbury (Mr. Crouch). In matters dealing with health services and other social affairs he adopts a very reasonable and humane attitude.

Reorganisation with a view to great efficiency, however desirable—and I make no bones about the desirability of greater efficiency—is no substitute for further development of the National Health Service into a humane and fully comprehensive service. I heard the Undersecretary make play yesterday with the word "management". I took the point he made—that management need not be restricted to a narrow definition. In my student days we used to talk about the management of certain diseases and illnesses, for example, tuberculosis, rheumatic fever and cardiac illness. We meant the total care of the patient, his drug therapy nursing attention as well as medical attention, his diet, his physical and mental wellbeing and so on. In this sense the word is certainly appropriate. If it was used in that way, I make no criticism of its use by the Undersecretary.

Tribute has been paid to the architect of the National Health Service—Aneurin Bevan—but Bevan did not envisage a static National Health Service. He looked forward to one which would grow—to which would be added parts all the time —a health service which would dedicate itself to the mental and physical welfare of our people. At the moment we have not a health service but an ill-health service, where too much emphasis is placed on diagnosis and cure. I admit that this is an immense advance on medical provision in most parts of the world, but insufficient attention is paid to the prevention of illness. I am afraid that the Bill does precious little to alter that imbalance.

The second general criticism I make of it is that it is a perpetuation, as I believe, of an elite in the system of control. I have no doubt that what will emerge from this massive reorganisation will be a continuation of domination of the Health Service by the big white chiefs of the medical profession—the demigods of the scalpel and the hypodermic. The proposals for reorganisation are not democratic; there is too much appointing of members of committees and boards and little or no provision for public participation.

It is, unfortunately, sometimes forgotten that the National Health Service was instituted for the benefit of the people and not the medical profession.

In deference to your wish that we should be brief, Mr. Speaker, I hasten to the main point of my remarks and make only a passing reference to one of the main areas of contention in this reorganisation scheme, and that is finance. I echo the views of my right hon. Friend the Member for Coventry, East (Mr. Crossman) in that I also see no reason for ruling out a system of national financing of local authority services in respect of health matters.

I want now to turn to Clause 4, which yesterday engendered so much heat and controversy. I understand the views of those who genuinely and sincerely feel that the extension of family planning services could lead to increased promiscuity. My views, however, are based on my present work as a family planning consultant in a large centre and on 20 years in general practice. I offer these views in a completely undogmatic way, in the full realisation that we are always in a constantly changing situation in which not every factor is known and in which psychological and physical motivations are not entirely understood.

The Margaret Pyke Centre of the Family Planning Association, in which I do a regular clinic, has become an important and well-known centre for study and training in family planning. It houses a busy family planning clinic with a staff of 50 doctors and 48 nurses. It began in 1969 and by 1971 was so successful that in that year 12,674 patient visits were made to it. In the following year the number had increased to 16,826. In this year, 1973, the patient visits are expected to jump to over 40,000 because patients are being seen at the clinic at the rate of about 1,000 per week.

In 1971, the proportion of married to unmarried patients who attended the clinic was equal. In 1972, 25 per cent. of those who attended were married and 75 per cent. were unmarried. The age breakdown makes interesting reading. Seventeen per cent. were under 20, 45 per cent. were between 20 and 24, 24 per cent. were between 25 and 29, 6 per cent. were between 30 and 34 and 8 per cent. were above 35. We in the clinic are pleased that young people are seeking advice.

My conclusion is that, since 98 per cent. of the unmarried who attend the clinic for the first time are already having sexual intercourse before seeking advice on contraception, the existence of our family planning service can hardly be said to have been an incentive to promiscuity. What might appear to be an increase in promiscuity is in fact a much more open and less inhibited attitude towards sex.

I have no wish to labour this point. All I say is that we have to have a balanced judgment, perhaps on a par with the judgment that was made when free contraceptives were available to Servicemen during the war. Did it make them more promiscuous, or was it a form of protection for those who would be promiscuous in any case? In this debate we have to get away from the preaching of people who raise the spectre of promiscuity, calling in aid their own innate prejudices, their own inhibitions and repressions. We cannot allow ourselves to be influenced too much by people who think that sex is, at best, a sordid necessity which must be tolerated in certain circumstances and at worst a vile lust which must be suppressed.

The emphasis must be on a completely free family planning service—free advice, free treatment and free appliances. Money should be no barrier, not even a small barrier—because it is the very people who should be encouraged to take advantage of family planning services who are most likely to be deterred by any form of payment, whether through poverty, irresponsibility or lack of knowledge. That is the position we must face. We may not like it, we may be annoyed by it, we may even sometimes rant and rave about it, but that is the situation and we ignore it at our peril.

As the individual stands to benefit by the extension of family planning services, so does the nation. I make no apology for referring to the report of the Population Panel, which was published last week. It produces a picture which is clear enough to those who take an intelligent interest in our environment without being doom watchers. It is difficult to understand those sceptics who compare it with the predictions of Dr. Malthus, 175 years ago. Are those sceptics suggesting that the scientific techniques available nowadays are no better than the inadequate ones of the eighteenth century? Are they suggesting that the accumulation of knowledge and technology in the last 150 years does not enable us to make reasonably accurate predictions?

We find from Table 6 on page 30 of that report that in the United Kingdom, taking the decades between 1901 and 1972, in the first decade from 1901 to 1911 the live birth rate was 27.2 per thousand and the death rate was 15.4 per thousand. The difference was 11.8. It is this difference that makes the increase in population. By 1971–72 the difference had fallen to 3.5.

During all this time the birth rate fluctuated from year to year. It is not a constant factor, it varies enormously. Britain's population at the moment is ijncreasing at the rate of about one million every five years. All we are saying is that if the birth rate continues to be higher than the death rate an increase of population will occur. There is no guesswork in this, and we cannot adopt a Micawber-like attitude.

The experience of Aberdeen has been mentioned, and I commend Mr. Alistair Service on his report. Tribute must also be paid to Sir Dugald Baird, whose foresight was responsible for the tremendous improvement in Aberdeen.

Aberdeen has one of the lowest infant mortality rates in the world. In 1970 it was 14.5 per 1,000 live births, compared with Glasgow's 23, 19 for Scotland as a whole, and last year it was down to a little over 12.

No one, surely, will suggest that the women of Aberdeen are unhappy because fewer children are born in that city. One always has to have regard for cause and effect, of course, and not jump to hasty conclusions. But there seems to be no doubt in the mind of the Medical Officer of Health for Aberdeen that the city's enlightened attitude towards family planning is the major factor in that happy situation.

A recent national opinion poll indicated that 64 per cent. of the British electorate favoured a free contraceptive service for all.

We in this House are often accused of being out of step with our electorate. Here is a matter in which we could show that we appreciate the needs of our people. A large part of our annual increase in population would disappear if only we adopted a strenuous and effective programme to ensure that no woman has more children than she wants to have, nor has them before she wants. That is a quotation from a recent book on Dr. Malthus. I contend it is surely a sensible and desirable aim if we are truly concerned about welfare and emancipation.

7.12 p.m.

Dame Irene Ward (Tynemouth)

I wish first to congratulate my right hon. Friend on having introduced the National Health Service Reorganisation Bill.

I have always had a great admiration for the team that runs the health and security services. In an operation of this kind there must naturally be all sorts of issues in the Bill on which one would like to comment. But in the limited time available, I can do no more than say how much I appreciate the efforts the Secretary of State has made to have a health service which contains all the qualities that the majority of the people of this country, and not only those in the House of Commons, wish to see embodied in the Bill.

I wish to speak today because I happen to be a Vice-President of the Royal College of Nursing. I am very proud of that office and always do my best to represent the point of view of the Royal College of Nursing in the House of Commons. Although there is much that I should like to say about the Bill, I will restrict myself to putting forward some of the points made by the Royal College of Nursing in its report. As I shall be able to mention only one or two of the anxieties and requests of the College, I hope that when I send my right hon. Friend the report of the Royal College of Nursing, he will examine the points of view there expressed and let me have an answer before the Committee stage of the Bill. That will enable me to shorten my speech today.

Without going into the matter in detail, I should say that I have also had representations on the Bill from Northumberland County Council. I will send its proposals and comments to my right hon. Friend and hope he will read them very carefully. If he can meet some of its criticisms I shall be very grateful, as I know Northumberland County will be too.

The report of the College of Nursing is very complicated. It is very important from the point of view of the administration of the service and of the nursing service within the health service that attention should be paid to it and that there should be an effort to meet the points of view put forward by the Royal College of Nursing. Therefore, one or two of what I consider to be the main points should be put forward in the debate and so recorded in HANSARD. However, it is very difficult in a short space of time to comment on them.

The first matter on which the College of Nursing makes a comment is the structure of the reorganised service. It says, The Royal College of Nursing sees this as creating a complex structure resulting in an expanded management chain which will be expensive of resources both in terms of finance and manpower and likely to create frustrations for those at the level of operational management; it is also considered that it could prove counterproductive in terms of the efficiency of the service. A great deal is said about this in the report. I have picked out that one sentence only because I have noted during the speeches made from both sides of the House that this criticism has already been expressed.

As to the Central Health Service Council, the Royal College comments: The present constitution (as embodied in the Bill) provides ex-officio membership for the Presidents of the Medical Royal Colleges and for the Chairman of the Councils of the British Medical Association and the Society of Medical Officers of Health, but makes no comparable provision for either the Presidents or Chairman of the Councils of the Royal Colleges of Nursing and Midwives. Additionally, its membership is weighted to an entirely disproportionate extent in favour of the medical profession, even allowing of their particular contribution to the service. I am a great supporter of the medical profession and I will not therefore comment on that. At the same time, however, it has been said by a variety of people from both sides of the House that we must be careful that other people who are just as interested in the effective working of this new Bill also have their place.

I notice—and it is right that this should be so—that great tribute is always paid to the nursing profession. With the introduction of a Bill of this kind, when great emphasis is placed on the part played by the nurses in the health service, it seems extraordinary that no provision has been made for either the nursing profession or the midwives to be represented at the highest level on this council.

My right hon. Friend is always very generous and listens attentively to what one has to say, although not necessarily always agreeing with one. Indeed, that is the right of any Secretary of State because he would go mad if he had to agree with everything that everybody said. He must make his judgment. But I wish him to know that I make this specific point on behalf of the Royal College of Nursing which, after all, plays a large part in the health service and feels that it is being neglected in the higher grades of the establishment of the councils. This I believe should be rectified. It will give the Royal College of Nursing, the Royal College of Midwives and myself very great satisfaction because, of course, both those Royal colleges have been consulted by the Minister who is in another place and has met some of the suggestions of the Royal College of Nursing but not all of them.

It may be easier for me to argue here that it would be right for representatives of the Royal College of Nursing and of the Royal College of Midwives to have their place among the medical profession which also, of course, is very generous in its appreciation of the nursing services provided in the health service.

I hope that my right hon. Friend will give me satisfaction on this point when he receives this report.

I am sorry that I do not have the time to say many other things. I wish that Clause 4 could be taken out of the Bill and introduced as a separate Bill. We could then have a full debate upon all the implications of the population report. What worried me, listening to the debate yesterday, was that so much was said about Clause 4 and so little was said about the other clauses. I do not always support my right hon. Friends but I will support my right hon. Friend's Bill tonight. It would be better, however, to have a full debate on the whole issue of population since the report has just come out.

The report from the Royal College of Nursing continues under the heading, Relationship between officers at the same level of management. It says, The Royal College of Nursing welcomes the emphasis placed on equality between members of the team in respect of status and involvement in the work of the service as a whole, but it is in no doubt that this equality will only be meaningful if it is also reflected in the salaries of the different members of the team at each level in the structure. Salaries and conditions of service, are, subject to negotiation, or determination, by the bodies set up for that purpose, namely the relevant functional Councils of the Whitley Councils for the Health Service and the Medical Review Body. The Royal College of Nursing is already pressing its view on this subject as the organisation holding the largest number of seats on the Staff Side of the Nurses and Midwives Whitley Council and it is fully supported by the other Staff Side organisations. However, it believes that this issue involves a matter of principle which will need to be accepted at Government level before meaningful negotiations can take place. That is that the salaries must be reflected as equal when equality of service on councils is brought into operation. I do not see why I need even argue this. All members of the Government have said that they are in favour of the rate for the job and equal pay for equal work. Here is an opportunity.

What worries me about Governments is that they adore making statements which sound acceptable but when it comes to putting them into operation, all sorts of reasons are put forward for not doing so. The Chancellor of the Exchequer and the Secretary of State for Social Services agree with me about the introduction of equal pay for equal work. Here is an opportunity which my right hon. Friend could take without any opposition from the Treasury, and I am sure with the full support of the House. I look forward to my right hon. Friend accepting the point of view of the Royal College and demonstrating to us that the Government do believe in equality. The people who will work on this council will work as a team and there is no reason why women drawn from the nursing or midwifery services should not have the same salary at the top of the profession as the medical profession.

I am glad that my right hon. Friend has invited Sir Alan Marre to be the Commissioner for the Health Service and I am even more pleased that Sir Alan Marre has accepted the post. For many years I have been a member of the Parliamentary Commissioner's Committee. We know and value the effectiveness and competence of Sir Alan Marre. My right hon. Friend is lucky that Sir Alan was able to take on the additional job. I know that it is a very involved organisation which is being set up and that the National Health Ombudsman will have only the "final" problems raised with him. This is very satisfactory.

What I do not know is what happens when a decision has finally been taken— when a decision is made whether there has been maladministration. Will my right hon. Friend then do what is normally done with the reports from the Ombudsman? Will a report from the Commissioner be presented to the appropriate committee and shall we then, as in the case when the report is presented to Parliament, have the opportunity of cross-examining the officials concerned who may be or may have been brought into the cases? It is important that we should have this because it makes for good relationships between Parliament and the Departments.

I am a little worried that there is but one tiny reference in the whole of the Bill to the remedial professions. That is something to do with staff hidden away in one little clause. For many years I have been on the Council of the Chartered Society of Physiotherapy and have done quite a lot in my small way to try to help the remedial professions. It rather worries me that there is just this little reference, because the remedial professions have a large part to play in rehabilitation and all sorts of things connected with the health service.

Sir K. Joseph

I would like my hon. Friend to know that this Secretary of State has the remedial professions very close to his heart and that their representatives are lunching with him tomorrow to discuss matters of mutual interest.

Dame Irene Ward

I hope that my right hon. Friend will have a good lunch and will be able to meet the requirements of the remedial professions.

We should all be grateful for the effort that has been made by the Secretary of State and his team in bringing forward this Bill. I hope that when it is put into operation we shall have a better service for looking after patients and making a further contribution to those who require our care.

7.30 p.m.

Mr. Eric Ogden (Liverpool, West Derby)

By 7.30 in the evening the House has usually reached the part of the debate when the 10 minutes limit for speeches applies. I shall do my best to limit myself to that time, even though I had a false start yesterday at about this time, due to a confusion of identity, fortunately for my hon. Friend the Member for Nottingham, North (Mr. Whitlock) and myself. I hope that, because of the voluntary time limit, the hon. Member for Tynemouth (Dame Irene Ward) will excuse me if I do not follow her speech and take up the details of what she was talking about. It is because she has a special knowledge of her area, and not because she turned on me rather like a tigress when I sought to intervene by making a comment during her speech. The hon. Lady's contribution, as usual, was cogent, forceful and completely un-copyable—inimitable is the word.

Welsh Members have accepted with remarkably good grace the intrusion of English and Scottish Members in the debate, which was to be mainly but not exclusively reserved for the effect of the Bill on the Principality. I make no complaint about that. I made no complaint yesterday when the hon. Member for Pontypool (Mr. Abse) intervened during the English part of the debate. I plead in justification that perhaps Welsh Members will recognise that Merseyside is not too far from North Wales, that hospitals and facilities are used extensively by people from North Wales and that we are interdependent in respect of such services.

My first point comes from the speech of the Secretary of State for Wales. It is unusual for an English Member to be able to raise a point made by the Secretary of State for Wales. The right hon. and learned Gentleman contrasted the three-tier system in England with the two-tier system in Wales. When he referred to the impact that the constitutional commission might have on further reorganisation, the possibility of a council or an assembly for Wales in future, and the effect that that would have on the health service organisations in the Principality, it might have been thought by some hon. Members that what he said he and his Government were proposing would automatically exclude the possibility of a council or assembly for England. I declare my English interests. If we are to have a council or assembly for Wales and one for Scotland and another for Northern Ireland, there may well be pressure, and rightly so, for there to be a council or assembly for England. I am not saying that there has to be, but such a council or assembly should not be automatically excluded. Hon. Members may have got the impression that that was the Government's intention.

When the Secretary of State for Social Services opened the debate yesterday afternoon, he said: The whole purpose of the health service reorganisation which the Bill proposes is to provide an improved service for patients. I recognised that over the past few years the Secretary of State and his colleagues have achieved an impressive record of improvements in sectors of the National Health Service and the facilities that it provides. He has taken advantage of a "spending Government" to obtain major improvements in a whole series of sectors, namely, the disabled, the elderly, the mentally handicapped, among others. He has had to be stimulated and pressed by Labour hon. Members, but there have been changes, and that must be recognised.

I doubt if the right hon. Gentleman will claim that the Bill, with all the care that has gone into its preparation, is his greatest achievement or endeavour. There are clear and definite doubts and fears that it will not achieve the aims and objectives that he claimed yesterday. The right hon. Gentleman said: There is some well meant criticism of our proposals."—[OFFICIAL REPORT, 26th March, 1973; Vol. 853, c. 924 and 932.] Indeed, he heard more criticism yesterday and he has heard more today. I have no doubt that in the months to come he will hear criticism again and again from hon. Members on both sides of the House and from organisations and individuals outside who have no political affiliation.

The Bill no doubt follows months of consultation and discussion. It would be interesting if we could see the original draft, and see the changes, compromises and alterations that have been made since that date. I hope that the right hon. Gentleman will accept that the Bill in its present form can and should be altered so that it is improved and will do more good and less harm.

The House must recognise that Parliament, as a legislator, comes into the progress of a Bill of this kind at a very late stage. Discussions take place between interested parties and the Department, and the Legislature comes into the picture at a much later stage. That might be inevitable, but it is unfortunate. It seems that when we sometimes consider ways of involving Parliament in developments of this sort we are guilty of ignoring the ways that are available to us and the reports and discussions that have been made available to us in the past, and often only the recent past.

For practical purposes the Bill is an enabling measure. Throughout the debate hon. Members on both sides have introduced different aspects of it and have brought in their individual and special experiences. The Committee stage is likely to be a lively one, and not necessarily a comfortable one for either the Government Front Bench or the Opposition Front Bench. During the Committee stages of Bills of this kind there have been alliances between hon. Members on both sides. They have been temporary alliances but they have been very effective. There is nothing like an alliance of back benchers to encourage both Front Benches to make progress in a practical and realistic direction.

The Bill has 57 clauses, five schedules and 93 pages. I congratulate the hon. Members who have spoken today for managing to achieve a better balance on the whole of the 57 clauses than was managed yesterday, when Clause 4 took a greater proportion of time than I thought necessary. I cast no doubt on the importance of Clause 4. Its place in the organisation proposed in the Bill is not to be doubted. However, one third of the debate yesterday was spent on that clause. Let me simply say that I support Clause 4.

It is the custom and practice that on social matters of this kind the House is allowed and has almost the right to a free vote. It may well be a way of getting various parts of the House and sections of the Government out of difficulty if in Committee or on Report Clause 4 is allowed a free vote on both sides of the House. Those who conscientiously support it, or oppose it, for moral reasons should be able to do so without fear of the Whips. Other legislation of this kind has been given a free vote over the years. To a large degree the major Bills on social legislation have been Private Bills, which, of course, have a free vote.

Mr. Timothy Raison (Aylesbury)

Surely the problem here is that money is involved? That is what distinguishes it from the normal so-called Private Members' conscience Bills.

Mr. Ogden

Money always seems to get involved somewhere along the line. It is a matter of degree. It would still be possible for the House to have a free vote on Clause 4. On the wider issues raised by that clause, I quote for the first time in Parliament a comment made by my wife. As far as I can remember she said: I will try to listen more patiently to men who insist on lecturing women on the rights and wrongs of contraception, pregnancy or abortion when men themselves can become pregnant. There are times when men take too officious and righteous a rôle in saying what should happen in such situations. My wife was making the point that if men had some of the duties, obligations and abilities of women we might well look at these matters rather differently.

What of the other 56 clauses and five schedules? There are three about which I am specially concerned. The first is the membership of the district, the area and the regional health authorities. The amount of power seems to be concentrated at the top of the pyramid—namely, the regional health authorities—rather than at the base. That is not a good thing. We must examine closely the relations between the districts, the areas and the regions, and the relations between those three authorities and the Secretary of State. Whether we have democratically-elected authorities or appointed authorities, Members of Parliament could provide a link between the regional, area or district authority and the House. I am not volunteering for that job—I have much less knowledge or experience than other Members from Merseyside—but, for example, the late Mrs. Braddock, who rendered such service to hospitals in Merseyside, would have been a very valuable link between a health authority and Parliament. It is a proposal that the Minister might like to consider.

My second cause of concern is the relations and communications between the local hospital and health services and the local social services. I was informed today, in a letter from the Secretary of State for Social Services, that he is to visit Liverpool on 2nd April—Monday next—that in the morning he will meet teachers and students in social work and in the afternoon social workers in Hale-wood. I have no doubt that he will listen carefully to the doubts, fears and anxieties which some of these social workers have expressed to me. Some of those doubts have been expressed in this debate, so it is an opportunity of which I hope he will take full advantage.

My third point relates to patients' interests. However good the community health council or the Health Service Ombudsman are in redressing grievances —and this is important—my experience of hospital service is that difficulties arise when the staff, whether doctors, consultants or nurses are under extra pressure and stress. This happens when they are trying to do an hour's work in 30 minutes. We should provide better facilities and support, so that fewer difficulties are likely.

I make one suggestion to all those employed in the National Health Service generally and hospital services in particular. There are too many divisions both among the professions and within each profession. It is ridiculous that in 1973 there should be so many unions and professional organisations representing so few people. There could well be a more unified representation structure, whether within the nursing service alone or for doctors and consultants. There are too many individual groups arguing about wages and conditions. They have in the main one employer, and the more united the front among those employed, the better the conditions of the service will be.

My hon. Friend the Member for Wol-verhampton, North-East (Mrs. Renée Short) yesterday detailed the misuse of the private sector. There has been misuse, but there is a dilemma here. In South London children's hospitals, for a a simple operation like a tonsillectomy the average stay for a child aged between 6 and 10 is five days, and the waiting list is about nine months. In the North-West the average stay from the day before the operation is again five days and the waiting list is 12 months.

I have personal experience of the dilemma of public or private practice. A little while ago my own son was told that he required a tonsillectomy. My choice was to wait nine months or to go to a private consultant and be able to have the operation in a fortnight. I took the view that, for myself, I could decide to deny myself private facilities, be big and brave and wait my turn, but that I had not the right to deny the best possible hospital services to my own family. We arranged the matter, and he had the operation, which was very successful, within two weeks. That is the contrast —between nine months and two weeks—

Mr. Leslie Huckfield

This is disgraceful.

Mr. Ogden

It is all very well for my hon. Friend to say that this is disgraceful—but I did not have the right to deny the best possible hospital treatment to my own child, although I could deny it to myself.

Mr. Huckfield

Will the hon. Gentleman give way?

Mr. Ogden

No, the hon. Gentleman will not give way. This is a personal decision that I had to take and, rightly or wrongly, that is the decision I took. I would sell my house or anyone else's house to get medical attention for my son. But I should not have had to be in that position. This is the practical situation. Incidentally, why should my child be in hospital for one-and-a-half days for this private operation when the length of stay is five days for a National Health patient? Is it because they thought that I could look after my child better? There are some difficulties. This is a dilemma that I had to face. I did not have to tell the House about it. It is one that other hon. Members will have to face.

There are no differences between this side of the House and the other side about the aims in the Bill. My right hon. Friends have moved their amendment because they believe that the Bill is so bad that it cannot be altered. In practical terms I doubt whether that will be so after 10 o'clock. It looks as though the Bill will go forward, much though hon. Members opposite dislike it. So we have to see how much we can alter it to make it do less harm and more good and to prepare for another Bill which will get down to the real need, which is for an improved, expanding and really effective National Health Service.

7.45 p.m.

Mr. Nicholas Edwards (Pembroke)

I will not follow the comments of the hon. Member for Liverpool, West Derby (Mr. Ogden) except to say that our wives are in agreement and that I agree that the Bill can be improved.

First, I must apologise to the House for the fact that I have not been here for the whole debate, but I am a member of a Standing Committee considering the Social Security Bill and it is one of those occasions when one's priorities are very difficult to decide.

However, I was privileged to hear the notable speech of my right hon. Friend the Member for Wolverhampton, South-West (Mr. Powell). I should have liked to say more about it, but time does not permit, except for this comment. It seemed to me that he drew a conclusion which was deeply depressing—that we should make no change, that no improvement, apparently, is possible, that we must just grin and bear it. If my understanding of his argument is correct, that is an approach which it is hard to accept.

I turn to the speech of the right hon. Member for Cardiff, West (Mr. George Thomas). I am sorry that he is not here at the moment, but of course I understand the reason. We have debated the reorganisation of the health service twice in the Welsh Grand Committee. Having re-read the report of those debates, I was astonished, as I listened to the right hon. Gentleman today, at his effrontery as he attempted to skate over the magnitude of the policy upheaval that he was trying to defend.

In July, 1971 the right hon. Gentleman proposed, as he had in his 1970 Green Paper, that the area health boards should be directly responsible to the Secretary of State. He made it plain that he would not pre-empt Crowther-Kilbrandon. In the meantime, until the Government had taken decisions on the Commission's recommendations, the Welsh Office would form the top tier. His position was exactly that of the Secretary of State today. My right hon. and learned Friend said that, when the recommendations were available, the Government would reconsider the present arrangements.

But not so the Opposition. They have decided to pre-empt the report and to go back on their 1970 Green Paper and 1971 reaffirmation. They now promise that, whatever the Commission reports, they will go ahead with their new scheme and put the control of the health service in Wales at regional level in the hands of an elected council for Wales. It is characteristic of the Labour Party that they should appoint a commission to consider what should be done but should in the meantime decide to act in their own way, regardless.

Mr. Elystan Morgan (Cardigan)

I am sure that, in the interests of accuracy, the hon. Member would make this distinction between the Green Paper of 1970 issued by the Labour Party, and the White Paper of August, 1972, issued by his own Government. The Labour Party's Green Paper did not set out any argument of merit against an all-Wales body. Such an argument is deployed in full in the White Paper of 1972. In other words, it seems clear that whoever wrote the White Paper of 1972 had a conviction that an all-Wales body was wrong anyway. There is no statement of such a conviction in the Green Paper of the preceding Government.

Mr. Edwards

The fact is that the Secretary of State for Wales made it clear this afternoon that the Government would consider the commission's recommendations when available and would judge the organisation of the National Health Service in that context. But the Labour Party, come what may, has decided to go ahead with its scheme. It will be interesting to see what happens if the commission decides something quite different.

In past contributions on this subject I have stressed three points. First, I have stressed the need for as much devolution as possible from the centre; secondly, the need to leave the main job of management within the area authorities to professionals of high calibre responsible to authorities composed of people of diverse talents; and thirdly the need to improve the effectiveness of the community councils. I believe that there will be devolution because I expect the area boards to exercise key functions and to play a vital réle in those parts of our health service where the impact on the general public is greatest. This will be particularly so in Wales where they will carry the executive function below Secretary of State level without the intervention of a further tier and where they will be subject to a degree of local scrutiny, while the Secretary of State will be responsible to Parliament, I fear that in England the regional board may be just that much more remote either from control by or contact with the people.

I turn to the way in which authorities will operate. It is important that the committees should primarily be policy-making and not administrative bodies. A committee cannot effectively carry out a detailed management function over such a range of services. I agree with the right hon. Member for Coventry, East (Mr. Crossman) that it should be done by officers. The paper on management arrangements makes it clear that this is the Government's intention. I am encouraged by the Welsh Office circular of March 1973, which makes it clear that officers will have executive authority and that the area boards will have wide powers, subject only to overall monitoring and budgeting systems.

The area boards will have important policy-making functions and the duty to prod, probe and examine the work of their officers. If this is what the area board will have to do, then four is not an adequate number to be appointed by the local authorities. I was relieved to hear the Secretary of State for Social Services say yesterday that there is no magic in the number 15 for the boards as a whole. In Wales we have some very large local authority areas. For example, Dyfed covers more than 25 per cent. of the land mass of the Principality. It contained three old counties and four proposed health service districts. What we need from policy-making bodies is vigorous questioning and intelligent suggestions from people who know their locality and its problems. I do not believe that four local government appointees, with all their other responsibilities, can do the job properly, particularly in large rural areas. I pressed my right hon. and learned Friend on this point on a previous occasion and I do not apologise for doing so again.

I turn to the community councils. In the Grand Committee I asked that better means should be provided to make sure that the councils knew what was taking place. I demanded that they have their own fully-informed and independent officers for the expert presentation of their case to management. It was clearly unacceptable that they should only have staff and financial resources made available to them from the area authority. My wishes in this respect have been largely met by amendments now made to the Bill.

One point requires clarification. My noble Friend Lord Aberdare in another place spoke on Report about staffing. He said that staff would be seconded by regional health authorities. Presumably, in Wales they would be seconded from the Welsh Office, though I am not clear on that point. Perhaps my hon. Friend will say what he has in mind when he replies. If they are to be seconded from the Welsh Office, then I have some doubts about it and a little sympathy with the remark made by the right hon. Member for Cardiff, West when he suggested that they would not be sufficiently independent. We must consider whether an alternative source should be available to them. Perhaps they could have power to recruit staff independently.

It is unusual to come to a Second Reading debate having already discussed the Bill with Ministers in Committee, but this is the position in which Welsh Members find themselves. On the last occasion I made two criticisms. One of them has been met in that the community council is now a much more convincing instrument. I hope the Government will again consider my other point and enlarge or give permission for the enlargement of, local authority representation. If they do that, I shall be satisfied. This is in large part a good and much-needed Bill. It is a Bill which had its origins in the proposals of the Labour Government and deserves our support. It will have mine.

7.57 p.m.

Mr. Frederick Mulley (Sheffield, Park)

I hope that the hon. Member for Pembroke (Mr. Nicholas Edwards) will forgive me if I do not take up his arguments involving the Welsh organisation of the National Health Service. I want to be brief and shall confine my remarks to only one point. I make no apology for so doing because this matter deeply affects my constituents and the city of Sheffield.

As a result of the reorganisation proposed by the Bill it has been decided in principle by the Secretary of State that from 1978 the headquarters of the Sheffield region should be transferred to Nottingham. I wish to thank the Undersecretary of State for having received my colleagues and myself when we discussed these matters, and indeed I am grateful to the Secretary of State for his replies to a question which I asked only yesterday to the effect that he will further consider all aspects of the situation and will receive a deputation from the area. I shall then be able to argue the matter at greater length than I propose to do tonight.

Had it not been for the fact that the cause of Nottingham had been espoused by the Secretary of State, I would have said that there was no argument but that the headquarters should remain in Sheffield. When a change is proposed, the onus of proof surely lies heavily on those who want to make a change.

The burden of the Nottingham case, as deployed yesterday by my hon. Friend the Member for Nottingham, North (Mr. Whitlock), is simply that from studying the various statistics it is argued that provision for patients in the East Midlands part of the region is less adequate than in the Sheffield area. This stems much more from the fact that Sheffield has a medical school in the university and a teaching hospital, and I welcome the fact that these facilities are being provided in Nottingham and Leicester. It is a scandalous suggestion that the members of the Sheffield Hospital Regional Board—who by no means come exclusively from Sheffield, and indeed the board for some years had a Nottinghamshire man as its chairman—have been coloured in their outlook by the mere chance that their meetings take place in one city rather than in another, or to suggest that by transferring the headquarters they will make greater provision for patients in one part of the region than in the other.

Members of Parliament from all parts of the region need to press for more generous resources for the region as a whole. We would be better able to do that if the Secretary of State did not go ahead with an expensive building pro- gramme to move the headquarters from Sheffield to Nottingham. I understand that the cost is estimated to be over £2 million. In my view, that would be much better spent on increasing the facilities in this area.

It is further proposed that if the headquarters were moved the great majority of the staff would remain in Sheffield. This seems a prescription for inefficiency which again can only rebound on the poor patients who will suffer in consequence. I concede that if we were setting up a new region which was rather untidily divided between the South Yorkshire-Derbyshire end and the East Midlands end there might be an argument for the headquarters being located in Nottingham. However, I believe that on balance we would have a stronger argument for the headquarters being in Sheffield. Apart from the fact that Nottingham is now to have a medical school—I understand that Nottingham University has been most active in propagating this suggestion— there is an argument that it would be more central and therefore more convenient. However, this falls down on an analysis of the distance from the regional authority's headquarters to those of the area authorities because Sheffield would be marginally nearer than Nottingham.

People in the East Midlands are by no means unanimous that they want the headquarters to be at Nottingham. The chairman of one of the Leicester Hospital Management Committees was recently most outspoken. He said that he wanted the headquarters to stay in Sheffield. There is a great deal of evidence that opinion in the East Midlands is divided, whereas there is absolutely solid support in South Yorskhire and Derbyshire that the headquarters should remain in Sheffield. I am authorised by my Yorkshire colleagues to say that they will give full parliamentary support to any steps that we in Sheffield may feel it necessary to take.

In addition to the problem in hospital management terms, there is an enormous problem for the staff, not least because they will not know until 1978 what is likely to happen. I understand the staff problem and I am grateful that the Secretary of State is studying the representations that have been made. However, the real concern and anger in Sheffield goes much wider than the mere issue of the headquarters. It is not a matter of civic pride. We understand, as the right hon. Member for Wolverhampton, South-West (Mr. Powell) pointed out, that the regional hospital authorities will not be so important in the new set-up.

We in Sheffield are concerned about future employment in the city, particularly in the clerical and administrative spheres, as a result of the rundown of employment in our traditional industries —steel, heavy engineering and coal. Two years ago we were granted intermediate area status. Everyone thought that that would help to bring employment to the city. But, rather than bring employment, it has tended to result in our losing it. First, British Railways, with the approval of the Minister of Transport Industries, transferred its headquarters work from Sheffield to a new headquarters in York. Now the Secretary of State for Social Services proposes to take a sizeable block of clerical and administrative employment from Sheffield and to transfer it to Nottingham.

I have never, in the 23 years that I have been a Member of this House, sensed such universal indignation—I have certainly never had so many representations from an enormously wide sphere of organisations and individuals—about the decision that was announced shortly after Christmas to move the headquarters from Sheffield to Nottingham.

I hope that the Under-Secretary understands and will convey to his right hon. Friend the depth of feeling that is shared throughout the population of Sheffield, which goes much wider than the argument of civic pride, for the retention of the headquarters in our city. There are many economic and social factors, as well as strong administrative logic, for the headquarters remaining in Sheffield. The region needs substantial investment in medical facilities. I hope that the further consideration that is being given to the matter in the Department will lead to a correct and early decision that the headquarters shall remain in Sheffield Such a decision will give great satisfaction to the citizens of Sheffield and be of great assurance to the staff.

Several Hon. Members rose—

Mr. Deputy Speaker (Sir Robert Grant-Ferris)

Perhaps I can help the House by saying that I can call about three hon. Members from each side if they speak for only ten minutes each. If they speak for rather less time than that, I think that I can call every hon. Member who wants to be called. Of course, I am on the hands of the House. Hon. Members must speak for as long as they wish. Mrs. Kellett-Bowman.

8.6 p.m.

Mrs. Elaine Kellett-Bowman (Lancaster)

Before my right hon. Friend the Secretary of State for Social Services opened the debate yesterday I was extremely worried about four particular aspects of what I consider in general to be a very good Bill.

First, I was worried about the impact of the Bill on the newly shaped Lancashire county, with its unusual inheritance —as a matter of fact, I was looking at the map when Mr. Deputy Speaker was kind enough to call me—of a very large area of five ex-county boroughs plus my own substantial hospital centre of no fewer than 3,250 beds. However, as my right hon. Friend said, at col. 930 of the report of yesterday's debates he gave my colleagues and myself from the North-West a very good crack of the whip— ample opportunity of discussing this matter with him—about a fortnight ago. We put our points of view and he promised to consider them very carefully and give us a reply in the not-too-distant future. I know my right hon. Friend to be a sympathetic and wise man. I hope that the decision will represent some concession to the strong feelings we have about the matter.

Secondly, I am concerned, with many others, about the future of social work in hospitals. Having been a social worker I feel particularly strongly about this matter. However, there is no point in raising this question at the moment, as my right hon. Friend has promised a statement this week and I prefer to wait for that.

The third matter which concerns me deeply is not so much the building of new hospitals as the emptying of existing hospitals. This has been a pet theme of mine for many years. Some years ago, when I worked in welfare, we had what I can only call a barter system with elderly people. If an elderly person desperately needed to go into hospital we could often get that person into hospital only if we agreed to take a geriatric patient out. If we had many more hostels and homes to which they could go, with a sheltered environment, we could take about half the people out of our mental hospitals today, with drug control, and so on. I know that my right hon. Friend the Secretary of State hopes that what he calls the "whole needs" of the elderly and the mentally handicapped will be catered for by the health care planning teams. But local authorities will still have to find the money. I am a little worried about the division of responsibility.

The fourth matter which worried me arises on Clause 4. I make no apology for mentioning this matter because I regard it as of considerable importance. It would be wrong in principle, as well as being thoroughly ill-advised, to levy prescription charges on vital life-saving drugs and to supply contraceptives entirely free of charge. I am glad, therefore, that my right hon. Friend, in his wisdom, has stated that contraceptives will be subject to charges like any other prescribed medical product—subject to remission for those who cannot afford the charge. To go any further than this would be both wrong and potentially dangerous.

I am sorry that the hon. Member for Liverpool, West Derby (Mr. Ogden) has left the Chamber. He said that his wife complained that men often discussed this in terms of the impact upon them. Yesterday the hon. Member for Pontypool (Mr. Abse) said that a man is more likely to have a sterile wife or a stillborn or premature or defective child if he marries a girl, particularly a young girl, whose first pregnancy has been terminated by an induced abortion."—[OFFICIAL REPORT, 26th March 1973; Vol. 853, c. 1028–9.] My right hon. and learned Friend the Member for Huntingdonshire (Sir D. Renton), for whose calm wisdom I have the greatest possible admiration, said yesterday that we in our generation will fail future generations by not offering free family planning and drawing attention to its advantages.

Neither of those hon. Members, nor any others apart from my hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight), have spoken of the dangers of the pill. I believe that we should be failing in our duty to the next generation and succeeding generations if we do not do so.

The short term dangers of the pill— thrombosis—are well known. It would be fair to admit that they are overbalanced by the dangers of pregnancy. But the dangers of increasing venereal disease and the resistant strains of it which are coming out were dealt with very fully by my hon. Friend the Member for Edgbaston. No one, however, has mentioned the possible long-term genetic effects of upsetting a woman's hormone balance by the use of the pill. We cannot know what will be the effect on women of taking the pill not for five or 10 years but for a lifetime. Members of the Opposition laughed yesterday at the idea that pills would be freely available to all those over the age of 65. Perhaps in a generation this idea may not be so funny, as the effect of using the pill over a lifetime may well be to cause a woman to remain fertile for very much longer. On the other hand, what will be the effect on a child born to a mother who has been on the pill for 15, 20 or 25 years?

My belief has always been, and remains, that we should encourage our children to be less and not more permissive. My hon. Friend the Member for Dorking (Sir G. Sinclair) spoke yesterday of the great change that has taken place in public opinion.

I believe that the change is one in the opposite direction to that which my hon. Friend implied. People are beginning to realise that the pill is no substitute for chastity outside marriage and loyalty within it. It may be trite, but I think that the best form of oral contraceptive is, as it has always been, the perfectly simple word "No".

I beg my right hon. Friend not to heed the blandishments of some of our hon. Friends, and to stick firmly to his proposals in this very important respect.

8.14 p.m.

Mr. Neil McBride (Swansea, East)

I hope that the hon. Member for Lancaster (Mrs. Kellett-Bowman) will forgive me for not following her arguments.

The primary objective of the National Health Service is and must always be the making available to the patient of the best medical care, drugs and appliances in order to cure him of the ailment or the effects of the accident from which he suffers. Medical need should be the only yardstick, and not ability to pay. This service should be entirely free.

I am rather taken aback when I consider that while this is the primary objective, on which social and elected lay opinions must bear heavily, the Bill seeks to remove the aspect of public accountability provided by the lay representative.

For many years it has been important that democratic participation in the National Health Service should always include a high proportion of elected representatives—despite the fact that sometimes in the nomination to the executive councils trade unionists and others were passed over for someone else. The dedicated lay opinion and expertise built up over many years by people who have given their lives to this service is being relegated to the limbo of things forgotten in favour of the maxim that professionalism should run riot. I recall the words used in describing these non-elected agencies by the right hon. Member for Wolverhampton, South-West (Mr. Powell).

The Secretary of State for Wales is exclusively responsible for health matters in Wales. It follows that the proposals must be closely analysed in order to ascertain, in relation to the most personal and intimate service, which is the envy of the world, the end result of the Bill. The end result should be the betterment of the health service for the patient, with no decrease whatever in local authority influence and representation on all the bodies proposed. This will not be greatly furthered by the Bill.

Too much emphasis has been placed on the managerial structure, to the exclusion of the elected democratic influence. The representation of lay councillors, on their road to the top of the National Health Service, stops at the area health authority. That is a retrograde step. It is especially so when one recalls the valuable, devoted service given in Wales by people who are real experts in these matters.

My right hon. Friend the Member for Cardiff, West (Mr. George Thomas), to whose excellent speech we all listened with close attention, would agree that in the Principality, in the nature of things, there is a closer relationship between elected councillors, Members of Parliament and the electorate than exists in England. I have found that to be so after many years of residence in Wales. People are in the habit of discussing matters with their councillors more often and more intimately than they are in even my native area.

I approve of the strictures mentioned by my right hon. Friend the Member for Cardiff, West. There should be solely Welsh provisions in this matter. The voice of the Welsh people will not be heard. Welsh interests have been treated in a cavalier fashion. The stupidity of this arrangement by the Tory Government is seen in the City of Swansea. Unfortunately, my hon. Friend the Member for Swansea, West (Mr. Alan Williams) has been detained in Committee tonight. He would have wished to catch the eye of Mr. Speaker. We represent areas which form part of the new county of West Glamorgan. Within a radius of 12 miles of the city live 350,000 people. We find that the lay representation is insufficient.

This is considering the fact that in Swansea we have two large base hospitals, Morriston and Singleton, and I think that the city council should be much more heavily represented on the area health authority and that in the nature of things, if one considers right and morality, the representatives should be elected councillors.

The specification of functions is some-think that is clearly lacking in this Bill —and the policy is to involve the selection of people for their personal qualities, whatever they might be. This is clearly stated in the Welsh handbook which deals with management. The right hon. and learned Gentleman know that to be true. I submit that if this personal quality provision is favoured to the exclusion of experience and ability he will be creating a legion of rubber-stamping nominees. No one will deny that the community health services will be toothless wonders in the figurative sense. In the actual sense they will have no power of decision whatsoever. The right hon. and learned Gentleman knows this as well as anyone. He is failing in his duty in not giving powers of decision to these community health services. The only weapon in their armoury is the submission of an annual report. How stupid can a Government get?

Mr. Leslie Huckfield

My hon. Friend would be surprised.

Mr. McBride

My hon. Friend the Member for Nuneaton (Mr. Leslie Huckfield) says I would be surprised, but I can assure him that in Wales we have no cause for surprise. The measures in the Bill clearly define the fact that, with the exclusion of local authority accountability, we are seeing the creation of a vast army of bureaucrats. Indeed, from area level down there is a pyramidal structure which, as my right hon. Friend the Member for Coventry, East (Mr. Crossman) said, can only remove the people further from the Health Service, even with the proposals for a commissioner, when they wish to make a complaint.

My right hon. Friend the Member for Cardiff, West referred to complaints. A very clear embargo is contained in the clause dealing with the commissioner, because the complaint has to be put in writing. We all know, since we are all more or less welfare officers, on a gigantic scale, that many good, decent people will be deterred if they cannot put their complaint through a Member of Parliament. This is a conclusion that has been reached by a corporate Government. The voice of the people is being eliminated steadily.

I proceed to the consultation document issued by the right hon. Gentleman on 7th December in which the Todd Report is dealt with in relation to the establishment of a medical school in Swansea, in the constituency of my hon. Friend the Member for Swansea, West. In the Todd Report it was said that the land was available—and it is. In the right hon. and learned Gentleman's consultative document he says that the land is not available—and he is wrong. Consequently I think that the Todd Report of 1968, recommending that this medical school should be established in Swansea, was clearly based on the best principles of logic.

The Secretary of State knows that there is a shortage of native trained doctors in the Principality and that the pressure on Cardiff is heavy. Indeed, the pressure on all medical schools is heavy. He will have seen the plan at Singleton, which shows clearly that there could be a splendid result from the faculties there if the medical school were established. I ask the Minister who is to reply tonight to say definitely—because the Government owe it to the Principality—"Yes" or "No" to the question, will this be established?

The management of the National Health Service involves careful handling of large amounts of money, but this service differs in many critical aspects from the purely accountancy principles of ordinary business, since care of the patients and the principles of humanity and compassion cannot be quantified in terms of intrinsic assessment, but are factors of paramount influence and importance. The Welsh are, above all, a compassionate people.

Equally, the Bill limits the participation of the elected citizens of the community, and that is totally wrong. To hack about, for political, dogmatic reasons, the National Health Service in Wales is an insult to the brilliant Welshman who was the architect of this service which all nations envy. This measure they have formulated is no credit to the national Government and to Wales, and they will be judged on it.

The introduction of the soulless business efficiency concept by the managerial consultants is no substitute for compassion and experience and is alien to the wishes of the people I represent. The Secretary of State should consider afresh and most carefully. I say quite honestly that I do not think he is a bad man personally, although politically I would oppose him any time, but this is a measure which should rise above political dogma, and clearly dogma rules the day here. Therefore, the many objections that have been made should be considered carefully, and governing every other consideration should be the warm human feeling which is so prevalent in Wales and with which I am very proud to be associated—consideration of everything that is for the betterment of humanity.

8.26 p.m.

Mr. Timothy Raison (Aylesbury)

I do not propose to speak about private practice, but perhaps I should declare an interest as a director of Private Patients' Plan.

I shall not follow the speech of the hon. Gentleman in detail, but I should like to make an elementary point which applies to the whole of the Opposition's case, namely, that the object of better management is to serve the patient. The very first paragraph of the dreaded grey document sets this out well. It says: The objective in reorganising the National Health Service (NHS) is to enable health care to be improved. … Management plays only a subsidiary part, but the way in which the service is organised and the processes used in directing resources can help or hinder the people who play the primary part. That is a very good summary of an important point.

I support the Bill, and the principle of unification. Frankly, I regret that we have not been able to combine the Health Service with local government. I am one of those who believe that of all of the many documents—White Papers, Green Papers, grey papers, and so on— that have appeared over the years, in many ways the best was the 1944 White Paper put forward by the Coalition Government, which talked about com-binding the two services in local government. However, I have to recognise that this is prejudice on the part of the medical profession, and to a much lesser degree financial considerations mean that this reform will have to wait for the next time round, in 30 years' time, shall we say.

Having said that, I want to go on to speak about the organisation pattern which has been designed, and to make the point, first, that one of the difficulties from which we are suffering is that the Government have decided to talk about regional health authorities and area health authorities.

The truth is that neither is an authority. There is only one authority under the proposed structure of the National Health Service, and that is the Secretary of State. It is because this misleading word has been adopted that a certain amount of the confusion has been caused in the debate.

Many hon. Members, notably on the Labour side, have said that they would like to see these authorities elected. The nature of an elected authority is, pre- sumably, such that the power will lie with it, but the fact is, and always has been, that the power lies with the Secretary of State. There might be a case for greater elected representation in these subsidiary bodies—which I prefer to call boards or committees—but they would not be there as people exercising real power; at the most, it would be delegated power.

I am still not persuaded that a regional tier is necessary. I do not regard this as a five-tier system, because the community health councils are not part of the management set-up But it is a four-tier system, and I am not sure that it needs to be. If one considers the powers or duties of the regional authority one finds it not too difficult to imagine that those duties or powers might be pushed down the line or up the line to some extent. It does not seem impossible for the Department of Health and Social Security to allocate resources between the regions. There are regional imbalances. This is something which could be done centrally, on an Elephant and Castle to area authority basis, perfectly well. There is no need to go through the regional set-up in between.

There is also the question of services which are thought to be too wide in their span to be decided by the area authorities—for example neurology, neuro-surgery, radiotherapy, and so on. If there is to be some sort of decision as to how these services are to be combined over the part of the country covered by special areas this could be done better and more simply by the Department itself. All the proposals for the regions in these matters would be chewed over at great length by the Department and it would be much simpler and much easier for people to get at the sources if decisions of more than area significance are taken at the top, where we, as parliamentarians, could get at them more easily. So I hope that at this late stage my right hon. Friend the Secretary of State will reconsider the need for the regions. For one thing it will prevent him from having to exercise his terrible judgment of Solomon between Nottingham and Sheffield, and I am sure that would appeal to him.

It has been represented to me by dentists in my constituency that there is a lack of dental representation in the proposed structure. They say that the draft legislation makes no provision either for dental membership of the new authorities or for consultation specifically with the dental profession for the appointment of members. Although there is no specific representation I would have thought that the terms in which the schedule is drafted suggests that the dentists would probably be listened to. I hope that my right hon. Friend will give an assurance about the suggestion that in the reorganisation circular dentistry will not be represented on the management team at regional or even area level. It seems clear that dentists are worried and I hope that it will be possible to meet their complaints or show that there is no ground for them.

I wish to deal with the vexed question of where the health social workers should go. It is a matter of peculiar difficulty. I have read quite a bit of discussion in the social work Press and, like other hon. Members, have received many letters on the matter. In principle I am still a Seebohm man—one who believes that the right place for social work is within the local authority social work services. Of course, if the principles of the 1944 White Paper were adopted the problem would largely disappear because they would all go under local government, but that is not being done.

So deep is the concern by the medical social workers and the psychiatric social workers in the hospital service that it might be worth looking at some kind of interim steps. It has been suggested for example by Phyllis Willmott, in Social Work Today— One solution … might be to drop Clause 18 … leaving in Clause 12 as the local authorities' back door—and then just wait a few years and see what happens. I am not sure that that is not the kind of thing it would be reasonable to consider. We have always been prepared to listen to doctors' protests about who is to run them and it would not be unreasonable to show something of the same kind of sympathy to medical social workers against the background of the long-term objective of the unification of the social work profession.

Lastly, I want to say a word about the vexatious issue of Clause 4. I believe this is a softer issue than some participants on either side would have us believe; and the Population Panel, to its credit, saw this. I do not believe the case for an absolutely free service has been made out. I do not believe that the proposed charges would be a deterrent or that there is any real need to subsidise the pleasures of the innumerable people who at present pay. But there is one really serious issue—the issue of the doctors' rôle. The classic view is that doctors exist to provide medical treatment, but in recent years we have begun to put on them another function altogether, that of providing social treatment.

We have to make up our minds whether we think doctors are the right people to provide social treatment and equally, and whether it is fair to them that they should have to do so. To be more specific, we have to make up our minds what we really mean both in Clause 4 as it stands and in relation to what my right hon. Friend the Minister said in talking of this. He said that the doctor will be authorised to prescribe medically suitably contraceptives. Later, he said the doctor will be entitled to prescribe them. Do we really mean that the doctor is to have a choice whether to provide a contraceptive, or do we not? Is he to have the choice, or is everybody to have the right to go to a doctor and say, "Give me a contraceptive"?

If the doctor is to have a choice, is it to be on purely medical grounds, or on social grounds as well? I do not think the choice can be on purely medical grounds. We all recognise that this is to a great extent a social and non-medical matter, but it seems to me that we cannot allow Clause 4 to go through, or to have anything substituted for it, unless we make absolutely clear whether or not a patient has a right to receive, as well as whether the doctor should have the task of considering the matter. Frankly, I am not quite sure what the answer is, but to allow this legislation to go through without making up our minds on this issue would be a very grave error.

8.37 p.m.

Mr. Harry Lamborn (Southwark)

Much discussion has taken place during this debate on what should be the democratic participation within the service. The hon. Member for Canterbury (Mr. Crouch) drew upon his experience as a member—as he said, a lay appointed member—of a regional hospital board to advocate that the selected appointed system was, because of the nature of the service, best. In my experience as a lay appointed member of a regional hospital board, a lay appointed member of an executive council and an elected member serving in the capacity of Chairman of the Health Committee of the London County Council when it was the largest health authority in the country, I have no doubt at all that if we are talking about the opportunities that are left for initiative, for contact with the community and for public accountability, the system of local authority control by democratically-elected representatives assisted, as they were, by the professional people co-opted on to the committee was by far the best.

The London Ambulance Service which was established by the LCC and was carried through to become an even greater ambulance service under the Greater London Council is, I believe, the finest service of its kind in the world. I hope that the decision taken in another place will be upheld and that the service will remain with the democratically-elected GLC. Anyone who has had experience within the health service over the past years must certainly have been aware of the need for a unified service. In my view, this Bill does not create the unification that is necessary. In my experience, the difficulties in the past have always been at the point where the existing services were closest together. Certainly this was true of geriatric cases. The shortage of beds in hospitals for geriatric patients has always presented a problem, and I expect that many hon. Members have experienced difficulty in trying to make representations on behalf of the old person who, in the view of the hospital, cannot benefit from hospital treatment and therefore should not be occupying a hospital bed, but who, in the view of the local authority needs more care and attention than can be reasonably given in an old person's home and who cannot be accommodated there.

I see nothing in the Bill which will prevent that vacuum in the services, and I think the same position applies in the area of mental health, and the relation- ship between beds in mental hospitals and beds in local authority mental health hostels. Here again the same void will occur. It is more logical to bring the whole of the services under one umbrella. That is why it is most important that we make a stand for democratic control of the health service because we shall be told in a short time that it is impossible to separate the social services from the hospital services under the control of local authorities. In my view this is very much the territory of the personal health and welfare services which are part of the local community services.

There will be further inroads as a result of these services joining the health services in the large bureaucratic body which we propose setting up. I make a strong plea for health and social services administered by the local authorities, by elected representation.

I refer now to what has always been the third rung of the tripartite set-up in the health services, namely the executive councils. I cannot see any difference between the general practitioners' committee proposed in the Bill and the executive council. In my experience the executive council, with 50 per cent. of its members from the professions having a strong vested interest in their professions, has always been one of the greatest obstacles to progress in health administration. It has been the greatest obstacle in the movement towards the comprehensive health centre, and I imagine that any layman who has served on an executive council for any length of time will have suffered the same frustrations as I have experienced.

I make a plea for democratically controlled health and social services for the benefit of the community

8.44 p.m.

Mr. Robert Boscawen (Wells)

I, too, have served for a considerable time on an executive council, and I share the view of the hon. Member for Southwark (Mr. Lamborne) about executive councils as they have been organised over the past 25 years. I agree with him that they are obstacles to progress, not entirely because of their membership make-up but because of the compartmentalised nature of the service as it is structured today.

I shall confine my remarks strictly to the organisation of the service. The essential part of the Bill is the creation of a pivotal managerial structure at area level. The Achilles heel of the service has been largely the lack of co-ordination between the various hospital boards, management committees and executive councils.

The various professions have been responsible for the difficulties involved in achieving a broader concept of a comprehensive service. But the local authorities have, too. They have kept their own private little armies close to their bosoms and sought not to try to co-ordinate enough with other authorities. The same is true of the institutions set up under the service—the hospital management committees, the executive councils, and so on. They, too, want to fight their own private little battles with the minimum of interference from the other bodies. Anyone who has seen the difficulties which each of those bodies has had in trying to get representation on the other bodies—for example, an executive council trying to get representation on the regional hospital board—will know what I mean when I say that each body has sought to preserve its own little holy circle and to keep out anyone else who might be thought to threaten to take over its little empire.

For that reason alone, I am wholly in favour of producing a new managerial structure, and I disagree strongly with the Opposition's argument that this should be a democratically managed structure. The day-to-day management of such a highly technical multi-professional organisation as the National Health Service is not best done by a mini-parliament. It must have accountability to the public and to those closely allied to the health service, and that is not best done by the body which has the day-to-day management of the service. My right hon. Friend the Secretary of State for Social Services has grasped the right nettle by setting up two bodies to run side by side—the area health authority and the community health council.

I want to see the community health councils become strong bodies. I hope that it will be possible for their chairmen to have access to the important meetings of their area health authorities. Obviously they cannot attend as executive members, but they should be able to attend as observers. They need to be fully aware of what is going on and to be able to do their monitoring and make their comments through their own channel of communication to the Minister about what is going on in the area health authorities.

I come then to the Health Service Commissioner, and in this connection I wish to comment on the speech last night by the hon. Member for Halifax (Dr. Summerskill). I must apologise for not being able to hear most of yesterday's debate. I was engaged in the Standing Committee considering the Social Security Bill. However, the hon. Lady said that she wondered whether the ombudsman or the Health Service Commissioner could look into complaints against general practitioners. I was surprised to hear her say that. The one good result to flow from the executive council system was the disciplinary or service committees which were able to hear complaints in a manner which did not frighten off complainants as a result of formality or expense.

The idea of not having hearings before a group of people consisting of laymen as well as professionals, in which the professional can always lighten the perplexities of the complainant as well as those of the layman, is a mistake. A Health Service Commissioner hearing a written complaint and being completely remote will not necessarily get as good an answer as did the disciplinary committees with the executive councils in the past. I have been on many of those disciplinary committees and generally I found that they came to pretty fair judgments in the cases laid before them.

My right hon. Friend has sought in this very difficult field to make the improvement in the health service which we all desire to see. He has learned many of the lessons over the past 25 years. Of course, we cannot build a perfect service in 25, or even 50, years. It will take a very long time to evolve. It will take more than a single Bill to get the right answer and a permanent structure. But this is a milestone in the development of the service which is the envy of the world. Although it has a long way to go before it becomes the service we want, this Bill is a milestone on the way. It makes important changes and it has to be made to work.

Half the battle is the way in which the area health authorities and the consultative councils work the system. Given the will to make it work and to liaise with each other to eradicate the Achilles heel of the service—lack of communication between the two major sides—this is a very good step forward in making a successful service for all.

8.53 p.m.

Mr. Goronwy Roberts (Caernarvon)

I rise to make one specific point which I have been asked to make. I should have liked to follow the right hon. Member for Wolverhampton, South-West (Mr. Powell) in what we must all have regarded as a speech of exceptional cogency, a speech which will repay study, not least by the right hon. Gentleman himself. I hope that having done so he might revise his views on the future of local government finance, but that is for a future occasion.

The specific point I want to put was referred to by the hon. Member for Wells (Mr. Boscawen) and many who have taken part in the debate. It is the immense importance of the community health councils. As I see it, we may have the most elaborate and indeed effective administrative structure at the regional and area level, but unless there is an effective grass roots voice—that is, community health councils which are not only consulted but listened to—the whole structure may well end in frustration and a health service which is constantly having to be changed and tinkered with to meet the deficiences which arise.

My right hon. Friend the Member for Coventry, East (Mr. Crossman) put his finger on the point when he said that there must be a sense of responsibility from the bottom up. Those of us who have experience of the health service meet a sense of frustration among the very people whom the health service is deemed to serve. Ministers and hon. Members have said that the health service is for the potential patients. It is they at district level, the people themselves, through community health councils, who can induce into the area, and it may be the regional structure, the knowledge of what those needs are and practical suggestions of how those needs can be met by the authorities which are designed to meet them.

I hope that when the Bill is in Committee, Ministers and members of the Committee will give careful thought to making the community health councils provided by the Bill truly effective bodies. To be that, they must be elected. The hon. Member for Wells decried the democratic process as a whole for this purpose, but, surely, even if the area and regional authorities are not so elected, there is no reason why the community health councils cannot be elected, properly serviced and deemed from the start not only to be consultative bodies but bodies which have the power of effective recommendation.

The Minister of State will recall that I raised with him a question of the outpatients in Portmadoc which bears this out. The outpatients' clinic was closed by the hospital management committee without consultation with the local people. The Minister of State has endeavoured to put the matter right and has written to me confidentially. I hope that he will soon be able to say publicly what has been done to restore the clinic. Had there existed a statutory elected body representing the people served by the clinic, and had that body been consulted, I am sure that neither the hospital management committee nor the Welsh Regional Hospital Board would not have made this terrible mistake which has affected 600 people.

When the outpatients' clinic was closed, those people had to go 30 miles to Bangor and to spend a whole day travelling and waiting in an overcrowded clinic. I hope that this example that has been brought to the Minister's attention will serve him well in Committee. As he has said in an intervention, he proposes to create community health councils in Wales which will have power and which will be properly served, so that the higher tier authorities will listen to them and carry out their wishes.

8.58 p.m.

Mr. Denzil Davies (Llanelly)

In view of the short time available to me, I hope to be forgiven for raising one constituency matter without developing the other arguments which I intended to develop on the Bill in general.

According to the Explanatory Memorandum, one of the main purposes of the Bill is to unify the local administration of the National Health Service under new health authorities covering the whole field of health care". I understand that to mean that the new health authorities—and in Wales that must mean the area health authorities in principle—should be able to provide the whole range of health services within their area. In many areas this may not seem to present great problems, but in my constituency there is a considerable difficulty which relates to the hospital services. The Bill makes no reference to this, but according to the White Paper the whole of my constituency will be part of the Dyfed Area Health Authority, whereas the area adjoining my constituency will be part of the West Glamorgan Area Health Authority.

Llanelli Hospital for various reasons is able to provide hospital services for only 55 per cent. of the people who live in its natural catchment area—an area which comprises between 80,000 and 100,000 people. The 45 per cent. have to rely upon the hospital services provided by hospitals in the Swansea area, and those hospitals in future will become part of the West Glamorgan Area Health Authority. This means that the Dyfed Area Health Authority, will not be able to provide full hospital facilities in Llanelli within the Dyfed area. As matters now stand, 45 per cent. would still have to use those hospitals in the adjoining health authority.

According to the Bill, it seems that the Secretary of State has power by order, and it is a negative order which is unlikely ever to be debated in the House even if it is prayed against, to delineate the boundaries of the new area health authorities. My fear, and that of my constituents, is that whereas the Secretary of State will provide by order that all other services in the Llanelli area will be part of the Dyfed health authority, the Secretary of State will enshrine in that order a provision whereby the hospital services in my constituency will be provided by, and fall within, the West Glamorgan health authority.

I implore the Secretary of State for Wales not to so provide by order, but rather to order that the whole of the hospital services for the Dyfed area, including Llanelli, should be provided by the Dyfed area health authority.

Meantime, I recognise that there have to be arrangements to provide for the present unsatisfactory situation in which 55 per cent. go to Llanelli and 45 per cent. to Swansea. I implore the Secretary of State not to enshrine that unsatisfactory arrangement within the order and, therefore, within the legislation.

It is very important he should ensure eventual provision within the Dyfed area of the whole of the hospital services necessary for my constituency otherwise the hospital services in Llanelli will run down. They will neither be part of Dyfed nor will they belong to the West Glamorgan authority. If he is to maintain and carry out one of the main purposes of the Bill he must ensure the provision of the necessary facilities so that the Dyfed health authority can eventually provide all the hospital services now in Llanelli.

The Bill appears to me in general to portray a certain lack of sensitivity on the part of the Government towards the National Health Service. This insen-sitivity should not surprise us, I suggest, because the Bill is brought forward by the heirs and successors of those who a quarter of a century ago without any shame utterly opposed the concept of a free National Health Service.

9.3 p.m.

Mr. Leslie Huckfield (Nuneaton)

I am most grateful to the hon. Member for Llanelly (Mr. Denzil Davies) and my hon. Friend on the Front Bench for permitting me seven minutes in which to say my piece.

I was a member of the Birmingham Regional Hospital Board for two-and-a-half years. I resigned because I thought the composition and actions of the board were totally unrepresentative of the horizons and aspirations of the ordinary working people. Nothing I have seen in the Bill or in the debate either today or yesterday convinces me that conditions will change or improve under the proposal to create area health authorities and, worst of all, regional health authorities.

The board of which I was a member comprised approximately a dozen consultants or other medical people and a dozen business or professional people. The remaining three or four were somehow supposed to represent the interests of working people. Since the Secretary of State took office he has appointed to the regional hospital boards—as I was told in a parliamentary reply on 22nd November 1972—no fewer than 57 doctors, dentists and nurses, 44 company directors and managers, and a mere 15 trade unionists. The Secretary of State has appointed 149 men and only 48 women. He has made only three appointments of people under the age of 30.

If the Secretary of State makes appointments like those under the present criteria, what kind of appointments will he make to area health authorities and regional health authorities, when the main criterion for appointment will be managerial ability?

I fear for those who have to go to work and clock in at half-past seven every morning. I fear for those who live on council estates, and for those confronted by an 18-month waiting list for a hernia operation. I fear for those people whose kids have to wait nine months for a tonsillectomy. These are the people whom the regional and area health authorities ought to be considering. Unfortunately, because of the composition of these bodies they are the people whose interests will not be considered.

It is worse than that. The people who ought to be making complaints about the health service—the more articulate middle classes—are buying their way out. It is because we have this incessant growth of private practice—one might almost call it an incestuous growth— that the people upon whom the Secretary of State is relying to make complaints to the Health Service Commissioner will simply go private and buy their way out. If the right hon. Gentleman really imagines that the sort of people who have most to grouse about under the present, and certainly the future, administration of hospitals will write about these complaints to the Commissioner, I am afraid that his contact with working people is sadly lacking.

We have a system whereby we are gradually moving towards private practice. We have American medical interests coming to this country. If the semi-success of the proposal to take over part of the Harley Street Clinic continues it could set the pattern for the hiving-off of near-private wings of hospitals all over the country. We have already seen the disappearance of the National Health Service in dentistry in many parts of the country. If this sort of thing continues we shall see the disappearance of the National Health Service within the hospital service, too.

The hon. Member for Reading (Dr. Vaughan) carefully overlooked all the evidence placed before the Select Committee on Expenditure, which examined private practice in the hospital service. This clearly brought home the point that no standard form of accounting for private practice was laid down by the Department, by regional hospital boards, or even by hospital groups. There is also no standard system for monitoring it.

How can the right hon. Gentleman claim that he will keep private practice in check? How will he prevent all the abuses whereby consultants charge fees for carrying out services many of which are provided by the National Health Service? The trouble is that even with all of what the right hon. Gentleman has proposed there will not be an end to the domination of the Health Service by the medical profession. Regional hospital boards and group management committees are dominated by consultants and senior men. The new regional and area health authorities will be dominated in the same way.

The only solution is to restore a measure of democratic control to the service. My preference would be to have area health authorities elected, directly responsible to the people who elect local government. Why not take the thing the whole hog and put the hospital services under local government? I recognise that there are problems of raising finance but this must be the most logical way to carry forward the reform of local government.

Many people have said that our surest defence against bureaucracy and the medical profession, particularly the senior echelons of it, will be the community health councils. We will all have the same power as members of such councils, we can all walk around hospitals. The only power which these people will have additional to that is the power to produce an annual report. If the right hon. Gentleman honestly thinks that such a power represents a bulwark against bureaucracy—if he thinks that power will keep the consultants in check—I cannot accept it.

I hope that my right hon. and hon. Friends will reject the Bill. I hope that we will abolish private practice, and eventually bring into being a fully demo-cractically-controlled Health Service.

9.10 p.m.

Mr. Elystan Morgan (Cardigan)

For two days the House has been debating the future of a service which is central to the concept of a welfare State, and the operation of which affects in the highest degree the lives of so many millions of people. Although this day was publicised as a Welsh debate—[HON. MEMBERS: "No."]—the accents of the Principality have not been as plentiful in their contribution as might have been the case.

I should be lacking in courtesy if I did not offer my thanks to whoever it is who is responsible for allowing a Front Bench opening and winding up on behalf of Welsh interests. By the same token, I should be utterly failing in my duty towards Wales if I did not express deep dissatisfaction with the Government's policy, as has been mentioned by my right hon. Friend the Member for Cardiff, West (Mr. George Thomas), not to have a separate Bill for the principality.

The Secretary of State for Wales has sought to justify his position by maintaining that the fundamental provision for the proposed reorganisation is common to both countries. That is a specious argument. He has failed to draw the distinction between common standards and general standards, on the one hand, and a difference of pattern and scale, on the other. Of course, Wales accepts that it must be its aim to achieve the same standards of health administration as prevail in England. In the Green Paper published by my right hon. Friend the Member for Cardiff, West in February 1970, that is accepted. The foreword says, The public will expect similar standards and similar procedures for obtaining services, whether in Wales or in England. If the situations are the same in both countries, then it may be asked why it is that over the years there has been a pattern developing of the publication of separate reports, separate sets of statistics and separate management studies for the two countries. The view of the Labour Party is borne out by what is set out in page 5 of the Green Paper of 1970, which says However, there are important differences between the two countries. A policy of administrative devolution to Wales is in progress, and it is in keeping with this policy that decisions affecting Wales and the Welsh people should be taken within Wales. Since 1st April 1969 the Secretary of State for Wales has been responsible for the administration of the Health Service in Wales (and jointly with his colleagues in England and Scotland for health policy as a whole). Wales is a small country and the Secretary of State and his Department are in close touch with local needs and aspirations. Again, the future organisation of local government in Wales will differ in a number of important respects from the system in England. Finally, the form of organisation at the all-Wales level needs careful consideration. Our case is that, if the very establishment of the Welsh Office and the publication of the various papers, studies and reports to which I have referred is not to be regarded as a completely useless and unjustifiable duplication of information and of systems, there is every reason why Wales should have a separate Bill on this most important reorganisation. When the National Health Service (Scotland) Bill of 1972 came before the House, it contained all the separate provisions for Scotland, although the main theme of that legislation compared in all essential respects with this Bill.

My right hon. Friend has already said that every hon. Member, certainly every Welsh Member, knows why the Government would not dare to put the provisions relating to Wales into a separate Bill. Although it would be possible, by the conscription of certain hon. Members, to " top up " the small number of Welsh Conservative Members who are members of the Welsh Standing Committee, it would be impossible for them to achieve a majority, due to the limits set by the Standing Orders of the House. Therefore, the Secretary of State would soon find himself in a slough of despond from which it would be impossible for him to extricate himself or his Bill.

That is the pattern with every piece of major legislation affecting Wales. The same has been true of local government reform and the reorganisation of water resources, and the same inevitably will prevail with every other controversial measure while we have this Government, whose policies and whose party have been so completely rejected by the people of Wales over the decades.

The Secretary of State for Social Services was fortunate yesterday in that the debate turned mainly on the issue of contraception. I do not know whether this was prudently and responsibly planned by him, but he certainly succeeded in preventing a conception by the public of the main rationale of the Bill.

The unification of the tripartite structure of the National Health Service has been accepted by the majority of people in the United Kingdom, certainly since the Porritt Report of 1962. But unification should never be regarded as an end in itself, but only as a means to creating a desirable situation. The goal is that persons who entrust their health and their survival to this service should be able to do so in the full confidence that they are at the mercy of a system which is efficient, humane, compassionate and just.

In order to achieve that, one would expect the Government to make a detailed examination of each and every component part of the service so as to see how each part could operate more efficiently, by itself and in conjunction with all the other parts. But that is exactly what the Government have chosen not to do. The Government parted with their responsibility and with £300,000 of their money to McKinsey, who are, after all, the modern counterparts of the Delphic Oracle or the Druids of the Isle of Anglesey.

Mr. Cledwyn Hughes

The Druids were much more accurate.

Mr. Morgan

There is no historical record of their having been proved wrong.

This firm of business consultants were no doubt admirably placed to dissertate on the efficiency or otherwise of certain commercial systems. However, in relation to the health service they have the wrong approach and inevitably they came to the wrong conclusion. They devised an expensive canopy of unification at the high level of management, but beneath that canopy all the old anomalies and deficiencies of the system were allowed to remain.

General practitioners, who are the most important unit in the health service, remain in astral isolation from the hospital service. There is the same deep historic chasm existing between general practitioners and consultants. There is still no resolution by the Government to put forward a dynamic programme for the provision of health centres in every locality in which they are needed. The same is true of group practices, the establishment of which is left entirely to the caprice and whims of individual doctors, as is provision of health centres to the widely differing attitudes of various local authorities.

In Wales—and I believe the acute needs of Wales are probably very much greater than other parts of the United Kingdom —we have at present 43 health centres and expect to have only 58 by the end of 1974. Many hon. Members on this side of the House, and I am sure many Conservative Members, regard health centres as probably the most important and intimate point of contact between the majority of patients or potential patients and the National Health Service. They regard them as units which provide a comprehensive range of services, including the services of medical social workers.

As my hon. Friend the Member for Halifax (Dr. Summerskill) said yesterday, the Bill is distinguished less by what it contains than by what is omitted from it. In a fine speech she listed a whole range of acute questions from occupational health schemes to the scandal of subordinating the rights and the massive needs of the ordinary patient to the privileges of the fee-paying few.

There is one matter of general interest which I wish to add to the list which my hon. Friend mentioned. I refer to the lack of cohesion which seems to exist in relation to older citizens. Where a person advanced in years needs special housing his case is the prerogative of the district authority. If he has to go into an old people's home it becomes the duty of the county authority, and if he has to enter hospital he comes within the sphere of the National Health Service. This situation double-banks itself and they are different faces of one central problem.

I would have expected a Bill such as this, with Government Ministers looking many decades ahead, to contain some dynamic and bold provision regarding the sort of situation which I have outlined. There is no greater welcome in Wales than there is in England for the area health authorities as now conceived. In Wales we see them as yet another addition to that vast plethora of non-elected bodies which embarrass and infest the life of the Principality.

The area health authorities clearly will be more responsible than any other body for the day-to-day running of the service in their areas. It will be to them that ordinary people will look for guidance and for redress. But the question which Ministers have completely failed to answer is whether it is right to place such powers, such authority, such responsibilities, in the hands of a non-elected body.

In the 1972 White Paper the Secretary of State for Wales made it very clear what he thought of the status of elected representatives in such a connection. He said: The health service is a complex enterprise. Each Area Health Authority will employ a large staff and administer an annual budget running into millions of pounds. Good management is essential to make the best use of these resources for the benefit of patients and the community; and this must be the dominant consideration in determining the composition of Area Health Authorities. What a slur on members of a local authority. As far as the Secretary of State for Wales is concerned, they are not the beautiful people who would receive the bounty of his appointment; they are people who would be profligate with the public purse and therefore are not to be entrusted with substantial finances.

The right hon. Member for Wolver-hampton, South-West (Mr. Powell) has advanced the argument to the House, in a speech which I thought was casualisti-cally mischievous, for all its brilliance, and contained little of creative proposals, that a distinction had to be drawn between a person who was an elected representative simpliciter and one who, elected, had the power to make decisions regarding the raising and the expenditure of money. I do not think that any such distinction can properly be drawn. After all, if this House were to set up a legislative assembly in, say, Northern Ireland without giving that assembly power to raise money by taxation, or, indeed, to have a voice over the expenditure of that money, those people would remain democratically elected representatives.

When an hon. Member rises in this House on an Adjournment debate to plead a case which, by definition, cannot involve asking for the expenditure of money, is he any the less a representative of his constituency or whatever interest he pleads at that moment? The expenditure of money often forms part of the full range of the duties and privileges of the elected representative. But it is not the essence of it. The essence of democratic representation is a mandate. It is not the able, wealthy, witty and powerful Members of this House who, over the years, have given this Mother of Parliaments the distinction that it enjoys throughout the world; it is the fact that we sit here in a free Parliament having been elected by a free and universal franchise. The fact that the people who sent us here have the right to withdraw that mandate in the fullness of time is the essence. It is the very absence of such a mandate relating to these authorities that makes them entirely unworthy of the reorganised structure that is now proposed.

Mr. Powell

Would that be true if the government of this country were carried on with finance provided by another body?

Mr. Morgan

I maintain that in such circumstances the powers of the elected representative clearly would be truncated, but he is no less an elected representative for that. I am quite sure that the right hon. Gentleman would not argue that if a person is charged with duties which involve the raising and the expenditure of moneys, that person is any the more a democratic representative on account of having been appointed rather than elected.

Mr. George Thomas

An extension of his duty.

Mr. Morgan

It is only by placing these authorities in the hands of democratically elected representatives that any meaning can be given to the system. It is such factors which breathe the spirit of life into the cold clay and dry bones of what would otherwise be a bureaucratic structure.

The community health councils are advisory bodies. The range of their functions is extremely limited. They can inspect only in the most formal and well-publicised circumstances. They are staffed and stabled by the area health authorities and clearly they can have no independence from those bodies which they are intended to watch.

I turn briefly to the blatant discrimination against Wales in the decision not to create a Welsh regional authority. No adequate reason has been given, in the debate or anywhere else, in justification of this decision. When the Secretary of State for Social Services was asked about this matter at a recent conference in London of the National Association for Mental Health, according to the second leader in The Guardian on 23rd March: Sir Keith Joseph was asked whether he was aware of the strong feeling in Wales that the NHS was going to be set back 20 years, under reorganisation, because the Welsh Office was taking over full responsibility for health. His considered reply "—

Sir. K. Joseph

I made a joke.

Mr. Morgan

The right hon. Gentleman's considered reply was: Isn't England lucky? No justification has been given by the Secretary of State for Wales, either, in his White Paper. He maintains that there would be the danger that such a regional body would be too remote. In the same article, The Guardian asks this rhetorical question: Can anything be more remote than unknown civil servants in their impregnable fortress at the Welsh Office? The answer is "Yes". The most remote figure of all is the ex-patriate Secretary of State for Wales, the right hon. and learned Member for Hendon, South (Mr. Peter Thomas).

We believe that the Welsh Hospital Board, for all the fact that it was appointed, was a body of intelligence and great enthusiasm. Over the years its intelligence and enthusiasm have embarrassed the Secretary of State and his senior officials.

I should have liked to refer to a number of matters. I mentioned them briefly. One concerns Powys. In making the boundaries of the new area health authorities co-terminous with those of local government, certain anomalies have been created by following those boundaries slavishly. As we have heard from the hon. and learned Member for Montgomery (Mr. Hooson), in Powys there is no prospect in the foreseeable future of a district hospital. Seventy per cent. of patients of that county go outside that area health authority for hospitalisation. When the Minister of State comes to delivering the epilogue, I hope that he pays particular attention to that question. I hope that he will consider setting up, for those areas outside the Powys area health authority, a district authority and, indeed, a community health council in the area of each district hospital which serves it. I have in mind particularly the catchment area served by Bronglais Hospital.

I should have liked to refer to the position of the small hospitals and to have some guarantee that their position is assured. I hope that the Minister of State will apply his mind to that matter. Time, the ancient enemy, has got the better of me and many matters will have to be left unsaid until another occasion.

The plan which the Government now place before us is defective because it is obsessed with superficial unification of the health service at management level rather than with more humane and efficient operation in the context of the patient. It is deficient in that it fails to meet so many of the deep and real needs of the people in Wales and elsewhere. We believe that it will fail because it has shunned the ideal of democratic involvement. In Wales, the confusion which the new reorganisation creates will be worse confounded on account of its having completely ignored the imminence of the Crowther Commission's Report.

Above all, we suspect this proposed reorganisation because there is a danger throughout the McKinsey Report of equating the position of the patient with the position of a customer. The patient is a person who more often than not has no choice. Owing to injury or disease he has surrendered the dominion over his own affairs to those who have his medical card. In such circumstances it is a travesty of language to refer to him as a customer.

For all these reasons, it will be our privilege on this side of the House tonight to vote against this measure.

9.37 p.m.

Minister of State, Welsh Office (Mr. David Gibson-Walt)

It is right that we should have spent two days debating the Second Reading of the first reorganisation of the National Health Service. It is right that time should have been given today to debating the Welsh reorganisation proposals, even though the differences between England and Wales are very small. When the National Health Service came into being 25 years ago, as has already been said during the debate it was no coincidence that the then Minister of Health represented a Welsh constituency, for the tradition of hospitals in the valleys of South Wales was a very strong one. It is right for us to remember in our debate today the tradition of the miners' hospitals in particular, and, indeed, the war memorial hospitals, in Wales.

This, however, has been an English-Welsh debate, as indeed it should have been, and during the two days we have heard a wide variety of views which show the wide variety of experience that right hon. and hon. Members have had in connection with the Health Service. Tonight I shall try to answer as many as possible of the questions that have been put to me from both sides of the House. Those that I cannot answer, particularly the Welsh ones, perhaps I can answer by letter later on.

The right hon. Member for Cardiff, West (Mr. George Thomas) asked me a question about staffing and membership of joint consultative committees, and to whom they are responsible. The joint consultative committees are the important links between the area health authorities and the local authorities. These are the committees whose function will be to help area health authorities and local authorities to collaborate and coordinate the planning and operation of their respective services. The proposal to set them up springs from the recommendation of the joint working party. I hope there will be local agreement on membership and servicing of the committees. Members of the committees will be responsible, of course, to their own parent authorities. I imagine that there will usually be a broadly balanced membership, and that area health authorities and local authorities will share in providing staff. There is provision for the Secretary of State to provide by order for the sharing of expenses and a means of resolving disputes. But collaboration can be a reality only if there is a real spirit of co-operation.

The hon. and learned Member for Montgomery (Mr. Hooson) referred to one of the obstacles to the transfer of the National Health Service to the local authorities, namely, the opposition of the doctors. That has been referred to by other members during the debate. In a lucid and powerful speech, the right hon. Member for Wolverhampton, South-West (Mr. Powell) put his finger on another of the major obstacles, namely, the problem of finance.

Whatever the hon. Member for Cardigan (Mr. Elystan Morgan) may have sought to do, he certainly has not convinced me that my right hon. Friend was wrong. Above all else the House, over many hundreds of years, has been responsible not only for levying money but also for seeing how it is spent, and I doubt very much whether many hon. Members would not like to be able to question the Minister at the Dispatch Box on matters of hospitalisation and health.

This is the strong point that some hon. Members may have forgotten. These obstacles were recognised by the Opposition when they were in power, and nothing has happened since to remove or ease the problems. I do not believe that my right hon. Friend the Member for Wolverhampton, South-West was quite so happy when he argued that the disadvantages of integrating the three arms of the health service would outweigh the advantages. Successive administrations of the last 10 years—and he, more than many people, knows the problems from experience—have examined the merits of integration in their discussion documents and, with the general weight of opinion behind them, are convinced that this reform is desirable.

I acknowledge that it will withdraw from local authority control a service of which they can be justly proud, but we see no reason why this service should not flourish in the wider context of the reorganised health service. Nor do we see it as diminishing the responsibilities of the medical officer of health or the opportunities for local initiatives. Many medical officers of health will become the community physicians of tomorrow. They have welcomed the Bill, and do not see in it a diminution of their contribution to the health of the community. On the contrary, they see their influence extending to include health services as a whole, including hospital services. The strength of the community physician is that he will be looking at the health service as a whole. His training will equip him to do just that.

The reorganisation proposals will enable the community physician to work in closer association with his clinical colleagues in the hospitals and in general practice, and it is expected that he will play a significant part in the professional advisory machinery. His background of public health should ensure the right balance between curative and preventive medicine. In addition, he has an important rôle to play in the provision of local authority services, particularly the school health service, in environmental health and as an adviser to the social services department.

Some hon. Members from English constituencies in particular, notably the right hon. Member for Coventry, East (Mr. Crossman), have criticised the English regional health authorities and expressed concern lest they sap away the responsibilities of the area health authorities. Here again I pay deference to the right hon. Gentleman as an ex-Minister of Health with considerable knowledge on the subject. But I should say that in a country the size of England, unlike Wales and Scotland, the administration of the National Health Service cannot be conducted effectively from one centre in London. Some form of regional organisation is necessary. This could take the form either of regional offices of the central department or of statutory regional authorities. We think the advantages of this latter arrangement are overwhelming. The alternative is to have over-centralisation and delay. The area health authorities will be showing a wide variety of initiative and it would be wrong to underestimate the rôole they will play.

My hon. Friend the Member for Devonport (Dame Joan Vickers) and my hon. Friend the Member for Tynemouth (Dame Irene Ward) touched on the very important question of the nursing proffession. In the normal way an officer who is accountable to a chief officer of an area health authority is not also invited to serve as a member of the authority itself. This rule, which has always been in operation, might make it difficult to bring a suitable nurse on to each area health authority. Incidentally, there is not the same difficulty with the medical professional. In these special circumstances my right hon. Friends accept that as an experiment nurses and midwives serving an area health authority should not thereby be debarred from membership of the authority itself. I hope that that will be a help to those hon. Members who have felt unhappy about this matter.

My hon. Friend the Member for Tynemouth asked about the constitution of the Central Health Services Council. There is already power, by order, to vary the constitution of the council. My right hon. Friend intends to use this power to reconstitute the council and in considering the revised constitution he will take full account of my hon: Friend's comments.

Dame Irene Ward

I thank my hon. Friend.

Mr. Gibson-Watt

The question of salaries, also raised by my hon. Friend, is also a matter of negotiation. The right hon. Member for Anglesey (Mr. Cledwyn Hughes), whose constituency was gravely insulted by his hon. Friend in his concluding speech, asked a number of questions. The first was: if an elected Welsh Council is set up, would the Government agree that health should be one of its responsibilities? All I can say on this is that we must wait to see what recommendations the Commission is to make. [Interruption.] If hon. Gentlemen are so certain what the recommendations are going to be, perhaps they will tell me whether the right hon. Member for Sowerby (Mr. Houghton) knows what the recommendations are to be. I shall be grateful if I may be allowed to finish. Until the commission reports no Government, even the Opposition in government, would be able to make future decisions in the way they are able to whilst in office.

Mr. Elystan Morgan

The Minister of State will recollect that when the Local Government Bill was introduced both he and his right hon. and learned Friend explained to the House that they had consulted the Crowther Commission on the Constitution in order to see whether there was anything in those recommendations which might be contrary to their own plan. Can they now tell the House whether they have had exactly the same consultations with regard to this measure? If not, why draw the distinction?

Mr. Gibson-Watt

With respect, I do not thing that there is any distinction to be drawn. I can tell the hon. Gentleman that we have not had further discussions with the Crowther Commission, and are waiting for it to produce its report. It is not the job of Government to preempt the decision of the commission, and I am surprised that others should have done so. We must wait to see what the commission's recommendations are. If it were to recommend an elected council for Wales it would presumably suggest what responsibilities such a body might carry, and for what services, what its financial powers should be, and how it would fit into the existing constitution. There would certainly be difficult and complex problems to resolve, on which the commission would no doubt offer guidance.

We shall be prepared to review central organisation in the Health Service in Wales in the light of the commission's report. I do not see how anyone could responsibly say more now. The right hon. Gentleman also asked a question with regard to the nurses' representative. We have made clear that on both the district and area management teams a nursing officer will be a full member of the management team, and he or she will participate fully in the team decisions. As far as members of health authorities are concerned, again, we have said that each area health authority will have one nurse or midwife member.

My hon. Friend has said the Welsh Office will increase its staff resources to fulfil its new role, and will include a pharmaceutical adviser. At area level, area pharmaceutical officers will be appointed, though in some areas they will not need to spend all their time on area duties. The hon. Member for Pembroke (Mr. Nicholas Edwards) asked a question with regard to the staff of the community health councils. It has seemed to the Government that it would be in the best interests of those councils to have staff who are knowledgeable about health services. However, we appreciate the strength of feeling on this matter. The Bill leaves flexibility on how the matter should be dealt with through regulations, and we shall certainly consider very seriously what hon. Gentlemen have said.

Throughout the debate hon. Members on both sides of the House have stressed that the person who must be at the centre of our thoughts is the patient. This has been so during the long discussions that have been held with the various interested parties before we finally produced the Bill, and it has been so during the speeches of right hon. and hon. Members in the last two days.

The major difference between our proposals for Wales and those for England is that we shall not have a regional health authority in Wales. Public reaction to that has been mixed. Among those most closely associated with the National Health Service, particularly those working in that field, the preponderant feeling is in favour of direct relationship between the Secretary of State and area health authorities as being the best way to ensure real responsibility at area health authority level and so make for good management as close as possible to the people. Commentators feel that an intermediate tier in Wales would inevitably set up tensions and be at the expense of the area health authorities. The bodies who have commented in this way include the Association of Hospital Management Committees in Wales, the Association of Executive Councils in Wales, the National Association of Hospital Group Secretaries, the Society of Medical Officers of Health, the BMA Welsh Council, the Welsh Counties Committee and the University of Wales. That is a fairly formidable list. Amongst those who wanted a regional board to continue, not surprisingly, was the present Welsh Hospital Board.

We feel strongly that if management is to be delegated to the area health authorities in the localities in a country as small as Wales, it would be wrong to interpose a further tier between them and the Welsh Office.

Another aspect of the decision not to have regional health authorities in Wales is the decision of the Labour Party to hand over the administration of the National Health Service in Wales to an elected council, to which I have already referred.

Mr. Grossman

Has the Minister received any representations from England that we would like the Welsh system introduced into England?

Mr. Gibson-Watt

I thought that we had been to considerable lengths to show that on this matter Wales had rather different problems from England.

Mr. Crossman

I am asking whether the Minister had representations from those in England who are envious of his admirable decision to liquidate the regional level.

Mr. Gibson-Watt

My right hon. Friend who receives these representations says that there have been some, but not all that many.

I have been trying to connect the speeches of the Opposition with the terms of their amendment. It is a difficult exercise. To my mind there is very little connection. I find the amendment as difficult to understand as some right hon. and hon. Gentlemen opposite. Perhaps the authors intended that this should be so. My hon. Friend the Member for Wolverhampton, South-West dismissed it in one word when he called it a "spoof". How right he was. The amendment says that the Bill proposes 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. During the course of the debate the Opposition did not appear wholly convinced that the service should be run by the local authorities. In his Green Paper of 1970, which has been quoted ad nauseam, the right hon. Member for Coventry, East (Mr. Crossman) said that the Government had decided, for the reasons that they had given, that the health service should be administered not by local government but by area authorities directly responsible to the central Government. The right hon. Gentleman agreed with us then. I think that in his heart he agrees with much of the Bill today.

In their speeches, right hon. and hon. Members on the Opposition benches have not sought to speak to their amendment, and it is my belief that they are not all that much opposed to the Bill—

Mr. John Silkin

The hon. Gentleman has been a little unkind about the Opposition amendment. As the only begetter of it, may I ask him what makes him think that members of boards appointed by the Secretary of State for Social Services or the Secretary of State for Wales will be better able to give a health service to the country than would elected members of the community?

Mr. Gibson-Watt

The right hon. Gentleman has underlined the difficulty, and he has not yet said where he stands. He keeps on talking about "elected representatives". He has not said whether he believes that those elected representatives should be local government representatives—

Mr. Silkin

Yes. I have said so.

Mr. Gibson-Watt

The right hon. Gentleman did not say that a moment ago. I enjoyed his speech yesterday, and I look forward to reading it again.

I believe that there is a very strong case for saying that the new National Health Service will be better run under the system that we propose. The right hon. Member for Deptford (Mr. John Silkin) and his hon. Friends complain about people being appointed to boards. However, he and his right hon. and hon. Friends have also made appointments to regional hospital boards in the past. The right hon. Gentleman is not on a very good wicket here.

One other point which needs answering is the argument of some hon. Members that fewer people will be working voluntarily on reorganisation in the service. Let me give the assurance that that is not so. All the figures and prognostications which I have make it clear that there will be more rather than fewer.

No administration setting out to reorganise the Health Service so as to bring its various arms together into a unit can be in any doubt about the magnitude and complexity of the operation. It calls for a large measure of understanding and a great deal of hard work from all those involved in the changes. Ministers are well aware of the need to ensure that the many people working in local government and in the health service whose careers must inevitably be affected by the Bill in greater or lesser measure are properly safeguarded. We have been at pains to ensure that the service and all those most closely concerned with it should be able to play a major part in shaping the new arrangements.

The Bill has been considered in detail in another place. The noble Lord, Lord Aberdare recognised readily that many points had to be considered. The noble Lady, Lady White made a notable contribution. There is a great deal of good will towards the Bill outside the House and much more in it than right hon. and hon. Members opposite are prepared to admit.

I commend the Bill to the House.

Question put, That the Amendment be made: —

The House divided: Ayes 259, Noes 285.

Division No. 90.] AYES [10.0 p.m.
Abse, Leo Delargy, Hugh Jeger, Mrs. Lena
Allaun, Frank (Salford, E.) Dell, Rt. Hn. Edmund Jenkins, Hugh (Putney)
Archer, Peter (Rowley Regis) Doig, Peter John, Brynmor
Armstrong, Ernest Dormand, J. D. Johnson, Carol (Lewisham, S.)
Ashley, Jack Douglas, Dick (Stirlingshire, E.) Johnson, James (K'ston-on-Hull, W.)
Ashton Joe Douglas-Mann, Bruce Johnson, Walter (Derby, S.)
Atkinson, Norman Driberg, Tom Jones, Barry (Flint, E.)
Bagler, Gordon A. T. Duffy, A. E. P. Jones, Dan (Burnley)
Barnes Michael Dunn, James A. Jones,Rt.Hn.Sir Elwyn (W.Ham,S.)
Barnett', Guy (Greenwich) Eadie, Alex Jones, Gwynoro (Carmarthen)
Barnett, Joel (Heywood and Royton) Edelman, Maurice Jones, T. Alec (Rhondda, W.)
Baxter, William Edwards, Robert (Bilston) Judd, Frank
Benn, Rt. Hn. Anthony Wedgwood Edwards, William (Merioneth) Kaufman, Gerald
Bennett, James(Glasgow. Bridgeton) Ellis, Tom Kelley Richard
Bidwell Sydney English, Michael Kerr,Russell
Bishop E, S. Evans, Fred Kinnock, Neil
Bienkinsop Arthur Ewing, Harry Lamble, David
Boardman, H. (Leigh) Faulds, Andrew Lamborn, Harry
Booth Albert Fisher,Mrs.Doris(B'ham,Ladywood) Lamond, James
Bottomlev Rt. Hn. Arthur Fitch, Alan (Wigan) Latham, Arthur
Boyden, James(Bishop Auckland) Fletcher, Raymond (Iikeston) Lawson George
Bradley, Tom Fletcher, Ted (Darlington) Leadbitter, Ted
Broughton, sir Alfred Foot, Michael Lee, Rt, Hn. Frederick
Brown, Robert C. (N 'c'tie-u-Tyne,W.) Ford, Ben Leonard Dick
Brown Hugh D. (G'gow, Provan) Forrester John Lestor, Miss Joan
Brown, RonaldfShoreditch & F'bury) Fraser, John (Norwood) Lewis, Ron (Carlisle)
Buchan, Norman Freeson, Reginald Lipton, Marcus
Buchanan, Richard (G'gow, Sp'burn) Galpern, Sir Myer Lomas, Kenneth
Butler, Mrs. Joyce (Wood Green) Garrett, W.E. Loughlin, Charles
Callaghan, Rt. Hn. James Gilbert, Dr. John Lyon, Alexander W. (York)
Campbell, I. (Dunbartonshire. W.) Ginsburg, David (Dewsbury) Mabon, Dr. J. Dickson
Carmlchael Neil Grant, George (Morpeth) McCartney, Hugh
Carter, Ray'(Birmingh'm, Northfield) Grant, John D.(lslington, E.) McElhone, Frank
Carter-Jones, Lewis (Eccles) Griffiths,Eddie (Brightside) McGuire, Michael
Castle, Rt. Hn. Barbara Hamilton, James' (Bothwell) Machine, George
Clark, David (Coine Valley) Hamilton, Winiam (Fife, w.) Mackenzie, George
Cocks, Michael (Bristol, S.) Hamling, William Mackie, J. Kevin
Cohen, Stanley Hannan, William (G, gow, Maryhill) Mahon, Simson (Bootle)
Concannon, J. D. Hardy, Peter Mallalieu, J. P. W. (Huddersfleld.E.)
Corbet, Mrs. Freda Harper, Joseph Marks, Kenneth
Cox, Thomas (Wandsworlh, C.) Harrison, Walter (Wakefield) Marquand David
Crawshaw, Richard Hart, Rt. Hn. Judith Marsden, F.
Cronin, John Healey, Rt, Hn. Danis Marshall, Dr. Edmund
Crosland, Rt. Hn. Anthony Heffer Eric S. Marshall, Dr. Edmund
Crossman, Rt. Hn. Richard Hilton' W. S. Mason, Rt. Hn. Roy
Cunningham, G. (Islington, S.W.) Hooson, Emlyn Mayhew, Christopher
Cunningham, Dr. J. A. (Whitehaven) Horam, John Meacher, Michael
Dalyall, Tom Huckfield, Leslie Mellish, Rt. Hn. Robert
Davidson, Arthur Hughes, Rt. Hn. Cledwyn (Anglesey) Mendelson, John
Davles, Denzil (Llanelly) Hughes, Mark (Durham) Mikardo, Ian
Davies, G. Elfed (Rhondda, E.) Hughes, Robert (Aberdeen, N.) Millan, Bruce
Davies, Ifor (Gower) Hughes, Roy (Newport) Miller, Dr. M. S.
Davis, Clinton (Hackney, C.) Hunter, Adam Milne, Edward
Davis, Terry (Bromsgrove) Irvine, Rt. Hn. Sir Arthur (Edge Hill) Mitchell, R. C. (S'hampton, Itchen)
Deaklns, Eric Janner, Greville Molloy, William
de Freitas, Rt. Hn. Sir Geoffrey Jay, Rt. Hn. Douglas Morgan, Elystan (Cardiganshire)
Morris, Alfred (Wythenshawe) Reed, D. (Sedgefield) Thomas, Rt. Hn. George (Cardiff.W.)
Morris, Charles R. (Openshaw) Rees, Merlyn (Leeds, S.) Thomas, Jeffrey (Abertillery)
Morris, Rt. Hn. John (Aberavon) Richard, Ivor Tinn, James
Moyle, Roland Roberts, Albert (Normanton) Tomney, Frank
Mulley, Rt. Hn. Frederick Roberts, Rt. Hn. Goronwy(Caernarvon) Tope, Graham
Murray, Ronald King Robertson, John (Paisley) Torney, Tom
Oakes, Gordon Roderick, Caerwyn E.(Brc'n&R'dnor) Tuck, Raphael
Ogden, Eric Ross, Rt. Hn. William (Kilmarnock) Urwin, T. W.
O'Halloran, Michael Rowlands, Ted Varley Eric G.
O'Malley, Brian Sandelson, Neville Wainwright, Edwin
Oram, Bert Sheldon, Robert (Ashton-under-Lyne) Walker, Harold (Doncaster)
Orbach, Maurice Shore, Rt. Hn. Peter (Stepney) Wallace, George
Orme, Stanley Short, Rt. Hn. Edward(N'c'tle-u-Tyne) Watkins, David
Oswald, Thomas Short, Mrs. Renée (W'hampton, N.E.) Weitzman, David
Padley, Walter Silkin, Rt. Hn. John (Deptford) Wellbeloved, James
Silkin, Hn. S. C. (Duiwich) Wells, William (Walsall, N.)
Paget, R. T. Sillars, James White, James (Glasgow, Pollok)
Palmer, Arthur Silverman, Julius Whitehead, Phillip
Pannell, Rt. Hn. Charles Skinner, Dennis Whitlock, William
Pardoe, John Small, William Willey, Rt. Hn. Frederick
Parker, John (Dagenham) Smith, Cyril (Rochdale) Williams, Alan (Swansea, W.)
Parry, Robert (Liverpool, Exchange) Smith, John (Lanarkshire, N.) Williams, Mrs. Shirley (Hitchin)
Pavitt, Laurie Spearing, Nigel Williams, W. T. (Warrington)
Peart, Rt. Hn. Fred Spriggs, Leslie Wilson, Alexander (Hamilton)
Pendry, Tom Stallard, A. W. Wilson, Rt. Hn. Harold (Huyton)
Perry, Ernest G. Steel, David Wilson, William (Coventry, S.)
Prescott, John Stoddart, David (Swindon)
Price, William (Rugby) Stonehouse, Rt. Hn. John TELLERS FOR THE AYES:
Probert, Arthur Strang, Gavin Mr. Donald Coleman and
Radice, Giles Strauss, Rt. Hn. G. R. Mr. John Golding
Rankin, John Summerskill, Hn. Dr. Shirley
Adley, Robert Cormack, Patrick Hall, Miss Joan (Keighley)
Alison, Michael (Barkston Ash) Costain, A. P. Hall, John (Wycombe)
Allason, James (Hemel Hempstead) Critchley, Julian Hall-Davis, A. G. F.
Amery, Rt. Hn. Julian Crouch, David Hamilton, Michael (Salisbury)
Archer, Jeffrey (Louth) Crowder, F. P. Hannam, John (Exeter)
Astor, John Dalkeith, Earl of Harrison, Brian (Maldon)
Atkins, Humphrey Davies, Rt. Hn. John (Knutsford) Harrison, Col. Sir Harwood (Eye)
Awdry, Daniel d' Avigdor-Goldsmid, Maj.-Gen.Jack Haselhurst, Alan
Baker, Kenneth (St. Marylebone) Dean, Paul Hastings, Stephen
Baker, W. H. K. (Banff) Deedes, Rt. Hn. W. F. Havers, Sir Michael
Balniel, Rt. Hn. Lord Digby, Simon Wingfield Hawkins, Paul
Batsford, Brian Dixon, Piers Hay, John
Bell, Ronald Douglas-Home, Rt. Hn. Sir Alec Hicks, Robert
Bennett, Sir Frederic (Torquay) Drayson, G. B. Higgins, Terence L.
Bennett, Dr. Reginald (Gosport) du Cann, Rt. Hn. Edward Hiley, Joseph
Benyon, W. Eden, Rt. Hn. Sir John Hill, John E. B. (Norfolk, S)
Biffen, John Edwards, Nicholas (Pembroke) Hill, S. James A.(Southampton,Test)
Biggs-Davison, John Elliot, Capt. Walter (Carshalton) Holland, Philip
Boardman, Tom (Leicester, S.W.) Elliott, R. W. (N'c'tle-upon-Tyne,N.) Holt, Miss Mary
Body, Richard Emery, Peter Hordern, Peter
Boscawen, Hn. Robert Eyre, Reginald Hornby, Richard
Bossom, Sir Clive Farr, John Hornsby-Smith, Rt. Hn. Dame Patricla
Bowden, Andrew Fell, Anthony Howe, Rt. Hn. Sir Geoffrey
Braine, Sir Bernard Fenner, Mrs. Peggy Howell, Ralph (Norfolk, N.)
Bray, Ronald Fidler, Michael Hunt, John
Brewis, John Fisher, Nigel (Surbiton) Hutchison, Michael Clark
Brinton, Sir Tatton Fletcher-Cooke, Charles Iremonger, T. L.
Brocklebank-Fowler, Christopher Fookes, Miss Janet Irvine, Bryant Godman (Rye)
Brown, Sir Edward (Bath) Fortescue, Tim James, David
Bruce-Gardyne, J. Fowler, Norman Jenkin, Patrick (Woodford)
Bryan, Sir Paul Fox, Marcus Jennings, J. C. (Burton)
Buchanan-Smith, Alick(Angus,N&M) Fraser, Rt. Hn. Hugh (St'fford & Stone) Jessel, Toby
Buck, Antony Fry, Peter Johnson Smith, G. (E. Grinstead)
Bullus, Sir Eric Galbraith, Hn. T. G. D. Jones, Arthur (Northants, S.)
Burden, F. A. Gardner, Edward Jopling, Michael
Butler, Adam (Bosworth) Gibson-Watt, David Joseph, Rt. Hn. Sir Keith
Campbell, Rt.Hn.G.(Moray & Nairn) Gilmour, Ian (Norfolk, C.) Kaberry, Sir Donald
Carlisle, Mark Gilmour, Sir John (Fife, E.) Kellett-Bowman, Mrs. Elaine
Carr, Rt. Hn. Robert Glyn, Dr. Alan Kershaw, Anthony
Cary, Sir Robert Goodhew, Victor Kimball, Marcus
Channon, Paul Gorst, John King, Evelyn (Dorset, S.)
Chapman, Sydney Gower, Raymond King, Tom (Bridgwater)
Chichester-Clark, R. Grant, Anthony (Harrow, C.) Kinsey, J. R.
Clark, William (Surrey, E.) Gray, Hamish Kitson, Timothy
Clarke, Kenneth (Rushcliffe) Green, Alan Knight, Mrs. Jill
Cockeram, Eric Grieve, Percy Knox, David
Cooke, Robert Griffiths, Eldon (Bury St. Edmunds) Lambton, Lord
Coombs, Derek Grylls, Michael Lamont, Norman
Cooper, A. E. Gummer, J. Selwyn Lane, David
Cordle, John Gurden, Harold Langford-Holt, Sir John
Le Marchant, Spencer Page, Rt. Hn. Graham (Crosby) Stodart, Anthony (Edinburgh, W.)
Lewis, Kenneth (Rutland) Page, John (Harrow, W.) Stoddart-Scott. Col. Sir M.
Lloyd, Ian (P'tsm'th, Langstone) Parkinson, Cecil Stokes, John
Longden, Sir Gilbert Percival, Ian Stuttaford, Dr. Tom
Loveridge, John Peyton, Rt. Hn. John Sutcliffe, John
Luce, R. N. Pike, Miss Mervyn Tapsell, Peter
McAdden, Sir Stephen Pink, R. Bonner Taylor, Sir Charles (Eastbourne)
MacArthur, Ian Powell, Rt. Hn. J. Enoch Taylor, Edward M.(G'gow,Cathcart)
McCrindle, R. A. price David (Eastleigh) Taylor, Frank (Moss Side)
McLaren, Martin prior, Rt. Hn. J. M. L. Taylor, Robert (Croydon, N.W.)
Maclean, Sir Fitzroy Proudfoot, Wilfred Tebbit, Norman
Macmillan, Rt. Hn. Maurice (Farnham) pym, Rt. Hn. Francis Temple, John M.
McNair-Wilson, Michael Quennell, Miss J. M. Thatcher, Rt. Hn. Mrs. Margaret
McNair-Wilson, Patrick (New Forest) Raison, Timothy Thomas, John Stradling (Monmouth)
Maddan, Martin Ramsden, Rt. Hn. James Thomas, Rt. Hn. Peter (Hendon, S.)
Madel, David Rawlinson, Rt. Hn. Sir Peter Thompson Sir Richard (Croydon, S.)
Maginnis, John E. Redmond, Robert Tolney
Marten, Neil Reed, Laurance (Bolton, E.) Trafford, Dr. Anthony
Mather, Carol Rees Peter (Dover) Trew, Peter
Turton, Rt. Hn. Sir Robin
Maude, Angus Rees-Davies, W. R. Van Straubenzee, W.R.
Mawby Ray Renton, Rt. Hn. Sir David Vaughan, Dr. Gerard
Maxwell-Hyslop, R. J. Rhys Williams, Sir Brandon vickers Dame Joan
Meyer Sir Anthony Ridsdale, Julian Waddington, David
Mills, Peter (Torrington) Roberts, Wyn (Conway) Walder, David (Clitheroe)
Mills, Stratton (Beltast, N.) Rodgers, Sir John (Sevenoaks) Walker-Smith, Rt. Hn. Sir Derek
Miscampbell, Norman Rossi, Hugh (Hornsey) Wall Patrick
Mitchell,Lt.-Col.C.(Aberdeenshire,W) Royle, Anthony Walters, Dennis
Mitchell, David (Basingstoke) Russell, Sir Ronald Ward, Dame Irene
Moate, Roger St. John-Stevas, Norman Warren, Kenneth
Money, Ernie Sandys, Rt. Hn. D. Wells, John (Maidstone)
Monks, Mrs. Connie Scott, Nicholas White, Roger (Gravesend)
Monro, Hector Scott-Hopkins, James Whitelaw, Rt. Hn. William
Montgomery, Fergus Shaw, Michael (Sc'b'gh & Whitby) Wiggin, Jerry
Morgan, Geraint (Denbigh) Shelton, William (Clapham) Wilkinson, John
Morgan-Giles, Rear-Adm. Shersby, Michael Winterton, Nicholas
Morrison, Charles Simeons, Charles Wolrige-Gordon, Patrick
Mudd, David Sinclair, Sir George Wood, Rt. Hn. Richard
Murton, Oscar Skeet, T. H. H. Woodhouse, Hn. Christopher
Neave, Airey Smith, Dudley (W'wick & L'mington) Woodnutt, Mark
Nicholls, Sir Harmar Soret, Harold Worsley, Marcus
Noble, Rt. Hn. Michael Speed, Keith Wylie, Rt. Hn. N. R.
Nott, John Spence, John Younger, Hn. George
Onslow, Cranley Sproat, lain
Oppenheim, Mrs. Sally Stainton, Keith TELLERS FOR THE NOES:
Osborn, John Stanbrook, Ivor Mr, Walter Clegg and
Owen, Idris (Stockport, N.) Stewart-Smith, Geoffrey (Belper) Mr. Bernard Weatherill

Question accordingly negatived.

Main Question put forthwith pursuant to Standing Order No. 39 (Amendment on second or third reading):—

The house divided: Ayes 285, Noes 260.

Division No. 91.] AYES [10.12 p.m.
Adley, Robert Brinton, Sir Tatton Critchley, Julian
Alison, Michael (Barkston Ash) Brocklebank-Fowler, Christopher Crouch, David
Allason, James (Hemel Hempstead) Brown, Sir Edward (Bath) Crowder, F. P.
Amery, Rt. Hn. Julian Bruce-Gardyne, J. Dalkeith, Earl of
Archer, Jeffrey (Louth) Bryan, Sir Paul Davles, Rt. Hn. John (Knutsford)
Astor, John Buchanan-Smith, Alick(Angus,N&M) d'Avigdor-Goldsmid.Maj.-Gen.Jack
Atkins, Humphrey Buck, Antony Dean, Paul
Awdry, Daniel Bullus, Sir Eric Deedes, Rt. Hn. W. F.
Baker, Kenneth (St. Marylebone) Burden, F. A. Digby, Simon Wingfield
Baker, W. H. K. (Banff) Butler, Adam (Bosworth) Dixon, Piers
Balniel, Rt. Hn. Lord Campbell, Rt.Hn.G.(Moray& Nairn) Douglas-Home, Rt. Hn. Sir Alec
Batsford, Brian Carlisle, Mark Drayson, G. B.
Bell, Ronald Carr, Rt. Hn. Robert du Cann, Rt. Hn. Edward
Bennett, Sir Frederic (Torquay) Cary, Sir Robert Eden, Rt. Hn. Sir John
Bennett, Dr. Reginald (Gosport) Channon, Paul Edwards, Nicholas (Pembroke)
Benyon, W. Chapman, Sydney Elliot, Capt. Walter (Carshalton)
Biffen, John Chichester-Clark, R. Elliott, R. W. (N'c'tle-upon-Tyne,N.)
Biggs-Davison, John Clark, William (Surrey, E.) Emery, Peter
Boardman, Tom (Leicester, S.W.) Clarke, Kenneth (Rushcliffe) Eyre, Reginald
Body, Richard Cockeram, Eric Fair, John
Boscawen, Hn. Robert Cooke, Robert Fell, Anthony
Bossom, Sir Clive Coombs, Derek Fenner, Mrs. Peggy
Bowden, Andrew Cooper, A. E. Fidler, Michael
Braine, Sir Bernard Cordle, John Fisher, Nigel (Surbiton)
Bray, Ronald Cormack, Patrick Fietcher-Cooke, Charles
Brewis, John Costain, A. P. Fookes, Miss Janet
Fortescue, Tim Langford-Holt, Sir John Roberts, Wyn (Conway)
Fowler, Norman Le Marchant, Spencer Rodgers, Sir John (Sevenoaks)
Fox, Marcus Lewis, Kenneth (Rutland) Rossi, Hugh (Hornsey)
Fraser, Rt. Hn. Hugh (St'fford & Stone) Lloyd, Ian (P'tsm'th, Langstone) Royle, Anthony
Fry, Peter Longden, Sir Gilbert Russell, Sir Ronald
Galbraith, Hn. T. G. D. Loveridge, John St. John-Stevas, Norman
Gardner, Edward Luce, R. N. Sandys, Rt. Hn. D.
Gibson-Watt, David McAdden, Sir Stephen Scott, Nicholas
Gilmour, Ian (Norfolk, C.) MacArthur, Ian Scott-Hopkins, James
Gilmour, Sir John (Fife, E.) McCrindle, R. A. Shaw, Michael (Sc'b'gh & Whitby)
Glyn, Dr. Alan McLaren, Martin Shelton, William (Clapham)
Goodhew, Victor Maclean, Sir Fitzroy Shersby, Michael
Gorst, John Macmillan, Rt. Hn. Maurice(Farnham) Simeons, Charles
Gower, Raymond McNair-Wilson, Michael Sinclair, Sir George
Grant, Anthony (Harrow, C.) McNair-Wilson, Patrick (New Forest) Skeet, T. H. H.
Gray, Hamish Maddan, Martin Smith, Dudley (W'wick & L'mington)
Green, Alan Madel, David Soref, Harold
Grieve, Percy Maginnis, John E. Speed, Keith
Griffiths, Eldon (Bury St. Edmunds) Marten, Neil Spence, John
Grylls, Michael Mather' Carol Sproat, lain
Summer. J. Selwyn Maude, Angus Stainton, Keith
Gurden, Harold Mawby, Ray Stanbrook, Ivor
Hall, Miss Joan (Keighley) Maxwell-Hyslop, R. J. Stewart-Smith, Geoffrey (Belper)
Hall, John (Wycombe) Meyer, Sir Anthony Stodart, Anthony (Edinburgh. W.)
Hall-David, A. G. F. Mills, Peter (Torrington) Stoddart-Scott. Col. Sir M.
Hamilton, Michael (Salisbury) Mills, Stratton (Belfast, N.) stokes, John
Hannam, John (Exeter)
Harrison, Brian (Maldon) Miscampbell, Norman Stuttaford, Dr. Tom
Harrison, Col. Sir Harwood (Eye) Mitchell,Lt.-Col.C.(Aberdeenshire,W) Sutcliffe, John
Haselhurst, Alan Mitchell, David (Basingstoke) Tapsell, Peter
Moate, Roger Taylor, Sir Charles (Eastbourne)
Hastings, Stephen Taylor, Edward M.(G'gow.Cathcart)
Havers, Sr Michael Money, Ernle Taylor, Frank (Moss Side)
Hawkins, Paul Monks, Mrs. Connie Taylor, Frank (Moss Side)
Hawkins, Paul Monro, Hector Taylor, Robert (Croydon, N.W.)
Hay, John
Hicks, Robert Montgomery, Fergus Tebbit, Norman
Higgins, Terence L. Morgan, Geraint (Denbigh) Temple, John M.
Hiley, Joseph Morgan-Giles, Rea-Adm. Thatcher, Rt. Hn. Mrs. Margaret
Hill, John E. B. (Norfolk, S.) Morrison, Charles Thomas, John Stradling (Monmouth)
Mudd, David Thames, Rt. Hn. Peter (Hendon, S.)
Hill, S. James A. (Southampton, Test) Murton, Oscar Thompson, Sir Richard (Croydon. s)
Holland, Philip Tilney, John
Holt, Miss Mary Neave, Airey Trafford, Dr. Anthony
Hordern, Peter Nicholls, Sir Harmar Trew, Peter
Hornby, Richard Noble, Rt. Hn. Michael Turton, Rt. Hn. Sir Robin
Hornsby-Smith, Rt. Hn. Dame Patricla Nott, John Van Straubenzee, W. R.
Howe, Rt. Hn. Sir Geoffrey Onslow, Cranley Vaughan, Dr. Gerard
Howell, Ralph (Norfolk, N.) Oppenheim, Mrs. Sally Vickers, Dame Joan
Hunt, John Osborn, John waddington, David
Hutchison, Michael Clark Owen, ldris (Stockport, N.) Walder, David (Clitheroe)
Iremonger, T. L. Page, Rt. Hn Graham (Crosby) walker-Smith, Rt. Hn. Sir Derek
Irvine, Bryant Godman (Rye) Page, John (Harrow, W.) Wall, Patrick
James, David Parkinson, Cecil Walters, Dennis
Jenkin, Patrick (Woodford) Percival, Ian Ward, Dame Irene
Jennings, J. C. (Burton) Peyton, Rt. Hn. John Warren Kenneth
Jessel, Toby Pike, Miss Mervyn Wells, John (Maidstone)
Johnson Smith, G. (E. Grinstead) Pink, R. Bonner White, Roger (Gravesend)
Jones, Arthur (Northants, S.) Powell, Rt. Hn. J. Enoch Whitelaw, Rt. Hn. William
Jopling, Michael Price, David (Eastleigh) Wiggin, Jerry
Joseph, Rt. Hn. Sir Keith Prior, Rt. Hn. J. M. L. Wilkinson, John
Kaberry, Sir Donald Proudfoot, Wilfred Winterton, Nicholas
Kellett-Bowman, Mrs. Elaine Pym, Rt. Hn. Francis Wolrige-Gordon, Patrick
Kershaw, Anthony Quennell, Miss J. M. Wood, Rt. Hn. Richard
Kimball, Marcus Ralson, Timothy Woodhouse, Hn. Christopher
King, Evelyn (Dorset, S.) Ramsden, Rt. Hn. James Woodnutt, Mark
King, Tom (Bridgwater) Rawlinson, Rt. Hn. Sir Peter Worsley, Marcus
Kinsey, J. R. Redmond, Robert Wylie, RT, Hn. N. R.
Kitson, Timothy Reed, Laurance (Bolton, E.) Younger, Hn. George
Knight, Mrs. Jill Rees, Peter (Dover)
Knox, David Rees-Davies, W. R. TELLERS FOR THE AYES:
Lambton, Lord Renton, Rt. Hn. Sir David Mr. Walter Clegg and
Lament, Norman Rhys Williams, Sir Brandon Mr.Bernard Weatherill.
Lane, David Ridsdale, Julian
Abse, Leo Baxter, William Broughton, Sir Alfred
Allaun, Frank (Salford, E.) Benn, Rt. Hn. Anthony Wedgwood Brown, Robert C. (N'c'tle-u-Tyne,W.)
Archer, Peter (Rowley Regis) Bennett, James(Glasgow, Brldgeton) Brown, Hugh D. (G'gow, Provan)
Armstrong, Ernest Bidwell, Sydney Brown, Ronald(Shoreditch & F'bury)
Ashley, Jack Bishop, E. S. Buchan, Norman
Ashton, Joe Blenkinsop, Arthur Buchanan, Richard (G'gow, Sp'burn)
Atkinson, Norman Boardman, H. (Leigh) Butler, Mrs. Joyce (Wood Green)
Bagier, Gordon A. T. Booth, Albert Callaghan, Rt. Hn. James
Barnes, Michael Bottomley, Rt. Hn. Arthur Campbell, I. (Dunbartonshire, W.)
Barnett, Guy (Greenwich) Boyden, James(Bishop Auckland) Cant, R. B.
Barnett, Joel (Heywood and Royton) Bradley, Tom Carmichael, Neil
Carter, Ray (Birmingh'm, Northfield) Hughes, Roy (Newport) Padley, Walter
Carter-Jones, Lewis (Eccles) Hunter, Adam Paget, R. T.
Castle, Rt. Hn. Barbara Irvine, Rt. Hn. Sir Arthur (Edge Hill) Palmer, Arthur
Clark, David (Colne Valley) Janner, Greville Pannell, Rt. Hn. Charles
Cocks, Michael (Bristol, S.) Jay, Rt. Hn. Douglas Pardoe, John
Cohen, Stanley Jeger, Mrs. Lena Parker, John (Dagenham)
Concannon, J. D. Jenkins, Hugh (Putney) Parry, Robert (Liverpool, Exchange)
Corbet, Mrs. Freda John, Brynmor Pavitt, Laurie
Cox, Thomas (Wandsworth, C.) Johnson, Carol (Lewisham, S.) Peart, Rt. Hn. Fred
Crawshaw, Richard Johnson, James (K'ston-on-Hull, W.) Pendry, Tom
Cronin, John Johnson, Walter (Derby, S.) Perry, Ernest G.
Crosland, Rt. Hn. Anthony Jones, Barry (Flint, E.) Prescott, John
Crossman, Rt. Hn. Richard Jones, Dan (Burnley) Price, Willian (Rugby)
Cunningham, G. (Islington, S.W.) Jones, Rt. Hn. Sir Elwyn (W.Ham,S.) Probert, Arthur
Cunningham, Dr. J. A. (Whitehaven) Jones, Gwynoro (Carmarthen) Radice, Giles
Dalyell, Tam Jones, T. Alec (Rhondda, W.) Rankin, John
Davidson, Arthur Judd, Frank Reed, D. (Sedgefield)
Davies, Denzil (Llanelly) Kelley, Richard Rees, Merlyn (Leeds, S.)
Davies, G. Elfed (Rhondda, E.) Kerr, Russell Richard, Ivor
Davies, Ifor (Gower) Kinnock, Neil Roberts, Albert (Normanton)
Davis, Clinton (Hackney, C.) Lamble, David Roberts, Rt. Hn. Goronwy (Caernarvon)
Davis, Terry (Bromsgrove) Lambie, David Robertson, John (Paisley)
Deakins Eric Lamborn, Harry Roderick, Caerwyn E.(Brc'n&R'dnor)
Lamond, James Ross, Rt. Hn. William (Kilmarnock)
de Freltas, Rt, Hn. Sir Geoffrey Latham, Arthur Rowlands, Ted
Delargy, Hugh Lawson, George Sandelson, Neville
Dell, Rt. Hn. Edmund Leadbitter, Ted Sheldon, Robert (Ashton-under-Lyne)
Doig, peter Lee, Rt. Hn. Frederick Shore, Rt. Hn. Peter (Stepney)
Dormand, J. D. Leonard, Dick Short, Rt. Hn. Edward (N'c'tle-u-Tyne)
Douglas, Dick (Stirlingshire, E.) Lestor, Miss Joan Short, Mrs. Renée (W'hampton, N. E.)
Douglas-Mann, Bruce Lewis, Ron (Carlisle) Silkin, Rt. Hn. John (Deptford)
Driberg, Tom Lipton, Marcus Silkin, Hn. S. C. (Dulwich)
Duffy, A. E. P. Lomas, Kenneth Sillars, James
Dunn, James A. Loughlin, Charles Silverman, Julius
Eadie, Alex Lyon, Alexander W. (York) Skinner, Dennis
Edelman, Maurice Mabon, Dr. J. Dickson Small, William
Edwards, Robert (Bilston) McBride, Neil Smith, Cyril (Rochdale)
Edwards, William (Merioneth) McCartney, Hugh Smith, John (Lanarkshire, N.)
McElhone, Frank Spearing, Nigel
English, Michael McGuire, Michael Spriggs, Leslie
Evans, Fred Machin, George Stallard, A. W.
Ewing, Harry Mackenzie, Gregor Steel, David
Faulds, Andres Mackie, John Stoddart, David (Swindon)
Fisher, Mrs. Doris (B' ham, Ladywood) Maclennan, Robert Stonehouse, Rt. Hn. John
Fitch, Alan (Wigan) McNamara, J. Kevin Strang, Gavin
Fletcher, Raymond (IIkeston) Mahon, Simon (Bootle) Strauss, Rt. Hn. G. R.
Rletcher, Ted (Darlington) Mallalieu, J. P. W. (Huddersfield, E.) Summerskill, Hn. Dr. Shirley
Foot, Michael Marks, Kenneth Thomas, Rt. Hn. George (Cardiff, W.)
Ford, Ben Marquand David Thomas, Jeffrey (Abertillery)
Forrester, John Marsden, F. Tinn, James
Fraser, John (Norwood) Marshall, Dr. Edmund Tomney, Frank
Freeson, Reginald Mason, Rt. Hn. Roy Tope, Graham
Galpern, Sir Myer Torney, Tom
Garrett, W. E. Mayhew, Christopher Tuck, Raphael
Gilbert, Dr. John Meacher, Michael Urwin, T. W.
Ginsburg, David (Dewsbury) Mellish, Rt. Hn. Robert Varley, Eric Q.
Gourlay, Harry Mendelson, John Wainwright, Edwin
Grant, George (Morpeth) Mikardo, lan Walker, Harold (Doncaster)
Grant, John D. (Islington, E.) Millan, Bruce Wallace, George
Griffiths, Eddie (Brightside) Miner, Dr. M. S. Watkins, David
Grimond, Rt. Hn. J. Milne, Edward Weitzman, David
Hamilton, James (Bolhwell) Mitchell, R. C. (S'hampton, Itchen) Wellbeloved, James
Hamilton, William (Fife, W) Molloy, William Wells, William (Walsall, N.)
Hamling William Morgan, Elystan (Cardiganshire) white, James (Glasgow, Pollok)
Hannan, William (G'gow, Maryhill) Morris, Alfred (Wythenshawe) Whitehead, Phillip
Hardy Peter Morris, Charles R. (Openshaw) Whitlock, William
Harper, Joseph Morris, Rt. Hn. John (Aberavon) Willey, Rt. Hn. Frederick
Harrison, Walter (Wakefield) Moyle, Roland Williams, Alan (Swansea, W.)
Hart, Rt. Hn. Judith Mulley, Rt. Hn. Frederick Williams, Mrs. Shirley (Hitchin)
Healey, Rt. Hn. Denis Murray, Ronald King Williams, W. T. (Warrington)
Heffer, Eric S. Oakes, Gordon Wilson, Alexander (Hamilton)
Hilton, W. S. Ogden, Eric Wilson, Rt. Hn. Harold (Huyton)
Hooson, Emlyn O'Halloran, Michael Wilson, William (Coventry, S.)
Horam, John O'Malley, Brian
Huckfield, Leslie Oram, Bert TELLERS FOR THE NOES:
Hughes, Rt. Hn. Cledwyn (Anglesey) Orbach, Maurice Mr. Donald Coleman and
Hughes, Mark (Durham) Orme, Stanley Mr. John Golding.
Hughes, Robert (Aberdeen, N.) Oswald, Thomas

Question accordingly agreed to.

Bill read a Second time.

Bill committed to a Standing Committee pursuant to Standing Order No. 40 (Committal of Bills).