§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Pavitt.]
§ 7.15 p.m.
§ Sir Geoffrey Howe (Surrey, East)
The Opposition have thought it right to give the House this opportunity to debate the most important subject of the National Health Service and to do so because it is a subject of grave and growing concern for a number of reasons. Some but by no means all of the concern arises from the attitude and actions of this Government. On those matters, I shall be critical. It is right to say, however, that other areas of concern arise from the institutional shortcomings and failures of the way in which the service is run. It would be wrong to suggest that these are the exclusive responsibility of this Government. But it is right, even so, to press this Government about them because they have now the responsibility for putting them right so far as they can.
The third group of problems arises from the present economic position of the country, from the condition of inflation and from the lack of economic expansion, both of which together raise fundamental questions about the volume of resources available for the Health Service and about the way in which we raise and deploy those resources.
The present position of the service and its resources is probably most fairly summarised in the recent report produced by the Royal Colleges, reported in the British Medical Journal of 26th October. I refer to it en passant only to summarise the way in which I approach the subject.
The Royal Colleges say that it would be wrong to conclude that the service is nearing disintegration. They point out that the service has provided, since its foundation, improving standards of service for the community but that advances in techniques and scientific progress have led to an almost indefinite expansion in demand; and that rising standards have themselves led to rising expectations, so that the service has always appeared to be chronically under-financed and probably, because the factors will always be at work, always will appear under-financed.
There has been a growing realisation that the problem of matching resources 1199 to demand is theoretically insoluble and as if that was not demoralising enough that continuing inflation makes matters for those working in the service a great deal worse.
Against that background, I hope that the Secretary of State will not seek to avoid responsibility for those matters which can fairly be laid at her door by trying to transfer all the blame for the present problems of the service to the previous Government. In previous debates, the right hon. Lady has had three more or less regular alibis which have never been convincing because they refer to only part of a continuing problem. And they become less and less relevant and more and more unattractive.
In the past the Secretary of State has argued that the problems of the service to a large extent are the fault of reorganisation. That is not so. In any event the necessity for substantial change in the organisation of the service was recognised by her predecessor but one, Richard Crossman. A substantial change was bound to come. When it came, it was bound to be a burden for all those working in the service. The right attitude to the consequences of reorganisation should be that of the Royal Colleges when they say that the structure of the service has been reorganised with the aim of making more effective use of existing resources and that the Royal Colleges and faculties will co-operate in an effort to achieve this objective. That should be the objective of everyone concerned with the service.
I hope that the Government recognise the unwisdom of the further disturbance involved in carrying through their proposals for the so-called democratisation of the service. It would be wrong to do that at this time, because the area health authorities would become too unwieldy to perform their management jobs. Secondly, it would be wrong to draw the community health councils, designed to be independent critics and champions of the consumer, into an unwieldy coalition with the area health authorities, involving them in a joint responsibility. It would be wrong, thirdly, because there is a fundamental misconception in believing that strengthening local authority membership is relevant; for that ignores the extent to which the service is financed 1200 largely from central financial resources, so that democratic control should to a large extent be exercised in this House.
The final reason why I urge the right hon. Lady not to press ahead with these changes now is that the prospect of any further substantial change may threaten a serious organisational breakdown. Indeed, if the Secretary of State is right in her original diagnosis, which I do not accept, that some of the problems spring from reorganisation, that is all the more reason for resisting the temptation towards further change at this time— change that is not directed to remedying whatever defects may eventually appear as the new organisation settles down. It is all the more true if this evening's reports of threatened industrial action by hospital administrators should turn out to be right. I hope that the Secretary of State will tell us something about the substance of that matter, because we have had only the briefest indications on the evening news bulletins.
The second of the Secretary of State's alibis is that the problems of the service are caused as a result of the curtailments of expenditure introduced in December 1973. Like other curtailments in public expenditure introduced by successive Governments over the years, they created difficulties. They underline the case, which has so far eluded all Governments in similar circumstances, for seeking a more sensitive method of reacting to the recurrent need to curb public expenditure programmes. But the right hon. Lady would be wrong to blame those for the much larger problems now facing the service, if only because she has not restored, except to a very limited extent, the effects of those reductions in public expenditure.
I understand that the only restoration undertaken by the Secretary of State was the increase of £25 million for capital expenditure for the social and health services announced by the Chancellor of the Exchequer. But there has been no restoration of any curtailment of resources relating to revenue expenditure.
The extra money for which the Secretary of State has taken credit has come in only two ways: first, that which is necessary to meet those pay awards beyond stage 3 that have been made to the nurses, the para-medicals and some 1201 other groups, although not to the doctors and dentists, to whom I shall turn later; secondly, those increases that were simply designed to take account of the impact of inflation on the service.
The Minister of State, in our debate on 1st November, at col. 641, recapitulated and enlarged on them slightly. The hon. Gentleman pointed out that £40 million had been made available during July and that an additional £14½ million was made available as announced in his speech there and then.
It is important to understand that those additional resources were made available not in any sense to restore the cuts made last December but for the limited purpose described in the Press release of 10th July 1974:The additional money now provided by the Government compensates health authorities, so that reductions need not be made in the level of services to patients in order to accommodate these recent increases in prices … further additional allocations will be made as necessary in the light of experience of further price increases.It is only in those two ways that the Government have made any additional resources available and only to a very limited extent attempted to restore the cuts made last December.
Looking at the picture in the longer view, the fact is that throughout the period of the last Government there had been growing provision in real terms for capital and revenue needs of the health service and the personal social services. The position was well set out by my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph), then Secretary of State for Social Services, on 28th January 1974 when he said:Over the last three years we have spent, on average, in real terms, 30 per cent. more each year than the average of Labour's last three years, and from that high rate of increased expenditure we now come down to a disappointingly lower rate: one which is lower than we would wish but still higher than Labour's last spending figure."—[OFFICIAL REPORT, 28th January 1974; Vol. 868, c. 115]That is a measure of the extent to which resources had been increasing.
The same is true of revenue expenditure, which was running for 1974–75 at 15 per cent. more in real terms than in 1970–71.
The Minister of State, in the debate on 1st November, dealt with the personal social services. He said: 1202I need hardly remind the House how rapid has been the expansion of expenditure in real terms in social services over the past few years. In real terms, the growth was 11 per cent. in 1971–72, was 17 per cent. from 1971–72 to 1972–73, and is estimated at 15 per cent. from 1972–73 to 1973–74."—[OFFICIAL REPORT, 1st November, 1974; Vol. 880, c. 643.]Therefore, throughout the period of the last Government until we have come up against the realities of the present economic situation, there had been a continuing expansion in real resources going into the service.
The reality today, as the Secretary of State was candid enough to tell the Directors of Social Services in Coventry on 6th November, is as follows:I will tell you frankly that you are not going to have it so good next year…. You won't be surprised if there has to be some check on this considerable growth.That is a candid statement of the position. It is a realistic recognition of the great difficulties facing our economy. I should like the Secretary of State to spell out the scale and implication of what she there said and, if possible, how she reconciles that statement with the reported statement of the Prime Minister to the British Medical Association, that the £111 million cuts of last December will be restored "as soon as is practicable".
The third argument advanced by the Secretary of State is that the problems of the service are due to the frustration of the last Government's incomes policy. That, again, will not wash. It is idle to deny that any attempt to contain the growth of incomes in a public sector service is bound to produce some difficulties and frustration. But it is equally idle to deny that any Government can escape from that problem in a publicly financed service of this kind during periods of inflation. It is idle to deny that this Government are now creating, prolonging and magnifying similar difficulties for themselves. Some of them are part of what seems to be the pattern of the service and its inadequate and often frustrating machinery for negotiation. I do not blame the Government for this. It is a feature that both sides have blamed each other for at different stages. However, I should like to refer to certain examples which are causing particular concern.
I begin with the position of the orthoptic profession, a small group of 1203 which we have not heard a great deal in our proceedings in this House. These people, who work in small units, have had their grading structure under review since 1971. Like many such groups, they find it almost impossible to secure answers and commitments in negotiations with the Department with which they are trying to deal.
I raised this subject in correspondence with the Secretary of State in mid-July and, after a delay of three months, obtained the somewhat Delphic response to the particular questions that I put as follows:The negotiations to which the Society refer took place not with this Department but within a sub-committee of the Professional and Technical Whitley Council 'A' with the Society represented on the staff side. None the less, I understand that there was no lack of will on either side to find alternative criteria on which to base a grading structure for orthop-tists, simply a failure to find criteria which adequately matched the way in which their service is actually organised.That is a fairly unsubstantial response to a genuine and continuing grievance.
A similar situation arises with the speech therapists, about whom there is particular concern at the moment, because, despite the recommendations of the Quirk Report and the Department's advice on the effect of reorganisation on the speech therapy service, no appointments have yet been made of area speech therapists, who form part of the intended structure. I should like to know when those appointments will be made and how far the Secretary of State regards a similar response to queries on behalf of that profession as likely to induce a great feeling of confidence that advance will be made.
In her letter to the Chairman of the College of Speech Therapists, of which the right hon. Lady sent me a copy, of 26th November she said:Whilst it may not be true to say that all pay developments in the meantime are, as it were, 'sub judice', the question whether any interim moves are possible … must be left to the judgment of the Whitley Council. … I do not think it is true in terms, unless informal advice has been misconstrued, that the Department has assured authorities that no Area Speech Therapist salary will be back dated. The Department is in fact in no position to say this because the operative date of any agreement is, of course, a matter for the Whitley Council—although it seems only fair 1204 to add that if no appointments can be made the issue of backdating does not, in logic, arise.That series of sentences makes the utterances of the oracle of Delphi a model of clarity and is hardly designed to encourage that profession to think that its problems are likely to be resolved quickly.
I turn from those, which are representative of the reasons why there is concern at the difficulty of trying to negotiate, as it has been put, with a jelly, to the difficulties facing the dental profession. Eight months after reorganisation no steps have yet been taken to secure the appointment of regional and district dental officers. This failure is severely limiting the effectiveness of area dental officers. Great concern is felt in the profession about the level of pay of clinical dental officers transferred from the local authority school dental service, and recruitment to that part of the service is virtually at a standstill. I should like the Minister to tell the House when progress may be expected on that front.
Finally, I turn to the position of the medical profession, leaving the work of the Owen Committee to the end, and ask the Secretary of State to tell us the position of hospital junior staffs, who are sometimes overlooked in the current concern with consultants and other grades.
A new model contract for junior staff has been under discussion—to say that it has been under negotiation would be to use too meaningful and purposive a word—since November 1973. So far there have been five meetings between representatives of hospital junior staff—in December last year and in January, April, June and September of this year—and they have apparently ended in an incapacity to agree minutes as to whether any agreement had been reached. Four letters have since been written by the junior hospital staff to the Department, but only one has received an acknowledgement. It is small wonder that three-quarters of this grade of staff in Northern Ireland have submitted undated resignations and that frustration amongst junior hospital doctors is extreme. This is illustrative of the way in which it appears to be impossible to get on top of the organisation to produce effective communication with the people with whom they are trying to negotiate.
1205 Another example is the family planning service. Failure to agree on a proper level of remuneration for family planning services in hospital and GP services is placing intolerable burdens on doctors, and it is even clearer than before that agreement on this should have preceded rather than succeeded the introduction of a free national family planning service. We ask the Secretary of State to tell us what is happening there.
The superannuation of doctors is a much more long-standing difficulty, that has persisted over many years. But detailed submissions were made earlier this year by the medical profession. Its representatives saw the Secretary of State on this matter on 8th May, and since then they have had no reply except on one or two minor points. It is becoming a matter of urgent and increasing concern, and one asks whether it might be possible to place responsibility for this with the Review Body as a means of making progress on it.
Turning now to the Review Body itself, one wonders about the further difficulties that arise. At the beginning of August of this year the professions were assured that the Review Body would be free to make a substantive review of doctors' and dentists' remuneration, to make such recommendations as it thought fit and to decide on the timing of those reviews. And in the light of that assurance the professions completed giving their evidence to the review body on 9th September.
Since then confusion appears to have reigned, partly because of the circumstances in which Lord Halsbury came to resign, partly because the Prime Minister I understand it is his function—has not appointed any chairman to take his place and partly because the Secretary of State in a rather disingenuous Written Reply said:It is for the Review Body to decide whether it is practicable for it to continue its work pending the appointment of a new chairman."—[OFFICIAL REPORT, 26th November 1974; Vol. 882, c. 111.]It is no wonder that the medical and dental professions are asking what has happened, who will be the chairman, when will there be a report, and what status will it have?
I deal next with consultants and private practice. Great concern is being caused 1206 by the way in which the Government appear to be forging ahead, in a way that is bound to provoke trouble, with two policies to both of which a substantial majority of doctors are opposed; namely, the commitment to a whole-timed salaried service and the phasing out, as it is put, of National Health Service private practice.
The folly of phasing out private practice from the point of view of the National Health Service and its patients was well summarised in an article in The Times on 20th November, when it was said:Separation of private and public medicine is bound to lead to a waste of resources, both of manpower and equipment. There will be a partial duplication of facilities, and the expensive equipment so important in modern medicine cannot be made full use of in the relatively small hospitals that the private sector needs. The existing uneven geographical distribution of medical services will be aggravated. There is likely to be competition for the service of doctors with high reputations, who may be lost to the public sector. The NHS will be deprived of its marginal but still useful income from private beds. If middle-class patients enter NHS hospitals less often it it possible that the pressures against their becoming a second-class service will be reduced.That seems to speak for itself, as it has on many occaisons.
From the point of view of the doctors, what is worse is the Government's total unwillingness to regard this commitment as negotiable. The Secretary of State seeks to reassure them about the future of independent medicine by asserting her willingness and that of the Labour Party to support private practice, albeit outside National Health Service hospitals in the future.
That assertion is rendered increasingly unconvincing by the enthusiasm with which back-bench Labour Members press the right hon. Lady to go further down this road; and by the fact that the Labour Party conference in October 1971 passed without dissent a resolution calling upon the National Executive Committee to press for the abolition of private medical insurance schemes and demanded that all private nursing homes should be brought into the National Health Service.
It is against that background that the Secretary of State must judge the credibility of her protestations that she intends to go thus far and no further. They carry no conviction.
1207 This is the importance of the other ground of concern, the massive pressure—financial, practical and moral—which the right hon. Lady is offering towards a full-time salaried service.
The right hon. Lady said on 7th November:At no time have we ever said it was our policy … to move to a whole-time salaried service in the National Health Service",but that, too, is rendered wholly unconvincing by the statement in the consultative document CJWP/FC 13—part of the welter of paper with which the Minister of State is surrounding himself—thatThe Government broadly accepts the argument for the desirability of a whole-time salaried service.The Government must realise the extent to which they are seen to be threatening professional independence and diminishing the good will and effectiveness of consultants and those who work in the service.
On this the arguments and the profession are indivisible. The hon. Lady the Member for Wolverhampton, North-East (Mrs. Short) has sought to suggest that the consultants are at odds with other members of the profession.
§ Sir G. Howe
The hon. Gentleman must hearken for a moment. The Chairman of the BMA's Hospital Junior Staffs Group Council said in the British Medical Journal of 16th November that hospital junior doctors fully supported the action being taken by the professional side of the Owen Working Party. He added that,These new proposals would force many doctors into the whole-time salaried service and so preclude them from doing any kind of work outside the National Health Service. This would greatly reduce the freedom of patients and doctors alike and provide further disincentives for junior doctors to go through the long training courses to become consultants.The medical profession sees the dangers of what is being proposed and this anxiety is not something that emanates only from Harley Street. Considerable anxiety is being conveyed to me from all corners of the country, from Newcastle, Manchester, Birmingham, Crewe, Preston, the East Midlands and Merseyside—not 1208 only from the cloistered precincts of a select few in Harley Street but from working doctors serving whole communities in the North, East, South and West. The Government ignore this at their peril.
The Government are wholly failing to understand the extent to which the National Health Service gets a great deal more value for its money than theoretically it is entitled to. Part-time consultants work many more hours than they are contractually obliged to do. I quote from one letter from a rheumatologist in the South of England because it is typical of many:I am writing to advise you that unless the present doctrinaire campaign being waged by Mrs. Castle against the most essential members of the Health Service is tempered by common sense and a greater regard for truth she will be very fortunate indeed to have a Health Service to manage by the middle of next month.On a personal note, I might inform you that in addition to being the only Consultant in my Specialty … doing 7,000 consultations a year I am also a member of the District Management Team, Chairman of the District Medical Committee, Secretary of the Cogwheel Committee, medical member of the Regional Authority's Working Party on Management Studies, Possum Assessor to the Regional Authority, member of the Disablement Advisory Committee and Director of the Department of Health's Demonstration Centre in Rehabilitation … I say this, not to attract any praise, but to point out how bitterly untrue and disgraceful it is to suggest that people such as myself devote only part of their efforts to the Health Service. I have a thriving Private Practice but it makes me very little more in money than the sum I have to give up from my National Health Service salary to indulge in Private Practice.Labour Members may scoff at that, but the reality is that the National Health Service is supported and sustained by people such as that working many hours beyond the call of strict duty to keep it operating. Those people feel that to make the changes proposed by the Government in the current negotiations will be to serve the National Health Service badly as well as them. I have another similar quotation, this time from a surgeon in the North of England. He states:I feel also that everybody after a forty-hours week should be eligible for extra duty payments and this would give rise to a greater and a happier National Health Service. Most of us have been working a sixty to a hundred hour week for thirty-one and a half hours pay. Why destroy good will for dreadful dogma like Mrs. Castle is trying to do? Above 1209 all, the retention of Merit Awards is very necessary. Everybody, part-timer and full-timer, should be given the chance of displaying merit. If, however, Mrs. Castle disposes of merit, seniority payments to both part-timer and full-timer should be the rule of the day, but let there be no doubt in anybody's mind that seniority payments give rise to mediocrity.That is the other aspect of the case. That is why it is essential that the Government move away from their present destructive and provocative attitudes and make it perfectly plain that they will not seek to pursue their objectives by compulsion, inducement, any other unfair weighting of the alternatives which may be made available to the medical profession.
Anyone who today is responsible for administering the National Health Service faces enough trouble, heaven knows, without seeking to generate other sources of strife and dissension. Shortages of resources, which I spoke about, pose a serious dilemma and an almost infinite scope for disappointment. We can all quote examples involving deterioration of the service in hospitals.
It is necessary for us to face up to the challenge of the present shortages of resources. It is no use pretending that those concerned in the NHS or in the other social services—or any of us who discuss these matters—can simply go on as though nothing serious was happening to the rest of the country's economy. Are the Government prepared to respond to the plea from the Royal Colleges and from the professional associations for an independent re-examination of alternative sources of finance of the NHS? If not, then the Government—and the Opposition—must have the courage to spell out to those in the NHS the implications of continuing shortages, and the necessity for choices to be undertaken between salaries and continuing expansion of services, between people and the provision of capital equipment, and between restricting functions and raising standards in other directions.
It is for all these reasons that I say that it is time for the Government to refrain, above all, from provoking new causes of disagreement, to get on with abating those that already exist, and to provide the leadership of continuing and open debate about priorities in this as in other social services, in a time of grave economic difficulty.
§ 7.43 p.m.
§ The Secretary of State for Social Services (Mrs. Barbara Castle)
This is a short debate and it will not, therefore, be possible for me to follow up all the detailed points fired at us by the right hon. and learned Member for Surrey, East (Sir G. Howe) in a cascade of unco-ordinated grapeshot. I owe it to the House to deal seriously, not superficially, with the problems facing the National Health Service. There will be other opportunities for dealing with other aspects of the details of our policy, such as our proposals for greater democratisation in the running of the service, to which the right hon. and learned Gentleman referred.
We have carried out detailed consultations on this aspect of our policy, and we shall be making statements on this and on other aspects to the House from time to time. There were certain details in the right hon. and learned Gentleman's speech to which my hon. Friend the Minister of State will refer in the concluding speech.
I want to deal in the short time available to me with two of the more fundamental issues to which the right hon. and learned Gentleman referred; the more far-reaching aspects of the future of the NHS, on which he was long on gloom but short on remedies. I shall concentrate on two of the major issues in which the House is interested: first, the financial prospects for the NHS and, secondly, the progress we are making in our discussions with the profession on a new consultants' contract and on our proposals for phasing out private beds in NHS hospital. I choose these two because in my view they are inter-linked. The greater the economic stringency with which the country is faced, the more essential it is that the Government should be seen to be building a fairer society. I do not expect hon. Members on the Opposition side to accept this. They have never understood this basic principle, because they are the instinctive guardians of privilege and, therefore, the instinctive guardians of pay beds and private privilege within our National Health Service. We on this side of the House take a different view of society. We believe that in a situation in which all of us in the country have to draw in our 1211 horns and make sacrifices, it is impossible for the Government to tolerate queue-jumping within a National Health Service designed to give equality of treatment to all our people.
The greater the pressure on the medical resources of this country the more imperative it is that those resources should be allocated on the basis of strictly medical priority. I have always made it clear that it is not our intention to outlaw private practice. That would be impracticable, even if it were desirable in principle. But I have also made clear that access to beds in the NHS hospitals must be on the basis of clinical need, not on the basis of ability to pay a fee and jump the queue. I do not believe that this country can get through the difficult economic time ahead unless the Government are seen to be endorsing this principle firmly. It is not a question of refusing to allow people to pay for privacy if they want it. Aneurin Bevan, the architect of the NHS, always catered for this need in the National Health Service through the institution of amenity beds, and we shall continue with them. Indeed, I believe that privacy is something which should, and can, be provided within the NHS. It is paying for priority of treatment that we reject. This principle remains central to our whole policy.
At the same time the consultants have some legitimate grievances about the nature of their contract, a contract which has remained unmodified and un-modernised since 1948. In the joint working party under the chairmanship of my hon. Friend the Minister of State we have been examining the consultants' proposals carefully and constructively. Our aim is to reward adequately those who give a greater commitment to the NHS and are willing to help us secure a better distribution of medical skill among neglected geographical areas and neglected specialities, such as geriatrics and psychiatry. Naturally, the negotiations have been tough, but we are trying to bring them to a conclusion as quickly as possible.
This issue highlights what I believe has been at the heart of all the recent talk about a crisis in the NHS—staff discontent. This has been the most serious part of our grim inheritance from the Conservative Party. When we took over 1212 from them, everyone who served the health service, from top to bottom, was in a state of revolt. The consultants in the health service were seething with dissatisfaction under the right hon. and learned Gentleman's administration long before the question of pay beds was ever mooted. Staff morale generally when we took over was at an all-time low as a result of his Government's rigid statutory pay policy. We decided then on a policy which has been summed up in the phrase, "People before buildings". The right hon. and learned Gentleman referred to it in passing but was very careful not to come down on either side of that choice.
I wonder sometimes whether the NHS staff realise the extent to which, in eight months, this Government have already put their priority on people and on ensuring that they are paid an adequate salary. First, there was the Halsbury award for the nurses. The professions supplementary to medicine are also being looked at by Halsbury. It is a little late for the right hon. and learned Gentleman to start talking about the complaints of pay clerks, orthoptists and speech therapists, We found them in a state of revolt as a result of three and a half years of Conservative policy.
The professions supplementary to medicine are also being looked at, as I said, and have already had an interim award, which will be followed by a final award when the substantive report is received. Hospital technicians, hospital pharmacists, work staff and ambulance men have all had substantial increases in pay. An offer has now been made to ancillary workers. All these awards have been broadly within the terms of the social contract. For the doctors and dentists, there will be a substantive review by their Review Body in April next year.
The effect of these improvements in pay has been to increase the proportion of total expenditure in the NHS devoted to salaries and wages from 48 per cent. in 1973–74 to an estimated 54 per cent. in the current financial year. All this costs money. The Halsbury award so far will cost over £180 million in England alone this year. The award goes further than a straight pay increase, further than merely dealing with the effects of inflation, and it has within it elements designed to develop a higher standard of 1213 patient care. Just one example is the provision of a proper reward for nurses who wish to stay in clinical nursing rather than enter management. Nevertheless, the Government have met the pay bill in full through additional money, without seeking offsetting savings elsewhere in the programme.
Then there are the steps to which the right hon. and learned Member referred which the Government have taken to protect and inflation-proof the NHS. The extra £40 million for England which I announced in July to offset rising costs, plus the additional costs of health services transferred from local authorities, has been followed by further payments of £17 million, and we have assured the health authorities that additional money will be made available as necessary to close the gap between the cost element originally allowed in their allocations for the current year and the actual level of prices. In all, Supplementary Estimates providing nearly £450 million additional money for the NHS in England to cover pay increases and increased costs have already been presented to the House.
The second half of our inheritance from the Conservative Party was inflation. The temporary bursts of expansion in NHS expenditure which the Conservatives launched in 1970 and 1971, and which they planned to finance by printing money, came to an abrupt end in December 1973, as all such exercises in financial profligacy do. This Government have been left to pick up the pieces not only in the NHS but over our whole economy. It is folly to pretend that this country can go on as our predecessors were doing, ricocheting from one extreme of financial policy to the other and ending with a disastrous climax of tight and arbitrary pay controls plus slashing cuts in public expenditure.
This Government's policy is to disengage this country steadily and systematically from the mess that we inherited. As the Chancellor of the Exchequer has said, this means that the rate of expansion must be slowed down over all public expenditure until inflation has been brought under control. Otherwise, we shall be continually chasing our tails and real improvements in the services that we provide will continue to escape us. That is why the Chancellor has announced that public expenditure as a whole will be 1214 planned to grow by only 2¾ per cent. a year over the next four years. The Government have been having intensive discussions on the application of this general formula to particular services.
The last Government's abrupt 20 per cent. cut in National Health Service capital expenditure for 1974–75 not only savagely reduced expenditure for that year but, if carried through to subsequent years, would have meant that there could be no new major building or development schemes for two years at least. We, on coming into office, therefore, faced the prospect of a complete moratorium on all major hospital starts. It was this sudden disruption which helped to create a sense of crisis in the service. That is why, despite the economic difficulties which will be particularly acute in the coming year, the Government have decided to restore some of the December cuts of the previous Government.
National Health Service capital expenditure for 1975–76 will be £255 million against a capital expenditure figure for this year, as a result of the Tory cuts, of £236 million—an increase in real terms of £19 million, or 8 per cent. This additional money is important because it allows us to lift our predecessors' moratorium and enables me to give approval to starting in 1975–76 a few—possibly about 30— substantial new building schemes of high priority. In addition, we are making another £10 million available next year for the revenue expenditure of the NHS to enable authorities to catch up on the backlog of essential maintenance work.
Nevertheless, I am well aware that many important schemes will have to be deferred. I must warn the House that the outlook for the next few years is not encouraging. As things now stand, it will not be possible to maintain this increase in expenditure in real terms over the next few years. In such a situation, we must all learn the language of priorities. I will now make it clear what my national priorities are.
First, I have decided to give top priority to capital facilities for primary care. Expenditure on health centres will be increased, not cut. Next year we expect to spend £20 million on health centres compared with £15 million this year. This should ensure an expanding health centre building programme. We are developing 1215 criteria of selection which, I hope, will ensure that we give priority to building health centres in areas of special health need. We intend, in this area as in others, to be selective and to start redressing the inequalities of health provision which, I fear, are still far too great.
Second, I have decided to maintain present levels of capital expenditure on geriatric, mental illness and mental handicap schemes. As I have frequently pointed out, these three areas have been neglected over many years. To cut them back now would be to prolong the life of some of the most appalling buildings and leave quite scandalous gaps in our present provision for these important groups.
Third, I am absolutely determined to ensure that we maintain our expanding medical student intake. I shall be in consultation with the University Grants Committee and, through that, with the deans of the medical schools. I shall do everything possible to ensure that those capital schemes absolutely vital for medical training are not affected. I have already committed myself to establishing the regional medium security units which are so badly needed. I will continue to allocate money to experimental schemes which help establish the pattern of services which will be most valuable in future.
One of our priorities will be to establish clinical priority as the sole criterion in the allocation of NHS hospital beds. When resources are tight, queue-jumping becomes all the more intolerable. One way of overcoming the problem is to shorten the queue. Nothing gives rise to a greater sense of frustration than long waiting lists. That is why I intend to allocate part of our limited resources to reducing them. Part of the answer lies in good management, and I shall shortly be issuing a circular to local authorities on the management of their waiting lists—a circular which has been agreed with the professions.
As we know this is partly a problem of staff shortages. But I know that the medical profession feels that extra capital resources are also required. I accept that capital is needed. As part of the other actions which I hope we shall be taking to deal with waiting lists, I shall be asking health authorities to identify specific capital schemes which will help 1216 reduce bottlenecks and which need not cost a great deal. I will do my best to provide scope for specific capital expenditure in this area to reduce waiting lists.
I accept that it is not only for the Government to decide the priorities. The present situation is a challenge to all who administer the health service and who work in it. For some months both the health authorities and the medical profession—and I include the Royal Colleges, whose representatives came to see me to discuss their memorandum—have been asking me to let them know where they stand and what resources they are likely to have so that they can put on their thinking caps and plan how they can put those resources to the best use.
This I am now in a position to do, and I shall be keeping my promise to them to call them into detailed consultation about the shape of the capital programme for future years and what would be the most cost-effective strategy. It is not just a question of eliminating waste, important though that is, and I believe that there could be great scope for savings of that kind. It is something more far-reaching that we have to do. We must work out a comprehensive system of health care, embracing both the health and the social services, which will deliver the highest possible level of provision for our clients' needs.
Having done that, we must then examine the implications of this for our capital programmes. I believe that they can be reviewed with benefit. Community hospitals, for instance, will clearly have an important rôle to play in future as part of the hospital complex in districts. So we now have the chance to re-think our health planning by health districts in a comprehensive way, linking primary health care, community care and hospital provision. If we seize this opportunity we may well find that, despite our limited resources, we strengthen the health service and enable it to give us even better value for money than it is already widely recognised as giving. That will be our aim, and I am confident that in pursuing it we shall have the understanding and co-operation of all who serve in the service.
§ 8.5 p.m.
§ Mr. Michael Alison (Barkston, Ash)
It is difficult to assess what the reputation of the right hon. Lady will be in the 1217 annals of history, but I suspect that she will be marked above all by the description of "propagandist". There is no great demerit in being a propagandist—a great many distinguished people have been propagandists at different times. At least the right hon. Lady has had the grace, as a propagandist, to change the tune of her propaganda when occasion dictated. We all remember the famous change of tune with "In Place of Strife". We are concerned with only one crucial feature of the propagandist in this context and that is the real hazard to the people of this country that she should come to believe in the myths which she propagates.
The supreme myth that the right hon. Lady has sought to propagate tonight—she has sought to base upon it far-reaching changes of policy—is the myth of queue-jumping occasioned by private practice in National Health Service hospitals. This is the greatest and most distinctive myth that bedevils the whole of this debate. I want to lead the right hon. Lady and some of her supporters step by step through the realities of this situation.
Patients make progress not when a hospital bed is available but when a doctor or a consultant is available. There can be any number of hospital beds, two-thirds of which may be empty. We could fill them with patients from the queues. But if there were no doctors available the condition of those patients would in no sense improve. When doctors treat private patients in hospital they are by definition—they must be otherwise they would be breaking their contracts—part-time consultants on a part-time contract, probably on a nine-elevenths contract. If they were full-time consultants on an eleven-elevenths contract they would not be allowed, nor would they want, to practise private medicine in hospital. On a part-time contract the time that they spend in treating private patients in hospital is, by definition, not available to NHS patients. It is time which does not belong to the NHS.
§ Mr. Alison
That is a subsidiary point with which I should be happy to deal for the benefit of the hon. Gentleman. When 1218 they are dealing with private patients in hospital they are spending time on those patients which is not available to ordinary NHS patients.
§ Mrs. Renée Short (Wolverhampton, North-East)
What about the use of the nine-elevenths of their time?
§ Mr. Alison
I should be happy to engage in an exchange with the hon. Lady, private, personal or public—
§ Mr. Alison
I greatly admire and respect the hon. Lady's insight into this complicated area, and I am sure that I am carrying her with me in this area so far.
§ Mr. Alison
The right hon. Lady must recognise that a part-time consultant who treats private patients in hospital is treating them in his own time. If the right hon. Lady's desire is to expel private patients from NHS hospitals and for doctors to continue to have a part-time contract, it necessarily follows that in the time that is available for private patients, doctors will continue to treat them, but away from the NHS hospital.
There are about 130 private hospitals and nursing homes outside the NHS, with some 9,000 beds being available. The bed occupancy for private patients in NHS hospitals is about 2,500. If private patients are expelled from NHS hospitals, the 2,500 will move into the private sector, displacing the 3,500 NHS patients in private hospitals, who will come back into the public sector. Doctors with part-time contracts will cease to practise in NHS hospitals and will continue to treat private patients in the private sector.
If private patients have been expelled from the hospitals, and if part-time consultants who are looking after private patients follow those patients out of the NHS hospitals into private hospitals, it will make not one iota of difference to the waiting list of NHS patients. The doctors will no longer be in NHS hospitals—they will be practising privately. The worst of all possible worlds will descend upon the unfortunate NHS patient. The doctor will have to spend more time in travelling, and will, therefore, spend less time in the 1219 National Health Service, and the queues will get longer. Furthermore, because NHS patients in private hospitals will have to come back into the public hospital sector to make room for private patients in the private hospital sector there will be a net increase in the queue. The myth of queue-jumping is exactly the reverse of what the right hon. Lady, by her own propaganda, has kidded herself it is.
The myth is that a privileged group is holding up the queue of NHS patients. The reality is that by expelling private patients on this trumped-up and propagandised myth of an excuse all we are doing is increasing the queue, the waiting time and the non-availability of doctors for NHS patients, and increasing the number of NHS patients seeking admittance.
The key question is: does the right hon. Lady believe her own propaganda? Does she believe that there is such a thing as queue-jumping, in this sense? Do her advisers get across to her that if private patients left NHS hospitals and there were still available for consultants a part-time contract, it would make not the slightest difference to the amount of time that NHS patients have to spend waiting for the doctor's time? The doctor's time is the key factor. The fact that doctors practise privately in NHS hospitals is of minor importance to private patients but of overwhelming importance to NHS patients who are given so much more than the contracted time by part-time consultants.
I come now to the contract which the right hon. Lady was at pains to spell out. I am delighted to see the way in which she has placed herself at the head of all personnel in the National Health Service who are out for a better deal in terms of remuneration. It is a glowing, encouraging and endearing picture to see her at the head of the marching nurses, waving her red banner and leading them forward into the promised land of better terms and conditions. The right hon. Lady has successfully led this marvellous inarch of the nurses to Halsbury, seeking to persuade Lord Halsbury to give them more than they have ever had before. So much for the nurses.
There is only one group in the hospitals more important than the nurses—the con- 1220 sultants, the people who actually deliver the fundamental curative health care. Will the right hon. Lady place herself at the head of marching doctors, to get an enormous increase? Let me remind her of the truth about the doctors. [Interruption.] I can hear a great deal of dissatisfaction at the presentation of the truth from the other side. The truth about the hospital consultant's contract is that it represents one of the biggest of confidence tricks. My hon. Friend the Member for Reading, South (Mr. Vaughan), who is a consultant at Guy's will agree with what I say. Hospital consultants work considerable overtime on the basis of a small notional time and pay contract. If they are full time they have a salary, in round figures without merit awards, of, say, £5,000 a year. They are paid that £5,000 a year to work eleven sessions of three-and-a-half hours each. That gives a Monday-to-Friday week, say, from 9.30 a.m. to 12.30 p.m., from 2 p.m. to 5.30 p.m., and from 9.30 a.m. to 12.30 p.m. on Saturday. That adds up to about 38½ hours, worth £5,000. My hon. Friend the Member for Reading, South will confirm those figures, as will any doctor whose advice the Minister has taken.
Has anyone heard of a hospital consultant who works to rule and interprets his contract in a narrow sense by coming in at 9.30 a.m., going to lunch at 12.30 p.m. and working again from 2 p.m. to 5 p.m., and on Saturday working from 9.30 a.m. to 12.30 p.m.? That is what he is paid for. On my calculations, most consultants work at least 14 hours a week over and above the 38½ hours for which they are remunerated, that is to say, at least two hours per day from Monday to Friday more than they are contracted to work, and another one hour or two hours over the weekend, which is at least 14 hours extra overtime.
Let us say that that is equivalent to four sessions. A session is worth £450, calculated by dividing the £5,000 by 11. What the consultant should be paid, pro rata, and assuming overtime at time-and-a-half, is at least another £2,500 to £2,700 without putting in any further work, just to compensate for the overtime at reasonable overtime rates.
I hope that the right hon. Lady, with the zeal she showed for increasing remuneration to the most important 1221 people in the profession of health care, will be in the van in the discussions on the new contract, to make certain that at least £22 million is made available to compensate hospital consultants for the vast amount of overtime which they work on their ordinary contract before there is any question of buying out private hospital patient time.
The right hon. Lady is a great propagandist. I sincerely hope that she does not believe the myth that by expelling private patients from the National Health Service she will reduce the hospital queue. On the contrary, the queue will get longer. I hope, furthermore, that the right hon. Lady will be in the van with the consultants, as she was with the nurses, to make certain that they are paid a proper rate for the number of hours they put in, which is about one-third as much again as the hours for which they are contracted. When she has put those two things right, we shall begin to believe that she has been persuaded about the truth of what the National Health Service needs and not just reiterate the old claptrap of propaganda about privilege.
§ 8.20 p.m.
§ Mrs. Renée Short (Wolverhampton, North-East)
The right hon. and learned Member for Surrey, East (Sir G. Howe) had the grace to say that not all the present troubles facing the National Health Service stem from the actions of this Government. He more or less said that some of the difficulties which the service is now facing stem from the period before 1964 when his Government were largely responsible for what went on in the National Health Service.
The hon. Member for Barkston Ash (Mr. Alison) seems not to take that view. He spun a fairy story this evening. I do not know whether many people accept it, but I suggest that instead of spinning stories of that sort he should take the trouble to read some of the evidence submitted to the Expenditure Committee which considered this problem. He will find a very different story told by junior hospital doctors and by full-time and part-time consultants. If his story of the long hours worked by some consultants is true—and I accept that many consultants in the National Health Service are working very long hours indeed—this is surely an indictment of what the Conservative 1222 Government were prepared to tolerate for so long from 1951 to 1964 and later during the recent period of nearly four years when the hon. Gentleman's party were in office.
Was the hon. Gentleman marching for the nurses? Was he marching for the BMA? Did he support them when they were campaigning for better conditions? Of course he was not. He need not think that he can make that sort of speech to the House and make us feel that we ought to fall flat on our faces before his propaganda. In fact, I do not think that he believes his own propaganda.
Going back to the difficulties which the National Health Service faces as a direct result of what was done in December 1973—because this is the legacy which my right hon. Friend had to inherit, as she said—the programme of capital expenditure in the health service by the action of the then Conservative Chancellor of the Exchequer was cut by one-fifth and the procurement expenditure on goods and services was cut by one-tenth. This was to meet a reduction in public expenditure for the year 1974–75 of £1,200 million in toto. This was a very considerable cut which was spread more or less right across the board. It meant that the Department of Health and Social Security had to face a cut of £111.2 million at that time. My right hon. Friend has indicated that she has been able to replace that money—and more: that she has been able to put back £450 million by means of Supplementary Estimates—[Interruption.] The hon. Lady was not listening.
§ Mrs. Short
—and that a good deal has been done and will be done in order to make good those cuts.
The House needs to understand what all those cuts in the Department of Health and Social Security meant in both the major areas of my right hon. Friend's responsibility. The effect of those cuts was disastrous.
§ Mrs. Short
The cuts in the Department were extremely difficult to carry out. The National Health Service building programme, for example, is not a 1223 programme which starts and stops at certain specific times. It is a rolling programme. Very flexible operation is necessary in order to carry it out and bring each phase forward when necessary. It means that commitments which were already undertaken could not be interfered with; otherwise building programmes would have stopped. Hospital building programmes would have ended and there would have been considerable claims for compensation as a result.
Therefore, about two-thirds of the building programme of the Department was already committed when those cuts were made. Only about one-third of the programme could bear the cuts that had to be carried out as a result of the Conservative Chancellor's decision. It meant that many new construction projects which were due to start had to bear the burden, but the burden fell on them to a much greater degree than would otherwise have been the case. According to evidence submitted to the Expenditure Committee which considered the effect of these cuts on the National Health Service, it amounted to a cut of about 60 per cent. on all new building projects. That was a considerable burden which had to be borne.
This is why in many parts of the country consultants are concerned about the shortage of beds to cope with the pressures on their own particular specialities. The consultant orthopaedic surgeon in Northampton wrote to me last week and said that he has only 58 per cent. of the beds that he ought to have in order to deal with all the cases on the waiting list, and that some 50 of those cases comprise elderly people waiting for hip replacement operations. They are now waiting 15 or 16 months before they can be offered a hospital bed. I hope my right hon. Friend will be able to say that in the new capital programme which she is prepared to underwrite she will look at the needs of areas like Wolverhampton where the second phase of the new district general hospital is awaited.
The cuts on the capital building programme were very considerable indeed. As a result, once the decision was made by the previous administration that these cuts had to be carried out, officials from the Department, instead of looking at the way in which the Department is run and 1224 considering ways in which the money already allocated could be better spent, were having to go round to the area health authorities and to the hospitals and decide how the cuts were to be made. That was a fruitless use of the officials' time.
Then there are the cuts in current expenditure, the procurement of goods and services, which, again, made very considerable difficulties for the hospitals. It meant that, besides capital projects being delayed, more minor capital works were held up, too. Such projects were of the kind that really help the patient and very often help the staff considerably. For a comparatively small expenditure of money a considerable improvement in services and conditions for patients and staff can be affected. I refer to such projects as improvements in lavatories, sluices and bathrooms, the provision of day rooms for patients and fire precautions. Surely economies ought not to be made in fire precautions. Also included in this type of project are improvements in old kitchens. This kind of project had to be abandoned because of the cuts in the minor capital works.
Regional disparities, too, were affected and made more severe. One of the greatest regional disparities is in the distribution of consultants. Perhaps the hon. Member for Barkston Ash will exercise his mind and tell us on another occasion the extent to which certain parts of the country, perhaps including his own, are short of consultant cover. He might be able to offer an explanation for that.
Although, with hand on heart, the Conservative Chancellor of the Exchequer and the Secretary of State for Social Services said that patients' interests would not be affected, the result was that patients' interests were in fact affected, including some of the vital provisions which are of considerable significance in maintaining a good standard of patient care.
More important, in order to save money hospitals left staff training schemes unfulfilled, and they left staff vacancies unfilled. In an already under-staffed and over-burdened service this also was a disastrous decision, and it was bound in its turn to affect patients. The treasurers of area health authorities, giving evidence to the Expenditure Committee, said that they were short of many millions of 1225 pounds in trying to carry through the programmes to which, they had assumed, they were committed according to the previous year's estimates.
We never have had enough money to finance the National Health Service adequately. That criticism, of course, applies to both Governments, but, without doubt, the effect of the uncaring attitude of the Conservative Party when in office has been to make the situation far more difficult for the people working in the service and for my right hon. Friend herself.
My right hon. Friend has given us the priorities of medical care and of capital expenditure which she intends to pursue. I have no quarrel with the health centre programme. I have no quarrel with her underlining of the previous priority for geriatric and mental illness care. I hope, however, that when my right hon. Friend is considering the expansion of medical students numbers she will make sure that the medical schools adopt a more reasonable attitude to women applicants.
This has been the cause of one of the major setbacks in the supply of doctors during recent years. I think it a great pity that there has been a numerus clausus against women medical students. I hope, therefore, that in the coming year, and especially since next year we are to celebrate International Women's Year— I must put in a plug for that—my right hon. Friend will make absolutely clear that there should be a fair number—I should like it to be fifty-fifty, of course—of women medical students in training.
I hope also that my right hon. Friend will spare some thought for the needs of the dental service within the National Health Service, a sector grossly neglected by the Conservative Party, which virtually presided over the disappearance of the dental service within the National Health Service. Attention must now be given to that.
Never again, I hope, will any British Government inflict upon the National Health Service cuts such as those inflicted on it by the Conservative Party when in power. We must decide what our priorities are to be. I hope that hon. Members on the Opposition benches will be here tomorrow when my right hon. Friend the Secretary of State for Defence makes his statement about defence cuts, and that they will be pressing the claims of the 1226 National Health Service for a share of that expenditure in the future.
§ 8.32 p.m.
§ Mr. David Crouch (Canterbury)
We all respect the hon. Lady the Member for Wolverhampton, North-East (Mrs. Short) for her knowledge of expenditure in health matters through her position on the Expenditure Committee, but I feel that she has misled the House with regard to the cuts announced in December last year by the Conservative Government. They were cuts across the board in capital expenditure necessary to meet a grave economic situation. The cuts in the National Health Service were capital expenditure cuts; that is, cuts in forward expenditure, not in expenditure this year. Those cuts have not been restored by the present Government, and we must have a statement tonight from the Minister about that to clear up the misunderstanding.
I should say at the outset, although I believe that the House knows it, that I have an interest in the health service. I am a director of a pharmaceutical company, and, more particularly, I am a member of a regional health authority. I speak in this debate, therefore, with that particular specialisation in mind.
I welcome what the right hon. Lady the Secretary of State said in stating that her aim was a strengthened health service. We ought not to bring too much party politics into these matters or criticise one another when we have aims of that kind. However—I am sorry that she is not here at the moment—I must tell the right hon. Lady that I do not believe, any more than my hon. Friend the Member for Barkston Ash (Mr. Alison) believes, that she has got things right. I think that she is deceiving herself by political dogma and doctrinaire beliefs in this matter.
I should like to think that, through the powerful position which she occupies, the right hon. Lady could take action to strengthen the health service, for, my goodness, it needs strengthening today. It is a weak service, weak in money and weak in people—not in ability but in numbers. The right hon. Lady spoke about the additional capital expenditure she would make available for progress in improving psychiatric and geriatric hospitals. I welcome that, of course, but 1227 the House should not be deceived into thinking that the sort of sums she was talking about can do more than scratch the surface of the real problem in the geriatric and psychiatric hospitals. The latter used to be known as mental hospitals.
In my regional area in Kent I have seen a geriatric hospital 120 years old that is more like Holloway Prison. Parts of it are designed on the basis of a nineteenth century prison because in the nineteenth century mental patients were regarded as prisoners. The hospitals were called mental colonies, and in 1974 they require not a few hundred thousand pounds to patch them up and modernise them but £10 million per hospital at 1973 prices. I do not know what today's price would be with the current rate of inflation.
The same situation applies across the country to psychiatric and geriatric facilities. This has been an area of great neglect, and we should not deceive ourselves into thinking that the neglect can be put right by small works.
The Secretary of State said she was planning to make specific capital expenditure grants to reduce waiting lists. I say "Thank you", and I shall be watching to see how successful that is. I shall not be carping about it.
I wish now to deal with a problem facing the National Health Service, those who work in it and its patients. It arises from the reorganisation which came into force on 1st April. I made a plea in the debate on 1st November for the National Health Service to be given a period to settle down. It does not yet have its new relationships right or sorted out. People in the health service, as the Minister knows, are spending too much time in committees on administrative matters and not enough time with patients and in dealing with their problems. Under the new structure it is much harder to get a decision in the health service than it used to be. People are feeling their way about. One senior administrator said to me today that it seemed necessary sometimes to consult 20 persons if a decision had to be made. He told me recently that he had rung up a member of a district team with a proposal which he said should be im- 1228 plemented at once. "Oh, no," said the team member," I am afraid that I must consult my colleagues, and that will mean weeks of delay". Of course, we recognise that doctors and members of the health service need time to settle down under the new structure, and we must give them that time.
The regions are not yet fully established but they are much more advanced than the areas. It has been necessary to ensure that the health service keeps going, even though the areas have yet to be established. The patient, quite rightly, must come first. The trouble is that the districts have begun to consider that they can do without the areas and are assuming area responsibilities. Since the area teams are not yet fully established, the regions are being forced to do the area jobs and provide area services which it was not planned they should do.
It may be difficult in the months and years to come to change this growing pattern back to the structure which the House decided upon for management of the health service. We all know how difficult it is to move civil servants in an administration once they become established, and the trouble is they may become established in the wrong pattern, a pattern which was not originally intended.
But we must allow the new system, the planned system, to sort itself out and settle down. The National Health Service and those who work in it cannot take much more disturbance. I have a letter from the Chairman of the East Sussex Area Health Authority, referring to my speech of 1st November. He says:I think you have put the situation very well, and the feeling of all of us is 'for God's sake leave us alone for a couple of years so that we can digest the present reorganisation.' The danger of the entire organisation collapsing is a very real one. I am going to the funeral of"—here he mentions the name of one of the former administrative secretaries who had died—this afternoon, whose untimely death was undoubtedly hastened by the strain and overwork of the past two years. I don't want the same thing to happen to my officers but two of them have had coronaries this year and both of them have been severely disabled.In quoting that letter, I do not seek to overstrain the House with any emotional 1229 overtones. But I know, and other who have seen the health service in these months of settling down know, that under the new administration there are people working long hours. I refer not just to the consultants but to all those in the service as they have tried to get the thing off the ground and to work.
The Secretary of State is creating today a disturbance that we cannot take, and I wish that she would stop it, for medical reasons. I know that she has political reasons for changing the health service yet again. Those political reasons are irrelevant and positively harmful to the service.
I want to take up the question of the consultants and their dispute with the Secretary of State and the Government. Some of those who put pressure on the Government have made a call for more dedicated men in the National Health Service, so the Government are considering a new contract for hospital doctors which would commit them exclusively to working in the NHS. I understand that the Government want a whole-time salaried service. It sounds idealistic at first hearing that everyone should become a whole-timer and that the part-time consultant should cease to exist. But what will this mean? There is a danger of its creating for the first time two standards of health care.
§ Mr. Crouch
This would make Aneurin Bevan turn in his grave. There would be one standard in the NHS and a better one for the private patient. I should not be prepared to countenance that. We have seen it happen in the United States, and we should never let it happen here.
What is a part-time consultant or maximum part-time consultant in the NHS? He is a consultant who contracts to give nine half-day sessions a week in the service. The rest of his time—two half days and evenings—he can use for his private practice. Many such consultants are not only doing as much as the whole-timer but are putting in more than eleven-elevenths, although their contracts with the NHS are for only nine-elevenths. In studies that I have seen the part-time 1230 consultant has been putting in as much as thirteen-elevenths in his contract with the NHS, for which there is no question of extra pay.
The Government are now talking about a 10-session contract. The compensation to the consultants will be about an additional £1,500 a year. That is an increase in their basic pay of about 20 per cent. I am putting that percentage at a generous level. Today a consultant can earn nearly £8,000 a year at the top level if he is a full-timer or nine-elevenths of that if only a maximum part-timer. In addition, he can obtain a merit or distinction award. That would increase the basic salary of nearly £8,000 by a maximum of between £1,200 and £1,500 a year to more than £7,000 a year if the consultant receives a merit award of A-plus. To do so he would have to be a man of great distinction in international medicine.
We must consider something much more than a consultant's salary or contract and how much he should be earning. Doctors may well think that another £1,500 a year is a poor substitute for giving up private practice. I want to think much more widely than that. The Secretary of State has chosen to upset the whole basis of the National Health Service and the consultants' place in it. She will remove the private fee-paying patient. She wants to cut out that source of income for doctrinaire political reasons. She is prepared to give the doctors more money from the State and from the taxpayer. She will give the consultants a new contract but it will be an anti-social contract for the patient.
The right hon. Lady is against private patients because, as she says, there is no moral justification for them. But by her action she will be hurting the prospects of the public patients. I create that phrase. Private practice will continue outside the National Health Service if the right hon. Lady takes the steps that she has outlined. I am afraid that such a move will attract the cream of the consultants and the National Health Service will be left to try to cope with ever longer queues of patients. That is not something that we can allow to happen. I have no time for the right hon. Lady's doctrinaire views. They are set in the nineteenth 1231 century and unrelated to the real problem of looking after the peoples' health.
My right hon. and hon. Friends have to fight the right hon. Lady's doctrinaire approach. We must all stand up for the patient. We must stand up for the doctor and the medical service that seeks to look after the people. That can include any of us when we are ill. If the right hon. Lady bans pay beds has she thought what that will mean? There will be a severe drain on the existing hospital facilities in many parts of the country. In some areas it will be much worse than in others. For some patients privacy is a medical need, and in many areas it will be unobtainable in the National Health Service.
Privacy is obtainable in some parts of the country. I have checked on the position with a consultant. It is obtainable in Aberdeen, for example, but not in the South-East. It is obtainable in a private nursing home in the South-East but not in a National Health Service hospital. The teaching hospitals will almost certainly lose many of their part-time consultants and teachers. The NHS will be faced with an influx of patients and an exodus of some of its best practitioners.
It is not only the NHS which needs a rest. I suggest that the right hon. Lady should also take a rest. Her NHS aims are irrelevant and dangerous. Her speech today was doctrinaire, dogmatic and utterly lacking in wisdom. The best service that she can give the NHS would be to leave it alone and to go.
§ 8.50 p.m.
§ Mr. William Hamilton (Fife, Central)
I, too, must declare an interest. As I think the House already knows, I am sponsored by the Confederation of Health Service Employees.
I remind the hon. Member for Canterbury (Mr. Crouch) that the National Health Service itself was introduced for doctrinaire reasons. When Aneurin Bevan initiated it, he was a doctrinaire Socialist. He said that the principle was to be that people would get health treatment on the basis of need and not on the basis of the depth of their purse. At the time, that doctrine was rejected vehemently by the medical profession and the Conservative Party. Indeed, the Conservative Opposition then voted against the principle on the Second Reading of the National 1232 Health Service Bill, and throughout its stages in the House they continued to vote against various provisions. The pay beds were a compromise enforced upon Nye Bevan to get the consent of the doctors to work within the NHS.
My hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) referred to the statement to be made tomorrow about cuts in defence expenditure. The survival of this country depends as much on expenditure on health and education as it does on arms. In fact, arguably it depends more so. Yet the workers in both education and health— teachers, nurses and ancillary staff— remain, even now, after Halsbury, among the most underpaid and disgracefully exploited of all our workers.
I do not think that anyone would seriously dispute that the National Health Service is an example of practical Christianity and practical Socialism. It has managed to survive the almost continuous inflation we have had since 1945, and I believe that it is still the envy of the world, although it is drastically in need of resuscitation.
In the most difficult economic crisis since the war, the Government have acted. I think that my hon. Friend the Member for Wolverhampton, North-East got the figures wrong. We have not restored the cuts of £111 million imposed in December 1973. What my right hon. Friend the Secretary of State said was that the capital expenditure was to be £236 million in 1974 and £255 million in 1975, which represents a restoration, in real terms, of much less than the 20 per cent. cuts announced last December. According to my right hon. Friend, revenue expenditure is to be increased by £10 million next year. This goes some way towards restoring the cuts, but by no means as far as we would like to go.
Similarly, the Government produced the Halsbury Committee on nurses' pay, and its recommendations were backdated to the day it was set up. Those recommendations have been accepted and are in process of implementation. They go some way towards remedying the immediate grievances of some of the hospital staff, although by no means all.
We should be deluding ourselves if we pretended other than that it is going to be a very long and expensive haul before 1233 we can build the National Health Service to the standard we all yearn for. By its very nature, despite all the technological developments, it is going to be for a very long time—right into the foreseeable future—a labour-intensive industry. It cannot, in the nature of things, be depersonalised. In that sense, of course, it is subject more than any other service to the vagaries and evils of inflation. In such a situation we are caught, as a nation, in a net of conflicting and competing priorities.
We simply cannot do everything at once. The fact that £180 million was found in England to implement the Halsbury recommendations showed at least some earnest of the good intentions of the present Government. But I must point out to the Opposition that Halsbury showed that between April 1970 and April 1974—in effect, the whole of the lifetime of the previous Conservative Government—average earnings of nursing staff barely kept pace with the increase in the cost of living, while the earnings of all other salaried workers more than kept pace with that increase.
In April 1974 the average annual earnings of a nurse were £1,578. That is just about £30 a week gross. I have got pay lines from many nurses showing that they were taking home less than £20 a week. At the same time, the average annual earnings of all salaried workers were £2,168. That is roughly £40 a week gross—in other words, one-third more than the average earnings of nurses. In general, over those four years the standard of living of most workers improved, but the standard of living of women nurses, at best, remained static, and that of male nurses actually fell.
The COHSE happens to represent a large proportion of the male nurses, who are predominantly mental health nurses. What astounds me is how we get men to work in that field at all, still less within the present salary scales. I am very glad that my right hon. Friend said that one of her top priorities was mental health. The hon. Member for Canterbury rightly referred to some mental health institutions as being prison-like. We have them in Scotland. We all have them up and down the country. It will need a colossal amount of capital expenditure before we get on top of that problem. How right was my right hon. Friend when she said, 1234 "People before buildings." We want both, but they both cost a tremendous amount of money, which is simply not there. It would be completely in line with the social contract—indeed, an essential part of it—if all workers in the National Health Service, including the consultants, received substantial pay increases over the next few years.
I want to make some comments about the doctors within the National Health Service. My hon. Friend the Member for Wolverhampton, North-East referred to the evidence given by the junior hospital doctors to the sub-committee of which she was chairman. They have endured a long-standing and intolerable injustice in their salaries and conditions of work. Their salaries and conditions are a menace not only to themselves but to the patients whom they presume to serve. The growling of the consultants comes into a category very different from the grievances of the junior hospital doctors. The consultants' high-toned moralising posture smacks to me and to many others of a mixture of humbug and greed.
There is a growing body of opinion within the medical profession that believes in the abolition of all private practice within the National Health Service. I should like a quote a letter which appeared some time ago in The Guardian under the names of two doctors:It may be salutary to point out that of 75,000 doctors in the NHS there are 10,000 consultants, of whom 60 per cent. are part-time. The rest, the majority, have no truck with private beds in the NHS and for the most part will welcome the Government's intention of phasing out private beds from NHS hospitals …For too long now have these powerful consultants spoken for the medical profession as a whole. The MCAPP"—that is, the Medical Committee Against Private Practice—would like to say that there are many doctors, most health workers, and 95 per cent. of the population who believe in the NHS, and who wish to see it improve.We believe that this can only happen if the burden of private practice is removed, and, with it, a major source of the conflict of interests that separates ideal health care from impoverished health care.The letter goes on to point out that we have now half a million National Health Service patients on waiting lists, and that 85 per cent. of NHS beds are full although 1235 only 65 per cent. of the private beds in National Health Service hospitals are full at any one time. The empty private beds facilitate the queue-jumping which an Opposition Member said did not exist. We all know that queue-jumping exists. We all know that anyone who has the money can go to a consultant and get an operation which otherwise he would wait for for 18 months, two years, or more. Everyone knows it, and no one can defend it. It it time that it was stopped, and I hope that my hon. Friend will say something about that.
The right hon. and learned Member for Surrey, East (Sir G. Howe) does not often break into a sweat in this House. The only time that he broke into a sweat today was when he was talking about this and about the need to defend the consultants and their part-time practice in the health service.
No one wants to deny the right of a consultant to engage in private practice in his spare time and with his own equipment. But let him get outside the health service, build his own buildings and use his own equipment, instead of stealing it from the National Health Service, as was confirmed by the evidence given to the Exependiture Committee a few months ago. That evidence spoke of consultants stealing equipment from the National Health Service and using it in Harley Street to fill their pockets. That is quite indefensible, and I hope that my hon. Friend will stand firm against it.
The whole of the Labour Party is firm on this. We have to return to the basic principles on which the NHS was founded. To have a situation in which private consultants use health service equipment, time and personnel is obscene. Nurses and junior doctors are being used to line the pockets of consultants. In times of scarcity all round we have to get our priorities right. I wish my hon. Friend good luck in his job. If he is accused of doctrinaire practices, I remind him that we need not be ashamed of our Socialist doctrines and philosophies. That is what the National Health Service is all about.
§ 9.3 p.m.
§ Mr. Michael Morris (Northampton, South)
At the outset of my remarks I must declare an indirect interest, in that I am married to a practising general 1236 practitioner. As a result, of necessity my comments are coloured by 10 years of mutual experience of the National Health Service.
Listening to the debate and remembering the comments on our previous debates on the subject, I cannot help marvelling at the way that the Secretary of State has managed to cloud the immense problems facing the National Health Service by the emotive issue of payment for medicine and the tiny proportion of private beds in the National Health Service.
In emphasising one point, I take issue with the hon. Member for Fife, Central (Mr. Hamilton). I hope that he will remember that it is we, the public, who own the National Health Service hospitals. Through our contributions on our stamps, it is we and our families who own the facilities in the service. Every family in the land, regardless of whether they decide to top it up with private expenditure, own these facilities. It is we who own them and not the consultants. It is we who have the right if we wish to top up and to use those facilities. It does not lie with the Government to rule that those facilities should no longer be available to those who wish to top up.
Will the Minister, in reply, indicate whether it is the Government's intention, according to the current rumour, to remove the facilities of the regional blood transfusion service from those who are at present using it outside the National Health Service?
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
I can reassure the hon. Gentleman on that subject now. There has been some speculation, which is totally unfounded. We have no intention whatsoever of limiting the blood transfusion service, whether people are in private or NHS practice. The service will be available to everyone.
§ Mr. Morris
I am sure that the public and those who take note of these matters will welcome that statement and reassurance from the Minister.
It is fairly common knowledge that we spend a lesser proportion of our gross national product on health than do many industrialised nations. I shall not weary the House with the figures. The latest 1237 figures that I can find in a recent reply by the Minister, refer to 1969.
It is also accepted by economists and medical practitioners that the demand is limitless. As our resources and wealth grow, albeit at a slow rate at the moment, the demand for medical services rises.
It is against these two factors—the reduced proportion of our gross national product and the unending demand—that we must judge the Secretary of State's actions over the last nine months—not eight months—and her plans for the future.
I believe that it is convenient to look at the situation from two angles—the hospital service and the general practitioner service. We have had a number of contributions on the hospital service. The issue of private beds is one aspect of the problem. On to this the Government have cleverly grafted their determination, once and for all, to get rid of medical independence by ensuring that we have a full-time salaried Civil Service-like contract. This seems to be the underlying desire behind the Government's actions.
The Minister knows full well that any person in this land faced with a medical emergency will be dealt with immediately, whether or not he or she be a private or NHS patient, to the best abilities of those who look after us.
Reference has been made to queue jumping. The truth of the matter is that there are parts of the country where there are no waiting lists of any great length. In certain parts of the country the private and NHS waiting lists are different, but key stress areas, of which Northampton is one, have grown so fast that there is no queue jumping by anybody because there are long waiting lists for both private and NHS patients. Therefore, regardless of any action to remove private beds, there will be no benefit at all in stress areas.
General practitioners are men and women who, by their contracts, have to provide cover 24 hours a day, seven days a week, 52 weeks a year, for the princely sum of £1.50 a head. These devoted people are angry at the way their real incomes have been eroded, particularly in the last two years. I recognise that that is not entirely the fault of this Government. These people are angry at the way in which some of their services 1238 are being abused by the public. They are angry at the way in which the family planning service has been removed, particularly those who have trained and spent a great deal of time building up skills in that area. They are angry because they have to spend so much of their professional time patching up under-staffed and under-financed services.
Having listened to the Secretary of State this afternoon, I am forced to say that if she wants to make greater provision for health centres she should restrict them to those areas of social need that are pressing for them, and where the general practitioners themselves are pressing for them, because at the moment local authorities are demanding health centres regardless of the conditions of doctors' surgeries. There are some areas with good doctors' surgeries and a good patient-doctor relationship, yet the local authorities there are still insisting on having health centres.
Looking to the future, I cannot help but draw back and wonder whether, just for once, the Secretary of State would reflect for a few moments whether it is right to push through some of the doctrinaire policies that she is suggesting. We have in the medical profession, as I think all hon. Members will agree, a body of men and women who are dedicated to healing. That is the motivation for their going to medical school, and it is that that keeps them going when they come out at all hours of the day and night— those of us who are married may experience this more than others—to deal with somebody who is ill. If these dedicated people are to be motivated in the best way possible, it will be done by working with them instead of against them. It will be done by providing them with incentives to seek to improve the service and by considering ways of encouraging them.
I believe that we have had, and still have, some of the best doctors in the world. I regret to say that we have never had—though one hopes we shall have at some time in the future—the best health service. Surely it is not beyond the wit of politicians to find a way in which to use the energies and resources of the medical profession. If we do not—this is the great worry today, nearly 30 years after the passing of the National Health 1239 Service Act—the best will emigrate. The signs are not encouraging at the moment, as the figures are 10 per cent. up on a year ago. We shall see the standards of newcomers to the profession falling—the Minister knows as well as I do that the signs are not encouraging here, either— and we shall see those who are left in the service begin to work to rule. I see that as being basically alien to the desires of the medical profession.
The Secretary of State rightly said that the outlook at the moment is not encouraging. It is a question of the language of priorities, and surely in that context we ought to be saying that the nation's priority should be to work with the doctors, not against them.
§ 9.13 p.m.
§ Mr. Bryan Davies (Enfield, North)
When I first realised that the Opposition had chosen this subject for debate on a Supply Day I assumed that the debate would be about—and that is what it has turned out to be in the later stages— those actions for which the Government are responsible. I assumed that the debate would focus on the issue of pay beds and that some of the more charitable Opposition Members would recognise the Government's contribution to improving the pay of nurses in the National Health Service.
I was, therefore, surprised when the right hon. and learned Member for Surrey, East (Sir G. Howe) opened the debate with a widespread attack on the Government on a whole range of issues which most of us would recognise are beyond the capacity of any Government to cope with in the short space of nine months. We all recognise the problem of under-capitalisation of the health service. We all recognise the poverty of resources in crucial areas within it. We also all recognise that several classes of workers in the health service remain crucially underpaid. But that fault lies not at the door of the present Government, who are already taking steps to remedy some of the worst abuses; it clearly reflects the Opposition's attitude regarding social expenditure.
The remainder of the debate, so far as Opposition speakers have been concerned, has been constructed upon the basic pretext of "I am principle, you are doc- 1240 trinaire, and he is bigoted." We on the Government side may be accused of being doctrinaire, but our definition is of one principle—a principle which I do not think Opposition Members seek to challenge. It is the principle of the National Health Service that help should be given to those in need.
We may get, as we got from the hon. Member for Barkston Ash (Mr. Alison) a rationalisation of private beds, in terms that the abolition of them would not increase resources to the NHS. But we all know—this point comes regularly from our constituents—that private beds represent queue jumping, privilege and advantage in terms of medical care. If that is not so, how can one explain the vast increases of private insurance schemes and the fact that these schemes are available to executives in firms, and not to the other workers, because the firms are putting high priority on this extension of priority care to those whom they value the highest and to whom they pay the most.
I maintain that two standards of health care within the NHS are contrary to its principle and contrary to good practice, and should be opposed. On that basis, I welcome the initiatives that are being taken by the Government and by my right hon. Friend the Secretary of State.
The defence of private beds, as we have heard it this evening, has been based on a number of points. First, it seems that there must be among the Opposition a belief in the inalienable right of people to purchase good health. We challenge that. People do not seek to purchase good health. People want and need good health, irrespective of their purse. It would be a sorry day if we were to ration health according to a person's purse, and in so far as we do this at present, such an abuse should be remedied, lest we move towards the situation in the United States where priority for medical care for road accident victims may depend on the strength of the insurance card which each individual carries in his pocket. We are a long way from that situation. We are a long way from it because of the absolute principle of establishing the National Health Service in 1947–48. Any deficiencies which were revealed in the health service at that time and which still exist today should be remedied.
1241 Secondly, it is suggested that private beds inject resources into the NHS. My hon. Friend the Member for Fife, Central (Mr. Hamilton) emphasised that private beds and private practice in relation to the NHS may represent a detraction from its facilities.
Thirdly, there is a suggestion that basially the same facilities obtain whether in the private health service or in the NHS, mainly with regard to requests for privacy. If that is the case, and privacy is to be defended as an essential medical need in some cases—as it almost certainly is— it is a facility that we ought to extend to all NHS patients, not just to those who can afford to pay for it according to the size of their purse.
It has been suggested from the Opposition benches, in a desperate attempt to defend consultants, that professional independence is at stake. Is this the position that the Opposition would adopt, for example, with regard to salaries in the universities, such as the salaries of university professors? Is it being suggested that such people have sacrificed their independence and capacity to criticise because there they are paid full salaries? Certainly not.
I believe that my right hon. Friend the Secretary of State should stand firm in her intention to abolish private beds. We must recognise that there may be some vested interests in the thin ranks of the Opposition, but on this side of the House there is a determination not only of a united party but of millions of people to fight privilege in the NHS, because they are no longer prepared to tolerate it. The Opposition have argued that when resources are scarce we should not concern ourselves with redistributing resources. There are always too few resources to promote equality, according to the Opposition, yet they are always sufficient to maintain savage inequalities.
One other thing which reflects on private practice and its relationship to the Health Service is an abuse which is growing and should be terminated before it equals the present abuse of pay beds. I have mentioned it before. I refer to the growing employment of agency staff, rising at present to as much as 10 per cent. of the staff in London hospitals.
Agency staffing leads to a sapping of the morale of those in the NHS. It en- 1242 courages the part-time, so that there are fewer full-time people to bear the load, and they then have to take the burden of the extra and onerous services while the part-timers can be much more selective. Second, it reduces the efficiency of the services. Agency employment is often used as a means of overtime, which often means a reduction in the quality of service provided because of the tiredness of the individual.
Third, the crucial resentment is that agency staff work alongside full-time staff but get more pay. They receive increased rewards for similar work. This abuse leads to demoralisation. Finally, of course, some aspects of agency work are degrading, such as the tawdry offers of free summer time holidays if nurses register with agencies at increased pay and more perks if they sell themselves to the agencies.
The Government aim to bring in legislation to remove the abuse of tax evasion by means of agency work in the building industry. But the "lump" is emerging also in the NHS, and it should be speedily terminated.
§ 9.22 p.m.
§ Mrs. Elaine Kellett-Bowman (Lancaster)
The primary object of everyone who cares about the well-being of the National Health Service and of those who work in it should be to make the best possible use of all available resources. This requires, first, that the terms and conditions of service should be sufficiently attractive to provide the happy team spirit which is so essential and to prevent doctors, nurses and ancillary staff from going to greener pastures abroad. Highly trained medical personnel are very much an international market today, particularly on the American continent.
Second, it requires that as much money as possible from all sources be channelled into the service. The greatest weakness in the health service is its almost total dependence on central Government funds. When our economy was expanding and plenty of money was, or appeared to be, available to the health service, its total dependence on State money was less damaging. Now, however, when so-called Government funds— which is simply money forcibly removed from the wage packets of members of the public by means of the highest tax rate 1243 in the world today—are seriously limited, alternative sources of finance should be carefully nurtured, and not cut off at the root as the present Secretary of State apparently wants.
If our health service, as it once was, were still the envy of the world, it would seem strange that other countries have not modelled their hospital services on it. The answer, which it is almost heresy to state to the Labour Party, is that there can never be enough Government money for all the calls upon the service. As the Secretary of State herself obliquely illustrated today, there is never enough for building, equipment, wages and research, because the calls are infinite. Yet we are the only industrial democracy in which State hospital treatment is wholly paid for by the Exchequer and private financing is actively discouraged. Yet more, not less, non-Exchequer assistance must be channelled into health care if we are not to face a steady run down in the service, with crises in one sector after another.
As my right hon. and learned Friend the Member for Surrey, East (Sir G. Howe) said, we are this evening faced with trouble among 150,000 administrative staff. This is inevitable if we do not give to the service the money which it needs. With cash in such short supply this is not the time to be cutting off the £30 million which private medicine brings to the NHS. When Aneurin Bevan set up the Health Service he put private beds inside the new hospitals, not for the convenience of doctors, or as a bribe, as the hon. Member for Fife, Central (Mr. Hamilton), who is no longer with us, suggested, but to make sure that the time and skill of the doctors were used to the best advantage. Instead of NHS patients and private patients being miles apart, having them under one roof meant that doctors could keep an eye on all of their patients at once instead of travelling hither and thither from public to private institutions.
The hon. Member for Wolverhampton. North-East (Mrs. Short) said that hip operation delays were due to the shortage of beds. This is in no sense the case. It is because there is a shortage of the consultants who perform such operations. The waiting time for a private operation of this kind is very nearly two years, 1244 which is about the same as that in the NHS. These surgeons are very much in demand abroad, and I fear that they may very well go if they are not given adequate remuneration and an adequate chance of practising privately in this country.
It is often said, as a reason for getting rid of private education, that too many middle-class parents send their children to private schools and, therefore, have little interest in the State system of education. Surely this should be equally so with our system of health care. It we drive from NHS hospitals those who are prepared to pay, and to sacrifice part of their heavily taxed income to do so, they will have that much less incentive to see that the national health hospitals are kept up to scratch. What is equally important is that these private patients bring great benefits by way of benevolence to the hospitals. They give private benefactions for research purposes. If we drive them from our hospitals we will drive their funds away with them.
In the hospitals in my constituency the Halsbury Report has made little difference to recruitment, I regret to say. The recruitment situation is much as it was six or eight months ago. We are down on establishment, and the only way we can come anywhere near to establishment is by recruiting untrained staff. We are thankful to have them because they do a wonderful job, but we do not want to reach the stage when we have to rely upon more of these people.
We have to give our health service workers of all grades a fair crack of the whip. In our Conservative election manifesto, at the time of the last election, we said categorically that we would put people and their wages before hospital building, necessary though that was. That is still our view today. We believe that it is still the human element that is important. We believe, too, that those who give their very lives to the health service should be allowed to do what they wish in their spare time. Why should they be driven to the golf course or to doing their gardening when, if they so choose, they can be giving help to private patients in their own time? They are not stealing the equipment. They are paying handsomely for it.
It is time we got rid of this sterile argument between private and public patients 1245 and all worked together for the benefit of the health service and the good of all.
§ 9.28 p.m.
§ Mr. Cranley Onslow (Woking)
This has been a short debate but one which, I hope the House will agree, has been useful. Its theme, which has been obvious to those who have listened to all the speeches with care, as I have, has been one of probing and warning. Hon. Members have been probing the many aspects of the health service about which the House and the country have every right to be concerned and have been warning the Government about the programme upon which they are embarked and which we believe to be dangerous. It is these areas which are most in need of closer attention.
It was clear from the opening speech of my right hon. and learned Friend the member for Surrey, East (Sir G. Howe) just how many grounds for anxiety exist within the National Health Service. He spoke of a "grave and growing concern," and no one who spoke after him—least of all the right hon. Lady—said anything to dispel the truth of that description of the situation we face.
The unfortunate truth about the right hon. Lady's speech is that it was in many aspects as inadequate as it was embittered. She at least made statements of fact which the House would have benefited from having in the debate on the Queen's Speech. Hon. Members who take an interest in this subject will want to look with some care at what she said about the finances of the health service and at the precise meaning of her forecasts, which I am not sure are particularly encouraging. If I took down her words rightly, the right hon. Lady told us that many important schemes will have to be deferred. The House will want to know as soon as possible which schemes. That, no doubt, is a subject to which we shall return in an early debate.
Again, if I took down her words rightly, the right hon. Lady said that it will be impossible to maintain an increase in expenditure in real terms over the years ahead. The country would like to know what those words mean. Is there to be zero growth in expenditure, or is there to be a decrease? If. as appeared from something else the right hon. Lady 1246 said, more and more proportionately of the NHS budget is to go on salaries, is the decrease in capital expenditure to be proportionately greater? I ask the Minister of State to tell us when we are likely to have a statement about this, because it is a matter which we in the House, the NHS and the country view with great concern. [HON. MEMBERS: "Where is the right hon. Lady? "] I do not know where she is. I would much rather that she did not come. She would only annoy me.
The right hon. Lady spoke of cutting the waiting list. One of the best ways of doing that might be to staff up the empty beds in public wards. If more patients could be treated, the waiting list would be cut.
The right hon. Lady talked about priority for health centres. It is as well to be sure that transport will be available, so that patients whose doctors' surgeries are centralised some distance away will be able to get to the health centres and make use of the marvellous new facilities. I say that with a typical case in my constituency in mind.
The right hon. Lady's speech was characterised by an ungenerosity and narrowness of mind which undermined her arguments and eventually they must destroy them. It is perhaps some consolation to reflect that the right hon. Lady carries within her the seeds of her own political destruction, and I do not think it will be long before they ripen.
I should like to give the Minister of State the chance to do what the right hon. Lady might have done, which is to answer the questions which are of public concern. I shall give him as much of the remaining time as I can so that he will be able to give us the answers.
It is not enough, as the right hon. Lady told my right hon. and learned Friend when he asked about democratisation in the health service, to tell us that statements will be made in the House from time to time. I reiterate the question asked by my right hon. and learned Friend. What is the time scale for a decision on that subject?
I will rehearse some of my right hon. and learned Friend's other questions in case the Minister did not get a note of them. It is perhaps too soon for a statement about the industrial dispute which 1247 has blown up amongst hospital administrators, but may we have an undertaking that there will be an early statement in the House about that?
May we have an early statement by the most convenient means about the orthoptists; about the anxiety of the speech therapists over the appointment of area therapists; about the anxiety of dentists over the appointment of regional and district dental officers; about remuneration of the family planning service; about contracts for hospital junior doctors; about the time scale for the decision on the Halsbury review into the remuneration of nurses and other para-medical services? In particular, may we be told what is the situation about the non-Hals-bury review which is looking into the remuneration of doctors and dentists? What is the state of play? When may we expect a new chairman to be appointed, and what is the relevance of the statement that a pay review will start in April? It may be that I failed fully to follow what the right hon. Lady said, but I do not think I was the only one in the House to be slightly puzzled about the exact state of that review body.
Finally, in this connection can the Minister give us any further reason why the Government so obstinately refused to commission an independent review of the sources of finance of the National Health Service on the lines suggested by the Royal Colleges? As a newcomer to this scene, I was surprised to see how little of the cost of the treatment of victims of road accidents is recovered from the insurers, and I was amazed that none of the cost of the treatment of accidents at work is recovered from the insurers of employers. It seems to me that substantial sums are involved and that this is a matter which ought to be considered very soon.
The dominant issue of this debate has been the pay bed controversy and the question of consultants' contracts. I regret that this should have been so. I share the view that this is an unnecessary and irrelevant controversy, and I hope very much that this matter will not dominate the Minister's reply. There is a whole range of other matters which are of great importance to every hon. Member because he and his constituents from ex- 1248 perience are the best judges of the way in which the National Health Service is living up to the duty which we lay upon it.
My hon. Friend the Member for Barkston Ash (Mr. Alison) dealt skilfully and inimitably with the so-called queue-jumping. He dealt very well with the hon. Member for Fife, Central (Mr. Hamilton) as well. My hon. Friend the Member for Canterbury (Mr. Crouch) was absolutely right in expressing the need to strengthen the Health Service, although I am not sure that I would agree that the relationship between the regions, the areas and the districts applies to every region or area or district throughout the country. However, I agree that there is a clear need to allow things to shake down. This makes me wonder why the right hon. Lady has thrown the joker of so-called democratisation into the situation.
There were, amazingly enough, one or two matters which were not mentioned. We did not hear about the Briggs Report. The House will want to know what is happening about nurses' training. Hon. Members will also be interested in any thoughts which may be developing on the humanisation of Salmon, if I may use that phrase.
I am sure the country will be interested to know what the Minister of State has to say about a recent report in the Press that new immigrant doctors will have to go through a language examination before they become active participants in the National Health Service. This is something which we may want to probe in the future. A more important subject is the adequacy of the number of doctors actually practising in this country and whether this is increasing or whether we face the danger of a decline.
May I say a word about a very important subject, the status and treatment of ancillaries which the right hon. Lady mentioned briefly. She told us that an offer had been made to the ancillaries under the Whitley Council procedure. I wish she could have explained why, when for years the hospital ancillaries have been treated as being comparable to local government manual workers, the local government manual workers have been allowed a £30 settlement whereas hospital ancillaries have been offered £29.45.
§ Mr. John Tomlinson (Meriden) rose—
§ Mr. Onslow
No, I am not going to give way to the hon. Member. These facts, which come to me from the chairman of my local COHSE branch, I am happy to hear commented upon and challenged by anybody, even the hon. Member, whose voice delights us, but we shall have to forgo that pleasure tonight.
I turn to another point of substance. How do the Government intend to deal with the anomalies which have sprung up in the South-East, in particular, in relation to the London weighting allowance? Hospitals in the same town—this is so in my case, at least—will be on one side or the other of the line, and the effect on hospital recruitment will be damaging to those which lie outside the London weighting ring. Yet within the same county—again, this is true in Surrey— all local government employees have been given a London weighting allowance.
I wish to honour my promise to give the Minister of State as much time as possible.
§ Mr. Onslow
There is no question of my having nothing else to say, though I assure the hon. Member for Fife, Central that I can find nothing to say about his inherently irrational remarks. I do not know why he bothers to bore us with them. If he wrote them all down, people would be able to buy them, and I dare say that some would. But the purpose of a debate of this kind is to afford the Minister an opportunity to give the House and the country information. One can always spin out a speech with a bit of waffle turned out by the Department, as the right hon. Lady reminded us this evening. But I want to give the Minister a chance to give us some facts.
However, before doing that, I must return for a moment to the right hon. Lady herself in order to ask her whether she really meant what she said when she told the House that the greater the stringency the nation faces the more necessary 1250 is it that the Government should be seen to be building a fairer society.
§ Mr. Onslow
Plainly, the right hon. Lady means what she says. I have to tell her, however, that that sort of argument puts me in mind not so much of "Animal Farm" or "1984" but of "Planet of the Apes", for who is to say what is fair? Is it to be only those who are parties to the social contract? Is it to be only those who are lucky enough to have the right hon. Lady's ear? Are the professions to be given an opportunity to say what is fair? Are the patients to be given an opportunity to say what is fair?
§ Mr. Onslow
Instantly, the right hon. Lady reacts, as she has so often done, by putting all the blame on her predecessors, never on herself. Ask her a question and she gives a non-answer.
Probably, it is impossible for any Government ever to spend enough on the National Health Service to satisfy everyone or to meet every need. The demand must always outrun society's collective ability to pay. I hope that the right hon. Lady will agree with me at least about that. It follows that the more that ability is limited the more irresponsible and the more obscene it is, to borrow the favourite word of the hon. Member for Fife, Central, to constrict the individual's right to add from his own resources to the total sum spent on care or the total effort devoted to care.
This debate takes place against the background of great national anxiety. The Government have a special duty to set dogma aside, to forgo narrow political objectives and to prove that they really do care, to prove that they are not interested in narrow political objectives but that they want the nation to have the chance to do everything it can for itself. When she comes to be judged—and may it be soon—the right hon. Lady will be judged not on her political invective but on her practical achievement. It is a tragedy that she has shown so little sign today of knowing what the real needs of the nation are.
§ 9.45 p.m.
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
I am sure the whole House will welcome the hon. Member for Woking (Mr. Onslow) to the Dispatch Box to talk for the first time on the subject of the National Health Service. No doubt we shall disagree on certain matters, but we are well aware of the interest which the hon. Member's wife takes in the subject and which the hon. Member will now increasingly take, and we welcome him to these debates.
I shall do my best to pick up certain points of detail raised during the debate and subsequently to deal with points of principle which hon. Members have been discussing.
The right hon. and learned Member for Surrey, East (Sir G. Howe) and other hon. Members asked about democratisation of the health service and the time scale of decisions. The hon. Member for Canterbury (Mr. Crouch) also raised this issue. We shall certainly not be putting proposals before the House until the new year. We have recognised all along that we shall have to proceed at a pace which the health service can stand.
Since we came into office only three weeks before the date set for re-organisation, we have accepted reluctantly that the room for manoeuvre and change would always be limited by the state of the health service, and as the reorganisation problems grew so we were bound to temporise on any changes we wanted to make by that fact, but we did not accept it as an argument for maintaining the status quo. We intend to adopt a voluntary appoach, and the proposals put forward for consultation primarily affected membership of the various health authorities.
The right hon. and learned Gentleman asked me about the most recent industrial dispute, and I shall deal with it briefly. The Administrative and Clerical Whitley Council has offered to reduce the conditioned hours of administrative and clerical groups from 38 hours to 37— 36 in London—from 1st April next, this being the date of the next 12-month pay settlement for this group of staff. The staff side has been seeking a much earlier operative date for the reduction of the conditioned hours. The management side did not feel that a date earlier than the 1252 next annual review was appropriate, but it has offered to submit the case to the Conciliation and Arbitration Service for arbitration, and I hope that the staff side will take up the offer of arbitration.
We recognise that many of the people involved in this matter have worked very long hours and have taken on the very difficult task of implementing some of the recent pay settlements, some of which have been extremely complicated, and I would hope that they would agree with us that this question should at least be put to arbitration.
A number of other questions have been raised concerning the orthoptists and speech therapists. These form part of the professions supplementary to medicine, and the Halsbury inquiry is now proceeding with its examination in depth bearing in mind the staff side's request to review each of the eight professions independently. We have been told by Lord Halsbury that it would be unwise to assume completion of this examination before the end of the year. It will be the first time some of these professions have been looked at individually and in such depth for many years.
The remedial professions generally need special consideration. They are extremely important in terms of rehabilitating people back into the community, and I hope that Lord Halsbury's inquiry will lead to major improvements which the whole House will be able to support.
I have been asked about dentists. I will look into the particular problem referred to, but I accept that the dental service needs close scrutiny. It is facing severe problems because of inflation. We have recently had to increase substantially the fees that dentists receive, and rightly so. We took the decision that we would not increase the charges to patients, and I agree that we now need to look in a fairly fundamental way at the problems of the dental service.
I turn now to family planning. It needs to be put on the record that the question of the GP's fee was put to the Doctors' and Dentists' Review Body and it made a recommendation which the Government accepted but which the profession felt unable to accept. It was largely because of that that we were not able to bring general practitioners within 1253 the embrace of the comprehensive family planning service, which is something the whole House wishes to happen. Negotiations are taking place between representatives of the family doctors and representatives of the hospital doctors, and I hope we shall reach a solution to these problems.
I have also been asked about junior hospital doctors. In November last year the Hospital Junior Staffs Group Council of the BMA submitted proposals for extensive changes in junior doctors' contracts. It was a lengthy document, which included 30 detailed and far-reaching proposals for changes in the contract. I do not complain about that. They relate to the content of juniors' contractual commitment, arrangements for residence, and hours of work. We have had a number of meetings with the council to discuss those proposals. I am very sympathetic to their objectives. Hon. Members on the Government benches have fought the case for junior doctors for many years. Firm agreements have been reached on several counts. Further consideration is now required, and we are due to have a meeting with the juniors next month.
§ Sir G. Howe
I hope that the hon. Gentleman understands, and will convey to those representing him in the talks, the extent to which the junior doctors feel that they are not receiving authoritative responses. They are truly frustrated—I know, because I had the opportunity to talk with them last week—by the recurrence of meetings which seem to lead nowhere. If the hon. Gentleman will impress on those conducting the discussions the importance of reaching firm conclusions it will be much appreciated.
§ Dr. Owen
I shall certainly do so. It is a cause near to my own heart. We need to look carefully into this matter and many other aspects of doctors' pay.
I was also asked about the appointment of a new chairman to the Doctors and Dentists Review Body. My right hon. Friend the Prime Minister told the House only last week that he would make a new appointment as soon as possible. The Government recognise the need for speed in that area.
1254 I come now to some of the detailed comments. The Government attach a great deal of importance to the Briggs Report on nursing, which offers the possibility of a major change in the whole nursing profession. Some hon. Members have said that despite the increase in nurses' pay recruitment in some areas has still not increased. There is much more to the problem of nurses than the matter of pay, although that is an important ingredient. Legislation will be needed before the reforms can be brought into effect. We intend to try to introduce a Bill at the earliest opportunity. On 18th September more details of the Briggs proposals, made after full consultation with all the interested parties, were sent to the statutory and professional bodies and service authorities for their consideration. Therefore, it can be seen that we are moving ahead as fast as we can.
My hon. Friend the Member for Enfield, North (Mr. Davies) referred to a problem which I know has worried him and many other hon. Members for some time—that of agency nurses. We are determined progressively to reduce the dependence of the National Health Service on nursing agencies. Increases in nurses' pay, together with the changes that have been taking place, the prospect of implementing Briggs, widespread concern about the use of agency nurses in hospitals, and the current financial restraints, make this an ideal time to take firm action. We shall be consulting the staff side before we issue a circular to help authorities on agency nurses.
Having dealt with many of the detailed points, I come to two central themes of the debate. The first was the question of financial resources. The hon. Member for Woking said that the House would want to know what schemes were likely to be deferred and when there was likely to be a statement of the details. The main thing that we must do first is to consult widely. My right hon. Friend the Secretary of State made clear that a number of consultations must take place. If we are to protect medical students' intake, we must consult the University Grants Committee as well as the deans of the medical schools.
The priorities that my right hon. Friend outlined have not yet been challenged. 1255 Although the debate has had some elements of controversy, the one area where there does not appear to be controversy in the House is the Government's decision to put the priority, at a time of difficult financial circumstances, on people before buildings. However, I hope that the House realises the consequences of making such a choice. Many projects close to the hearts of all hon. Members, and affecting their constituencies, will have to be postponed. The economic situation on capital account is not easy. Therefore, we shall all have to make choices, and the sort of choices outlined by my right hon. Friend will have severe consequences.
We cannot do as we hoped to do— namely, to protect the geriatric services, the mentally handicapped services and the mentally ill services—without feeling the pinch elsewhere. What must stop is the degree of special pleading in the House which tends to dominate the health services. If we are to make broad choices there is a responsibility on both sides of the House to try to stick to them through difficult times. We have laid out the basis on which we shall go to the health authorities. We shall let the House know the full implications for some of the capital projects as soon as possible.
I now deal with the issue of private practice. The right hon. and learned Member for Surrey, East talked about the Government seeking to generate strife and dissension. This is not a new cause of disagreement. The right hon. and learned Gentleman fails to realise that private practice within National Health Service hospitals has been a subject of controversy for many decades. It aroused controversy even before the National Health Service was established. The controversy has increased. It is bound to be the case that as health services are rationed services we cannot provide for and meet every need. If we are to provide a private service within a National Health Service hospital the co-location or the proximity tends to cause ill-feeling and emotion and raises controversy.
I must tell the right hon. and learned Gentleman and many Conservative hon. Members that they would do well to look at some of the documents—they were only negotiating documents but they had to be released and published because of 1256 a lot of leaks—before criticising some of the Government's proposals. Some of the documents to which I have referred appeared in the House in early November. They make it clear that the Government are not seeking to generate strife and dissension. The House owes it to itself to put some of the criticism in perspective. The Lancet, one of the most distinguished medical journals, says of this matterAnother interpretation, to which we inclined, was that the Government proposals (to which, as yet, no costing has been applied) formed a basis for negotiation. There was nothing here which inevitably put 'professional independence at stake' or which could be convincingly called 'the persecution of part-time consultants'. Indeed, on reflection, many consultants and near-consultants might find the proposed full-time contract decidelly attractive. Anyway they should be given a longer chance to consider all its aspects, before their representatives precipitate them into a confrontation which would drive deeper wounds into the vitals of the NHS.The fevered stance of the BMA and the Hospital and Consultant Specialists Association is almost, but not quite, one from which their representatives can unbend only with loss of dignity; and the Government must strive to offer them every chance to yield not too uncomfortably, to compromise.That is the view of one professional journal. In addition, we must consider some of the correspondence that has been published in the British Medical Journal. Many people believe that the Government's proposals offer a great deal to the National Health Service.
When considering private practice the House should ask itself a few basic questions. If society decides, as it did in 1946, that its national pattern of health care should be organised on the basis of need, it is inevitable that people will question the justification of a health care system organised on the ability to pay. The fundamental issue of principle is whether the Government should support a system of health care which may mean that the time of highly-skilled people is allocated not to those who most need such skills but to those who can pay for them.
The hon. Member for Barkston Ash (Mr. Alison) put his finger on the point when he said that doctors' skills are scarce. What we hope to have is distribution of such skills according to need and not according to the ability to pay. We recognise that the problem of waiting 1257 lists will not be completely solved by the abolition of pay beds within National Health Service hospitals. That is only part of the problem. One of the proposals—
§ It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.