§ Mr. Speaker
I have selected the amendment in the name of the right hon. Gentleman the Leader of the Opposition.
§ The Secretary of State for Social Services (Mr. Patrick Jenkin)
I beg to move,
That this House takes note of the Report of the Royal Commission on the National Health Service [Cmnd. 7615].
The purpose of today's debate is to give right hon. and hon. Members in all parts of the House the chance to express their views on the Merrison report. Since the establishment of the National Health Service after the last war, there have been a number of reports on various aspects of the Service, but this was the first set up to examine the Service in its entirety. Some had expected, perhaps, something more dramatic—a report which would signal a major turning point in post-war policies for health. Others anticipated a much more pessimistic document reflecting so much of the evidence which Sir Alec Merrison described at an early stage in the commission's work as "a high-pitched scream".
I know that I speak for the whole House when I express thanks to Sir Alec and his colleagues for the long and arduous hours which they devoted to their task. Whatever its origins—I shall come to that in a moment—the report stands as a valuable compendium of information and proposals about the nation's health care services. I believe that many, perhaps most, people will accept the commission's judgment that the National Health Service is neitherthe envy of the worldnoron the point of collapse".Many would agree, too, with the conclusion thatwe need not feel ashamed of our Health Service and that there are many aspects of it of which we can be justly proud.The commission recognised that it dealtonly cursorily, and sometimes perhaps even superficially, with important topics".That does not detract from the value of much that the report contains.
The commission started life in very curious circumstances. It was conceived in crisis. No doubt the appropriate parts of Mrs. Barbara Castle's diary will shed 455 as much light on the events leading up to the establishment of the commission on 20 October 1975 as they have on her defeat on "In Place of Strife"
Right hon. and hon. Members who were in the House at the time will remember that, as Secretary of State for Social Services, Mrs. Castle had succeeded in antagonising virtually every major group in the National Health Service, with the possible exception of isolated groups of trade union militants who were blacking private patients. There is little doubt that the main purpose of the establishment of the commission was to get Mrs. Castle off the hook. If she had not chosen to "stir it up" after the 1974 election, there would have been no Royal Commission, no 500-page report, none of the 117 recommendations, and little of the vast volume of evidence which the commission studied. So perhaps, after all, Mrs. Castle was not wholly in vain.
I begin my remarks on the report with three general points on which I hope there can be wide accord in the House.
First, although public concern about our health services tends to focus largely, sometimes even exclusively, on our acute hospital services, the health of the nation depends upon a far broader spectrum of services. It is sometimes said that the public health measures of the last century, coupled with the notable improvements in the standard of living of the country that have been made in this century, have done more to improve the health of our people than all the ministrations of the entire medical and nursing professions. Clean water, clean air, better housing, better standards of nutrition, the control of infectious diseases—all these have transformed the lives of our people as they have transformed the lives of countless millions all over the world, many of whom have no access at all to a national health service as we understand the term.
The point I am seeking to make is that the range of services which we usually think of as constituting the National Health Service form but a part of a much wider range of policies and attitudes which influence people's health. In this wider context, as much responsibility attaches to individuals as rests upon public authorities. There is a risk that if we attach disproportionate attention to the National Health Service in its narrow 456 sense we may fall into the error of underrating the extent to which individuals can and should accept responsibility for their own health.
That leads on to my second point—that the demand for health services exceeds the supply. There is no limit to the amount that could be spent on health services. The Royal Commission quoted one witness as saying that we could easily spend the whole of the gross national product on health care. The 1944 White Paper, and many of the debates and the legislation that followed, failed to recognise the truth of that point. The 1944 White Paper stated:The proposed service must be comprehensive in two senses—first that it is available to all people, and, second, that it covers all necessary forms of health care".The Royal Commission commented:The impossibility of meeting all demands for health services was not anticipated".It can say that again. Perhaps one of the heaviest burdens which our doctors and nurses and others who work in the National Health Service have to carry is the sheer pressure created by rising expectations.
Our people have been encouraged by successive generations of politicians to believe that they are always entitled, as of right, to have their every health expectation promptly and expertly satisfied. I believe that that is a sheer impossibility.
§ Dr. M. S. Miller (East Kilbride)
Will the Minister indicate whether that statement refers only to the National Health Service or to health services in general?
§ Mr. Jenkin
Obviously it refers to health services in general. In a privately financed health service—financed by insurance or by charges—a market can operate and demand can influence supply. My proposition is true generally. Certainly it is true in countries that finance their health services in different ways. Every Minister of Health has had to recognise that.
I note that my predecessor, the right hon. Member for Norwich, North (Mr. Ennals), is in the Chamber. He told the House in April 1978:Of course there are limits to the amount of money that can be made available and limits to what we can do within any given budget. We should all like more money for the NHS. But there is only so much that the taxpayer is prepared to afford."—[Official Report, 20 April 1978; Vol. 948, c. 700.]457 The right hon. Gentleman was right and, I am glad to see, still stands by what he said.
However, we must be prepared, as politicians, to accept the logic of that proposition. We must stop encouraging the public in the belief that they can have whatever they want, whenever they want it. We must begin to protect our doctors, nurses, hospitals and clinics from the ever-mounting pressure of demand which seems sometimes to threaten and engulf the Service. People must learn that if they consult their doctor for every minor ailment, or seek help for problems that are not really medical problems, if they demand "a pill for every ill", they cannot legitimately complain if the resources do not exist when serious trouble arises.
§ Mr. Laurie Pavitt(Brent, South)
Will the right hon. Gentleman consider the corollary of his statement? One of the greatest problems is early diagnosis, and to persuade people who are reluctant to go to their doctor anyway not to go would be just as counter-productive to the NHS as the nostrum he is putting before the House.
§ Mr. Jenkin
I realise that the hon. Gentleman knows a great deal about these matters. He is perfectly right. There is a real dilemma which people have to face. The hon. Gentleman must have complaints, as do many of my right hon. and hon. Friends, from general practitioners that their surgeries are filled with people who have no need to be there. Labour Members are always complaining about the huge drugs bill which is incurred by the National Health Service. Hon. Members are now receiving continuing complaints of people being referred to out-patient departments for treatment which in past years was carried out by general practitioners.
§ Dr. Shirley Summerskill(Halifax)
The right hon. Gentleman has mentioned the crowded surgeries and the huge drugs bill that results, but the Royal Commission report distinctly points out that the charges for drugs imposed on patients at the time of need do not make for "better doctoring" or discouragefrivolous use of the Health Service by the public".Will the right hon. Gentleman assure the House that he will make representa- 458 tions to the Chancellor of the Exchequer on the basis of the report, and that he will not raise prescription charges as they do not discourage patients from going to surgeries?
§ Mr. Jenkin
I shall have something to say about charges in a few moments. Perhaps the hon. Lady will wait until then for my answer.
§ Mrs. Elaine Kellett-Bowman(Lancaster)
With regard to the huge drugs bill, my right hon. Friend will have seen the report about various local authorities making vast savings on drugs. One of them has saved £100,000. If that were multiplied all over the country, would it not be true to say that we could get an equally effective, if not more effective, Health Service without paying at all?
§ Mr. Jenkin
Although we may have had some criticism of the campaign that my predecessor launched, with the funny little Disney-like figure, which irritated a lot of people, the objective is clear. There is a case for trying to persuade patients that they should not ask for a pill for every ill. Doctors should also try to be more sparing in their prescription of drugs. It is a clinical matter and it is dangerous for politicians to tread on clinical paths, but my hon. Friend is right in what she says. There are instances in which medical practices and hospitals have deliberately set out to try to reduce the drugs bill. They have found that by giving attention to the question it has been possible to succeed. That is the kind of thing for which we must look.
§ Mr. David Ennals (Norwich, North)
Will the right hon. Gentleman be dealing with the recommendation of the Royal Commission that there should be a limited list, which I believe would save a great deal of money that is being overspent on drugs?
§ Mr. Jenkin
There is a wide range of views on this matter. When I spoke to the British pharmaceutical conference in Exeter in September, I indicated that I was not much attracted by that proposition, but it will continue to be studied.
The point that I was making is that the National Health Service simply cannot attend to all ills. It used to be the envy of the world. The commission 459 believes that there are still aspects of it of which we can be proud. But even this muted praise will fade into recrimination if all of us who use the Health Service do not learn to do so with a greater sense of responsibility.
Doctors often tell us that their best patients are those in late middle age or older; they do not seek help unless it is really necessary. Many younger people, who have grown up knowing only the National Health Service, seem to have fewer inhibitions and are very much more demanding. I believe that there is a need for a widespread programme of public education to encourage a more responsible, a more restrained and a more informed use of our health services.
I have been told that the financial constraints of the last few years have in some ways been good for the Service, in that they have encouraged the elimination of much waste. I am sure that that is true. But have these constraints yet begun to influence patient attitudes? It is difficult to be clear about this. It is very subjective but I get the impression, in talking to doctors around the country, that there is as yet little sign of it. It is a fact that should give the House cause to think.
Of course, we can encourage individuals to do more to insure themselves and to seek treatment outside the Health Service. Of course, we can encourage people and firms to give voluntarily to finance Health Service projects. That must be common sense in the circumstances in which we find ourselves. But it will not be enough. Every developed country has had to take steps to restrict its expenditure on health services. We are no exception. I agree with the commission when it said:To believe that one can satisfy the demand for health care is illusory and that is something that all of us, patients and providers alike, must accept in our thinking about the NHS".After 30 years of rising expectations, it will not be an easy lesson to learn.
This brings me to my third point, which concerns resources. The commission stated:It would be unrealistic to suppose that the fortunes of the National Health Service can be insulated from those of the nation.The Government are committed to maintaining spending on the National Health Service at the level set out last January in 460 the White Paper of the Labour Government. We have every intention of adhering to that pledge.
The gross expenditure on the National Health Service for Great Britain for 1978–79 was £7,900,000,000. The estimated out-turn for 1979–80 is £7,930,000,000. The planned spending for 1980–81, set out in the White Paper published before Christmas is £8,170,000,000. If we look at the net spending, we find that the growth is rather more, because more of the expenditure is covered by charges. The 1978–79 outturn was £7,720,000,000, in 1979–80 it was £7,730,000,000, and the plan for 1980–81 is for £7,900,000,000.
The figures are clear. I have never tried to conceal that in the current year, 1979–80, the Service is facing difficulties. The squeeze on spending this year has to be contrasted with the obligations that we inherited—and have fully honoured—to finance the pay increases that we inherited, particularly those arising from the Clegg comparability exercises. By the end of the year, the Government will have had to find between £350 million and £400 million over and above the cash limits laid down by our predecessor. That is three times the amount that we have had to ask the Health Service to find by making savings.
No one can escape the facts. If we spend more on pay, there is less left for services, and 1 per cent. on the NHS wage bill could provide for 80,000 in-patients, or could build 1,000 hospital beds or buy 6,000 kidney machines. The trade-off between pay and services is evident.
For 1980–81, the Government will make up for this year's inflation and, over and above that, provide for 0.5 per cent. growth, which is precisely in line with the previous Government's projection. We can all recognise—this is common ground—that this rate of growth is not as much as the Service needs to cope with an ageing population, to keep up with medical advances and to maintain standards. We recognise that.
It cannot be said too often that what we spend on health depends on what we earn as a nation. Until the nation is earning more, we shall have to make do with this very low level of growth.
I have, nevertheless, decided to continue next year the redistribution of resources across the country that has been 461 going on since the Resource Allocation Working Party reported in 1976. No region should receive an increase in real terms in its allocation of less than 0.3 per cent. This will enable me to give the worst-off regions, as defined by the RAWP, an increase twice as big, of 0.6 per cent., when more funds become available to the Service in the future so that the redistribution process can go faster. I hope to announce the volume allocations next month.
It is against this financial background that we have to look at the Opposition's amendment and at the commission's suggestion, to which my hon. Friend the Member for Lancaster (Mrs. Kellett-Bowman) referred, that all charges should be eliminated. It put the cost at about £200 million at the price levels of a year or so ago. I have to tell the House that, if the charges were to be abolished today, this could be achieved only by a cut in spending on the National Health Service by an equivalent figure, and today's figure would be nearer £250 million. [Interruption.] Where do the Opposition think that the money is to come from? Would they have been any more successful in getting it out of a Labour Chancellor of the Exchequer? Of course not. It would be the equivalent of building five new hospitals each year, each costing £50 million. That is what we would have to forgo if we were to do without charges.
The commission, as an advisory body, was not faced with the practical consequences of abandoning charges, but the Opposition have been faced with those consequences. The pattern of their behaviour—I say this in all frankness—has been entirely consistent. In Opposition Labour Members invariably demand the abolition of charges. In Government they invariably put them up. That is the consistency of sheer humbug. I see hon. Members shaking their heads, but they should look at what happened with dental and optical charges. The Labour Government tried to put up road accident charges and produced a silly scheme that they had to abandon. Who introduced the present pattern of prescription charges? It was Kenneth Robinson, a Labour Minister of Health.
The Conservative Party does not say one thing in opposition and do another when in Government.
§ Mr. Jenkin
No. The right hon. Member is obviously poised to make a speech. He can make his point then.
We have never pretended that we could do without charges. Charges are an essential part of paying for the National Health Service. Unlike the Labour Party, we believe that that is one way of underlining the responsibility of the individual for his own health care—that he should pay part of the cost where he can afford it.
Against that background—of knowing that one can never meet all expectations, and that there is a limit to what the taxpayer will pay—is it so unreasonable for the Government to examine alternative methods of financing health care? I know of no other advanced industrial country that finances so high a proportion of its health care needs from taxation.
The Royal Commission pointed out some of the disadvantages—and I acknowledge them—that a shift to greater reliance on insurance might entail. These disadvantages are neither fanciful nor insubstantial. We have no intention, for instance, of trying to imitate the United States. However, across the Channel one finds countries that have comprehensive health care. People there are not denied the benefit of medical attention because they cannot pay for it. Such countries are able to pay a higher proportion of their gross national product on health care services but a substantial proportion of the cost is met by some form of health insurance. There are advantages in such a system.
My hon. Friend the Minister for Health and I, when touring those countries, noted some of those advantages. For instance, we noted the advantage gained in a hospital which can generate its own finance. It is thus autonomous and runs its own show in a way that is almost impossible in this country. I believe that any sensible Government, faced with financial constraints, should look at the experience of other nations to see what can be learnt.
I therefore make no apology for the fact that this Government have set in train an investigation of the possibilities of increasing the insurance element as a means of financing the National Health 463 Service, though I have to tell the House that it is likely to be some little while before I can report the outcome of this study. A number of bodies outside the Government are similarly engaged on work in this area, and we shall wish to take account of this in our own thinking.
I turn now to some of the specific recommendations of the Royal Commission on which the House will want to know the Government's views.
First, I shall deal with structure and management. The House will remember that on Second Reading of the Health Services Bill I specifically reserved my remarks on that subject for today's debate. We warmly endorse the Royal Commission's view that…large organisations are most efficient when problems are solved and decisions taken at the lowest effective point.I believe that more local responsibility will mean greater responsiveness to patients' needs and better staff morale. That is the thinking that illuminates the proposal which we have put forward for consultation in our document "Patients First".
The Royal Commission, in proposing a strengthening of management at the unit level and a simplification of the structure above that level, reflects a wide consensus. Attention both inside and outside the House has tended to concentrate on the elimination of the area tier. It has to be recognised that in many places there are six tiers of management, not three. There are the DHSS, region, area, district, sector and unit levels. In the Government's view, it is the last named, the unit level—that is, the hospital and the primary care services—which is much the most important.
The main thrust of the proposals in "Patients First" is aimed at pushing down responsibility to the hospital and primary care service levels. To achieve that, we need to strengthen the administration at that level so that managers can take on the greater responsibility that they will bear. We want senior administrators, senior nurses, back in the hospitals and running the community services. If this can become effective, we see no need for an intermediate sector level between the hospital and the health authority. By "the hospital" I mean, In some cases, a group of smaller hospitals.
§ Mr. Jenkin
It will reduce bureaucracy. We have had the grace to recognise mistakes and are doing something to put those mistakes right.
It is common ground that multi-district areas have not proved satisfactory in practice. There has been a duplication of staff and functions at area and district level and health authorities have been somewhat remote both from Health Service staff working with patients and from local communities. We therefore propose a rather larger number of smaller district health authorities normally covering populations between 200,000 and 500,000. Such authorities would make for more effective management of the services for which they are responsible and allow a much better understanding between health authority members, the staff and the public.
The Royal Commission gave consensus management what I think many people regarded as a surprisingly clean bill of health. For the management of districts, we will retain consensus management. In the Government's view, however, this team approach can never replace the personal responsibility of individual managers for managing the services for which they are answerable. What the Service needs above all else is good, effective local leadership, and leadership is essentially a matter of individual men and women in positions of responsibility.
The role of a consensus team is to take strategy decisions and deal with broad planning and matters of that sort. Their task is to gain the commitment and support of all the disciplines involved.
In "Patients First" we said that we would not change the system of family practitioner committees, which, on the whole, have worked well and given rise to few difficulties. We therefore disagree with the Royal Commission and propose instead to accept the views of the professions administered by the FPCs. We want them to be retained.
The question of the future of community health councils is more difficult. I am on record in the House, and outside, as paying tribute to the work of many CHCs on behalf of the public as consumers. Paragraph 26 of "Patients First" means exactly what it says. The 465 creation of more locally based district health authorities certainly raises the question about the need to have community health councils in addition.
Next year the cost of these councils will be over £4 million. It is certainly proper to ask whether that money would be better spent directly on patient care. However, the Government's mind is genuinely open on this question, and we shall listen with great care to what is said both in the House and in response to a consultative paper.
Another recommendation of the commission, which we have rejected, is its suggestion that regional health authorities should become directly accountable to the House. I do not see how that could accord with our constitutional arrangements. It is the Secretary of State who is accountable to this House for the Health Service and for the money spent on it, and it is he who can be made to answer on the Floor of the House or in Committee for failures.
I cannot see how the chairman of a regional health authority, let alone all the members of that authority, can be held accountable. In any event, it does not seem to us that it is consistent with our desire to give more authority and greater autonomy at local level.
We see a continuing and important role for regional health authorities, principally for the allocation of resources, for ensuring firm financial control down the line, and for strategic planning. Regions will have the immediate task of making proposals for the restructuring of the Service in their regions, but "Patients First" opens up the possibility of looking at regions rather differently in the future.
What we have in mind is that it would help to underline our desire to see more local autonomy if the regional role were more a co-ordinating and less a controlling role. That is why in paragraph 40 of "Patients First" we suggest that one possibility is for the majority of the members of the regional health authority to consist not of independently appointed people but of the chairmen of the district health authorities and their constituent districts. I must stress that any such change would come, not immediately but in perhaps three or four years, after the Service has been simplified at the local level as I described a moment ago.
466 We also propose to simplify the professional advisory machinery, so that the views of clinical doctors and other professionals will have more impact on health authorities, but at lower cost to the Service and with less wasted time by highly trained clinicians sitting on committees and doing tiresome paper work. I should like to make it clear that the same principle applies to community physicians. I share the view of the Royal Commission that the specialty of community medicine has a future, but the highly specialised doctors concerned must be allowed to concentrate on profesional matters and be given help to spare them merely administrative chores. If in our restructuring of the health authorities we can manage with fewer administrative doctors, they must be encouraged to move back into clinical work.
In the same way, the NHS needs the nurses who carry out essential administrative and managerial functions. However, I want to ensure that we do not have more managers than we need. Above all, I want to ensure that professional people who are mainly engaged in clinical work are not distracted from it by avoidable and repetitive administrative chores of one sort or another. In so far as they are, I believe that we must try to relieve them of the burden so that they can concentrate on their main task—the clinical care of patients.
London has especially difficult problems. The Royal Commission recommended an independent inquiry into London's problems. We came to the conclusion that this was a recipe for delay, and we do not propose to proceed in that way. As it happens, the problems are becoming better understood as a result of a number of studies by the London Health Planning Consortium, the University of London—the Flowers working party—and others. I recognise that difficult decisions lie ahead, but the Government are determined that they will be taken with the minimum delay. As a London Member, I say that London's problems have been left unresolved for too long. In the interests of Londoners and, indeed, of the rest of the country, the uncertainty must be ended—and this is what we aim to do.
I stress that the Government document is genuinely consultative. We have to strike a balance between giving time for 467 proper discussion and a long period of uncertainty for staff. There is also the danger of planning blight, stressed by the Royal Commission. We propose to take decisions in the light of comments on "Patients First" received by the middle of the year. We hope that all structural and managerial changes will have taken effect by the end of 1983.
I turn to the rest of the Royal Commission's recommendations. Obviously, I cannot deal with more than a few. Some of the recommendations involve heavy spending. In round figures, it is estimated that the cost of the Royal Commission's recommendations could be another £2 billion a year. Obviously, that amount of money does not begin to be available under present circumstances. Those recommendations must await the availability of money.
Many of the recommendations either endorse existing policy or can be taken on board in the course of normal departmental business. However, some of them touch on the wider issues which I mentioned at the beginning of my speech. The first is prevention. The commission set as itsfirst objective for the NHSthat it shouldencourage and assist individuals to remain healthy".This is as much a matter for each individual as it is for the Health Service. Certainly prevention is infinitely better than cure, and each of us must accept a primary responsibility for looking after our own health.
Health education is an essential process in creating understanding and in generating the will to safeguard one's health. When examining departmental quangos, I had no difficulty in deciding that the Health Education Council has an essential role, which is better performed outside than in Government. However, I have asked the new chairman, Professor Lloyd, to conduct a thorough review of the council's work, with a review to seeing how the council can become more effective in reaching out to the public and influencing the public's attitude on health matters.
I am in little doubt that much health education can take place only in our schools. That is the age at which the basic lessons of good health can be 468 learnt. Later in life, teaching has an uncomfortable way of turning into preaching, and that tends to be both resisted and resented. I want to see the Health Service playing a fuller role in health education. In one sense, every time a patient sees his doctor it should be an occasion for health education. I want to see health education officers playing a leading role at the local level as initiators, organisers, providers and distributors of information. My right hon. and learned Friend the Secretary of State for Education and Science has recognised in his rec0ent consultation paper on the curriculum the place of health education in schools. If we ask individuals to accept more personal responsibility, as we are right to do, we must ensure that they have the necessary knowledge to make that a reality.
The Royal Commission has endorsed the call for fluoridation of water supplies. I am fully alive, as is every Minister who has held my office, to the controversial nature of this recommendation. I have to tell the House that it remains the Government's view that extensive trials throughout the world have shown that it safely and effectively reduces the prevalence of dental caries—one of the commonest diseases and one which has lifetime consequences for general and dental health. Like all my predecessors in this post, I have been impressed by the authority of bodies which support fluoridation—the Royal College of Physicians, the British Medical Association, the British Dental Association, the United States Public Health Service, the Canadian Department of National Health and Welfare and the Australian National Health and Medical Research Council. The list is long and distinguished.
In Britain only 9 per cent. of the population is receiving fluoridated water. In Canada the figure is 46 per cent., in the United States of America 47 per cent., in New Zealand 63 per cent. and in Eire 90 per cent. Children in areas receiving fluoridated water have markedly healthier teeth, and I understand why the Royal Commission recommended legislation.
However, on such a controversial issue we in this country have to proceed by consent and I must tell the House that the Government have, at the moment, no proposals for legislation. Rather, let us see whether we can achieve better results by persuasion. [HON. MEMBERS: "Why 469 not?"]. The powers exist but we need to persuade people to use them.
§ Mr. Ennals
This issue is of extreme importance. When I was Secretary of State, it became clear not only that the evidence in favour of fluoridation was overwhelming but that the vast majority of the area health authorities wished to have it. However, I discovered that a modest amendment of the law was required to enable the health authorities to carry out their wish. I cannot understand why the Secretary of State does not proceed now, in the early months of a new Government, on a controversial subject and introduce that small item of legislation.
§ Mr. Jenkin
My hon. Friends want to know why, if the right hon. Member for Norwich, North is so sure, he did not introduce legislation himself. A motion has been signed by many hon. Members on both sides of the House supporting a view which is reflected in our postbags. This is not only a matter for the area health authorities; the water authorities also have a responsibility. In those circumstances, the right way to proceed, for now, is by persuasion.
§ Mr. Jenkin
No. I must move on.
The Government attach great importance to perinatal care. I am pleased to know that the new Select Committee marking my Department intends to complete the study started by its predecessor in the last Parliament. We await its proposals with great interest.
The House is already considering a Bill on seat belts. We await the decision. We are in the course of discussing with the tobacco industry new arrangements to replace the current agreement, which runs out at the end of March, covering advertising, promotions, the health warning, and reductions in the yield of harmful substances in cigarettes. It is often said that smoking is the greatest single preventable cause of disease and premature death. Yet some 20 million people in Britain continue to smoke. We are determined to make progress in this area.
The House will have seen that, in November, the Incorporated Society of British. Advertisers announced tighter guidelines on alcohol advertising—a wise 470 move which rightly recognises the seriousness of the problem of alcohol misuse.
The House will recognise that all this is a familiar catechism; but familiarity in no way lessens the importance of making progress in these areas.
There are two other general points on which I should like to touch. One concerns industrial relations in the National Health Service, about which the commission had much to say in chapter 12 of its report. I fully accept the commission's view that people who work in the National Health Service have special obligations and that the Government must not take advantage of this. The commission recommended that there should be a review of the arrangements for negotiating pay and settling disputes at national level in the National Health Service. I know that whereas, in general, the Whitley Council system has worked well, there is no doubt that "it grinds exceedingly slow" and this has, at times, led to frustration and strife.
The commission made the interesting recommendation that it should be for the TUC to initiate discussions with staff interests, with the objective of recommending agreed procedures to me. I am glad to be able to tell the House that the TUC has accepted this proposal and, at a meeting in my office last week, Len Murray told me that discussions will begin shortly. Of course, the issues concern staff associations and professional bodies which are not affiliated to the TUC, as well as many unions that are. Mr. Murray assured me that there would be no difficulty in bringing the non-affiliated bodies into these discussions, and this I very much welcome. He also gave an undertaking that the Department and management in the Health Service would be kept in close touch with their work as it proceeded. I wish this exercise well, which, as the commission points out, requires patience, good will and, above all, the determination to succeed.
The other matter to which I should make a brief reference concerns hospital policy. The Royal Commission made a number of recommendations on hospital services, and most of these are for hospital managements to pursue. Of course, the commission wanted to seea much more rapid replacement of hospital buildings",but this must depend on extra money becoming available.
471 The commission had a good deal to say about the human aspects of the sheer size of hospitals, and quoted criticisms about district hospitals that were too large, too impersonal and too remote. Concentrating services in a few large hospitals also deprives local communities of the benefit of much-loved smaller, local hospitals. Such hospitals are often the pride and joy of local communities and their closure strikes at the heart of community life. Smaller hospitals are much less prone to the difficulties of industrial relations and morale, and we have made no secret of our desire to try to save as many of our small hospitals as we can.
In the light of this, we have reviewed our hospital policy and have decided that the issue is one of such importance that we intend to put out the discussion document explaining the problems and setting out the options. We hope that it will be widely considered both inside and outside the Health Service. I attach great importance to this review, which in time will, I hope, lead to a reassertion of the human values in society without which any health service can become remote and impersonal.
The review of hospital policy is only one aspect of our overriding concern that the Health Service exists primarily for patients. Indeed, that was one of the central themes of the Royal Commission, and it is a proposition which illuminates the whole of the Government's thinking about the future of the Service.
In the foreword to "Patients First", my right hon. Friend the Secretary of State for Wales and I said:Our approach stems from a profound belief that the needs of patients must be paramount.We made another equally important point:It is doctors, dentists and nurses, and their colleagues in the other health professions that provide the care and cure of patients, and promote the health of the people. It is the purpose of management to support them in giving that service".These two principles seem to me to be paramount in any consideration of our National Health Service, and I know that they are principles which attract support in all parts of the House.
The commission's report is an important document which deserves a full 472 and rational discussion by the House. It is a pity that the Opposition have chosen the occasion for yet another party political re-run of their ancient and irrelevant prejudices. If they insist on voting on it at the end of the debate, I must ask my right hon. and hon. Friends to join me in the Lobby against the Opposition's ritual amendment.
§ 5.5 pm
§ Mr. Stanley Orme (Salford, West)
I beg to move, to leave out from "House" to the end of the Question and to add instead thereof:welcomes the Report of the Morrison Royal Commission on the National Health Service and particularly its unanimous endorsement of the principle that the National Health Service should be free at the time of need and nationally financed.I ask my right hon. and hon. Friends to support the amendment in the Division Lobby. The Secretary of State criticised it. Yet what the Opposition are doing is to support a unanimous recommendation by the Royal Commission.
This is an important debate about one of our major institutions. I endorse the Secretary of State's thanks to Sir Alec Merrison and his colleagues for, and his congratulations on, producing a lucid and comprehensive review of the NHS.
Before dealing with the report, the House should be aware that the debate takes place against a background of major policy changes from this Government, and, if many of these proposals are carried out, that will have the effect of making either redundant or more pertinent many of the key suggestions proposed by the Royal Commission.
I turn to the report itself. The most striking thing about it is that, after three years' intensive work, the commission is unanimous. That, of itself should carry a great deal of weight both in the House and throughout the country.
In paragraph 2.6 the report sets out what the Royal Commission believes the objectives of the NHS should be. They are to:encourage and assist individuals to reman healthy; provide equality of entitlement to health services; provide a broad range of services of a high standard; provide equality of access to these services; provide a service free at the time of use; satisfy the reasonable expectations of its users; remain a national service responsive to local needs.473 As the fundamental basis for achieving these objectives, the commission unanimously recommended that the Service should be free to all at the time of use, paid for by national financing, and that all charges should be abolished so that this principle could be fully implemented.
To meet this requirement of the report, charges would have to be phased out by a future Labour Government, and that is our policy goal. I make that very clear. This recommendation is central to the Royal Commission report, and the Labour Party believes that it is crucial to the future of the National Health Service.
§ Mr. Patrick Jenkin
The right hon. Member for Salford, West (Mr. Orme) must face the logic of the proposition. His party has been totally dishonest on the issue of charges. Does the right hon. Gentleman remember that in the Labour Party manifesto in February 1974 his party promised that a Labour Government would abolish prescription charges—
§ Mr. Jenkin
It said "abolish". I have the quotation here. The Labour Government did nothing about that.
In its manifesto of October 1974, the Labour Party boasted that it had frozen dental charges. But a Labour Government raised dental charges two or even three times over the next few years. The Labour Party cannot go on saying different things when in Opposition.
§ Mr. Orme
The prescription charge of 20p was not increased during the five years of Labour Government. I admit that the introduction of charges by a Labour Government was regrettable. We want to get back to first principles and we will. I make that statement on behalf of the party I represent.
This debate is taking place in the first weeks of 1980, a fresh decade, one far removed from 1948 and the inception of the National Health Service. The right hon. Gentleman referred to the problems earlier in the century, the need for better food, clean water and so on. I want to look at the position as it was in 1948. It was assumed then that, with the universal 474 availability of medicine and hospital treatment, better housing, food and education, the demand on the NHS in the ensuing years, both financially and physically, would diminish. That has not happened.
The following factors must be taken into account when we assess the present and the future. Technology and science have made vast steps forward in medical care. They play a major part in the pressure for hospital treatment. This is one of the big factors adding to the increasing hospital waiting lists. Demographic changes relating to the elderly, and particularly the over-75s, will bring an increasing burden, both financial and administrative. Inner city problems, with which the Royal Commission deals but to which the right hon. Gentleman did not refer in detail, are a major headache for medical practitioners.
The difficulties of financing and the increased pressure on limited resources will be with us for the foreseeable future. For a labour-intensive organisation such as the NHS now to have to pay decent wages and salaries to those employed in it means increasing costs. We do not dodge that. In addition, there is a need for capital development and the introduction of sophisticated equipment. All those matters add up to a continuing call upon our national resources. How people can say, as some do, that the NHS does not need more money beats me. That idea is not acceptable to me and my hon. Friends.
Those are some of the major problems. I shall deal with some as we proceed, but I want first to look at the Royal Commission's views on the proposed reorganisation—with which the right hon. Gentleman dealt, and which we discussed initially in the debate before Christmas—the removal of a tier of administration and the effects that that will have on the Service. The Government will be giving us details of their proposals, I presume, during the Committee stage of the Health Services Bill, after consultations have taken place. But I wish to make one or two central observations during this debate.
We, of course, support means of improving administration, as long as they lead to cost savings, less bureaucracy and simplification, and particularly if they will put right the disastrous measures introduced by the present Secretary of State for Industry during the last Conservative Government's period in office. But, while 475 generally supporting the proposals for change, we must beware of treating them as a panacea for all NHS problems. They will not raise morale overnight, they will not suddenly release vast resources to be spent on new buildings or cutting waiting lists. Nor will they make patients suddenly feel part of a small organisation instead of a large bureaucracy.
We must keep matters in perspective and realise that because there are no obvious answers, as the Royal Commission confirmed, there will inevitably be difficulties with the form of reorganisation selected. Every hon. Member is aware that when one starts out on change, both in local government and in the NHS, the ideas seem perfect or near perfect. One thinks that they will resolve all difficulties, but often they create many more than they resolve.
Another question with no easy answer is that of democracy and local accountability. The Royal Commission is almost silent on this. Although the report talks about the possibility of some forms of local democracy, perhaps through local government, it avoids making any firm recommendations. In this regard there are special considerations to be taken into account, as the report states. It says that the NHS:is a self-help system, reacting to individual demands but not actually seeking out those most in need of its services.In many instances it is the reverse of local government and its operation. Clinical judgment is also an issue with which there is no comparison in any other service, because the layman is not allowed to make a challenge.
For those reasons and many more that it is not possible to elucidate today, I acknowledge that there are no easy answers to the problems. But the issue of democracy and accountability is continually raised by people both in and outside the NHS, not least by the Labour and trade union movements.
The question must be asked: how many people using the NHS are aware of their representatives on district, area and regional authorities? I suspect that very few are. There is no direct link, no election. People know their councillors and their Members of Parliament, but they would be hard put to it to name members of those authorities. In an 476 organisation as important as the NHS, they should know who is responsible for decisions, of whom they should ask questions and to whom they should complain. If the Government go ahead with their proposals to reduce the numbers of elected local representatives on area and district authorities, that will further diminish the indirect local accountability.
Against that background, it is ironic that the Government should threaten the very existence of the community health councils, which are possibly closest to patient need and which the Royal Commission recommended should be strengthened. The Secretary of State did not allay any of our fears this afternoon.
§ Mr. Cyril Smith (Rochdale)
I am very interested in what the right hon. Gentleman is saying. Do I understand that his party is giving an assurance that, if and when it again forms a Government, area health authorities may have on them a proportion of members directly elected by the people? Does not he agree that the expression "elected representatives" usually means representatives of the political caucus of the town council, whichever that political caucus happens to be? Would it not be better to agree to direct representation through the ballot box?
§ Mr. Orme
I take the hon. Gentleman's point. We do not have the answer to the problem. In fact, the Labour Party evidence to the Royal Commission is very confused on this point. It talks of "on the one hand this" and "on the other hand that". But the question of election and accountability should be properly raised. There should be a public debate, and that is what I am trying to encourage. I am certainly not laying down any policy, because we have no policy on this matter, but it would do no harm to have an open and frank debate.
I turn to private practice, which is a major issue that the present Government are to introduce, turning us away from the fundamental principle under which the NHS was created. In its observations on private practice, the Royal Commission said that it was only a minor factor. But it made that comment under a different Government, when there were different types of policies which had been pursued by consecutive Governments since the inception of the NHS. If it 477 had had the right hon. Gentleman's proposals before it, the Royal Commission might have taken a much sharper view.
After careful study, the Royal Commission dismissed the insurance principle. On pay beds, which were being phased out, it advocated the strengthening of the Health Services Board, which is now to be abolished.
§ Mr. Patrick Jenkin
The Royal Commission accepted the existence of the Health Services Board. It made one recommendation about strengthening the powers of control over private medicine, a recommendation that is in the Bill that will shortly go into Committee—namely, that the aggregate of small developments should be open to inspection. It made no recommendation whatever about keeping or getting rid of the board. It took it for granted.
§ Mr. Orme
That is not quite correct. The board endorsed the policy of my right hon. Friend the Member for Norwich, North (Mr. Ennals) of phasing out pay beds. It went into some detail. There was no recommendation immediately to abolish pay beds, but the board recognised that it should carry out the proposals of the previous Labour Government. Surely the Secretary of State does not deny that he is reversing pay bed policy. The reversal is a major policy change.
The Royal Commission examined the insurance principle. After careful examination it dismissed it.
§ Mr. Ennals
I am sure that my right hon. Friend is as well aware of paragraphs 18.40 and 18.42 of the Royal Commission's report as is the Secretary of State. Paragraph 18.40 states:Pay beds arouse strong emotions.Paragraph 18.42 states:From the point of view of the NHS the main importance of pay beds lies in the passions aroused and the consequential dislocation of work which then occurs. The establishment of the Health Services Board led to a welcome respite from discussion of this emotional subject.Clearly, the Royal Commission welcomed the actions and the consequences of the Health Services Board.
§ Mr. Patrick Jenkin
The right hon. Gentleman will remember that on Second Reading of the Health Services Bill I quoted the views contained in a leader that appeared in The Guardian. The leader stated that the climate now is very different from that at the time of the furore in 1975. That cannot owe anything to the work of the Health Services Board over the past two or three years. The pay beds that it has phased out have almost exclusively been those that have been little used. The argument that peace is attributable to that policy and that dispute will break out again cannot be sustained. I do not believe that this will happen.
§ Mr. Orme
The Secretary of State seems sensitive about the work of the Health Services Board. We know that he intends to abolish the board. I am sorry to say that the arguments that existed prior to the board undertaking its work may return. I hope that that will not be so, but I foresee difficulties in future.
The Royal Commission advocated the abolition of charges. We have since seen charges increased by 250 per cent. We know that further increases will be introduced. My objection to private practice is that it is immoral. No one should have the right to buy health care that extends beyond that which can be obtained by another person. The insurance principle would have to be introduced to achieve a major increase in the private sector. The Secretary of State has confirmed this afternoon that he is giving serious consideration to doing exactly that. I acknowledge that that principle appeared in the Conservative Party's election manifesto.
It is worth repeating what Professor Brian Abel-Smith had to say in a recent lecture.
§ Mr. Orme
It is the facts that matter, not who states them. The professor said:The only problem which a switch to health insurance could help to resolve would be that of unemployment. If we followed the German or French examples it would mean creating some 150,000 to 200,000 extra bureaucratic jobs to collect the separate contributions and pay the individual bills for the over 500 million 479 separate parcels of health care used by the British population each year. The elimination of separate billing is one of the largest economies from having a national health service.The Secretary of State has criticised Professor Brian Abel-Smith. He said "He is one of your boys". Does he wish to contradict the facts that I have put before the House?
§ Mr. Patrick Jenkin
I understand that the right hon. Gentleman wants to know whether it will be possible to devise an insurance system that will not mirror the extraordinarily complicated three-tier structure of the French health service with its national caisse, local caisse and mutual scheme. I dare say that at some stage we shall be able to advise him that such a scheme has been devised. In the age of the micro-chip it does not seem necessary to make administrative problems the dominating factor. These are problems that can be overcome.
§ Mr. Orme
We shall await with some interest the scheme that the right hon. Gentleman brings before the House. A member of the Royal Commission told me that on a visit to the United States he was appalled, when visiting American hospitals, to see whole floors of accountants dealing purely with billing for the health service. I cannot believe that such a system is right.
§ Mr. Patrick Jenkin
The right hon. Gentleman labours this argument. My hon. Friend the Minister for Health and I visited a Belgian hospital. We pressed the management on this very issue. There is an insurance system in Belgium. We asked how many members of the staff in that hospital were engaged in sending out bills. Apparently the bills are sent out in duplicate—namely, one to the patient and one to the insurance company. We were told that only two people were so engaged. There were two people rendering bills.
§ Mr. Pavitt
I have been able to examine in some depth both the Blue Shield and Blue Cross systems that operate in the United States. My right hon. Friend is right when he describes the amount of paperwork that is involved and the number of forms that have to be completed for a schedule of different 480 matters. Probably Professor Brian Abel-Smith has made a conservative estimate.
§ Mr. Orme
I thank my hon. Friend for telling the House of his experience in these matters and for underlining my argument.
The insurance system would lead to the transfer of resources from stress areas to non-stress areas. That would be the result if market forces were allowed freely to operate.
Paragraph 2.12 of the Royal Commission's report states:about 60 per cent. of the total expenditure of the NHS goes on children, the old, the disabled, the mentally ill and the mentally handicapped.Those recipients would have no chance in a free-for-all system. It is worth saying that over 50 per cent. of NHS hospital beds are occupied by the elderly. It is no good the elderly going to BUPA and other such organisations for assistance.
§ Mr. Ronald W. Brown (Hackney, South and Shoreditch)
The Government seem to be getting all their advice from Australia. I am told that in Australia it is necessary for a patient to pay before he is given a blood transfusion.
§ Mr. Orme
I thank my hon. Friend for underlining my argument.
The Royal Commission recognised that the problems in the inner cities are of major proportion and concern. It considered it a sad fact that on average the worst primary care is to be found where health needs are greatest—in our decaying city centres. The Royal Commission quoted the courageous evidence of the Royal College of General Practitioners, which reads:Care by some doctors is mediocre and by a minority of an unacceptably low standard.I welcome what the Royal Commission reported, but I believe that we shall have to go even further. It is one of the major problems facing the Health Service.
The previous Labour Government initiated a move towards giving more health resources to deprived areas, including inner cities. The commission has rightly given considerable attention to the quality of primary care services in such declining inner city areas. This was a main plank in the Labour Party's evidence, and the commission has come out with bold proposals for retiring 481 elderly general practitioners, extending health centres, establishing general practitioners on a salaried basis and with limited lists, improving deputising arrangements and reviewing the control exercised by the Medical Practices Commission. Such proposals would bring about a substantial improvement in the health care of the population living in the centres of our great industrial towns.
The inner city problem is not unconnected with the whole question of preventive medicine. An extension of preventive medicine would be to the advantage of the whole population and I welcome the emphasis that the commission places on anti-smoking campaigns, compulsory seat belts, tackling the problem of alcoholics, the statutory fluoridation of water, and on bringing abortion more firmly into the National Health Service.
I appreciate that some of these issues are controversial, but, bearing in mind the Secretary of State's comments regarding smoking and fluoridation, we shall give him full support if he goes ahead along the lines suggested by the Royal Commission. We shall give him unstinting support, as these issues must be argued out with the public as well. As the Royal Commision said, smoking is probably the greatest factor contributing to ill health. To deal with the problems of smoking would not be unpopular with smokers, because many of them would like to be released from the habit. We welcome the proposals of the Royal Commission. They should be implemented. However, much more needs to be done concerning preventive medicine.
As regards inner city areas, the present Government's policy of phasing out school meals will have a detrimental effect upon child health. It will lead to an imbalance in diet and will be unsatisfactory for many children attending city schools.
The Secretary of State raised the issue of drugs. The widespread use of drugs and the escalation of their cost is an issue that the Royal Commission considered. However, it did not make any firm suggestions, apart from giving advice to doctors. The question of drugs will become an increasing problem, and some form of control over the drugs industry and the way that drugs are prescribed is inevitable. The Labour Party proposed 482 the bringing into public ownership of one of the major drug companies.
That should be seriously considered. However, the Tory approach of deterring people from obtaining drugs that they need, by imposing penal charges, is unacceptable.
§ Mr. Frank Haynes(Ashfield)
Does my right hon. Friend agree that the Government's policy of increasing prescription charges will encourage patients to take more drugs each time they visit the doctor, in order to cover a longer period so that they do not have to pay the increased charges so often?
§ Mr. Orme
My hon. Friend has underlined another problem facing the drugs industry. The prescription of drugs must be taken into account. The Service employs over 1 million people—800,000 in England alone—and, therefore, industrial relations and industrial democracy are vital factors. Much needs to be done. While some positive steps were taken in that direction by my right hon. Friend the Member for Norwich, North, he would agree that we were only at the beginning of the road. It is not impossible to bring together those in the profession and other workers so that an agreement and understanding can be reached.
We must return to the issue of pay beds, because the Government's policy will not help. I am disappointed that regional secure units in some areas have not been able to proceed because of difficulties in industrial relations. That is regrettable and I hope that the dispute will be cleared up soon, because those units should be fully operational. I have seen a unit in the Manchester area. What is happening now is most unfortunate.
The question of finance is at the centre of an organisation of the size and complexity of the National Health Service. It is quite right that we can no longer have such a service on the cheap. Consultants, doctors, nurses, craftsmen and all types of ancillary workers are entitled to decent wages and working conditions, with modern and better-equipped hospitals. More money is needed, and no short cut can be taken. Raffles, bazaars, casinos and street collections will not even scratch the surface of the problem, as the Royal Commission has clearly stated. If we are to maintain one Health Service that is available to all and is based 483 on the principles that I enunciated earlier, it must be financed nationally.
The National Health Service needs more money, and the British people should be made aware of the only sensible, humane and democratic way of financing that Service—through taxation. In return they will receive some of the best medical services available. Both the Labour Party and the Conservative Government aimed at a ½ per cent. growth rate, but that is not sufficient. The Health Service needs more resources and, if necessary, we must educate the British public. If they want that type of Service, they must pay for it. The only way to do that is through direct taxation. We now stand at a crossroads.
§ Mr. Orme
The statement made by the Chief Secretary last Saturday bodes ill for those principles. However, the Prime Minister slapped him down very firmly yesterday. The Chief Secretary referred to doctors visiting patients, and in her reply yesterday the Prime Minister talked about paying for visits. Perhaps the Secretary of State can clarify the situation.
§ Mr. Patrick Jenkin
There is no question of introducing a boarding charge for hospitals or of introducing a new charge for seeing a doctor, whether on his premises or at home.
§ Mr. Orme
The Chief Secretary referred to increasing prescription charges, and the Prime Minister did not repudiate that. Nor has the Secretary of State repudiated it today. I wish that the Secretary of State would show me where those charges were mentioned in the Conservative manifesto. The public were not informed that prescription charges would become 75p or more. That is not in the manifesto. The Government have carried out some sleight of hand.
The last paragraph in the report of the Royal Commission says,In our review of the National Health Service as it exists we found much about which we can all be proud. Our examination of foreign health systems for the most part reinforced that view. If in considering some aspects in detail we have made specific criticisms, we have done this in the hope that in the future the NHS can provide a better service, not because we think it is in danger of collapse".484 That is the conclusion of the report. It says that it has recognised all the difficulties and all the problems.
I believe that the Health Service can be improved and that some bureaucracy can be removed. Industrial relations can be improved. It will not be an easy job and it will not happen overnight. We can succeed only if the National Health Service is treated as such and is free and paid for by the whole community throughout its working life. That is the only way to improve the National Health Service, and that has been unanimously endorsed by the Royal Commission. I therefore have no hesitation in asking my right hon. and hon. Friends to vote for the amendment.
§ Mr. David Mellor (Putney)
The report results from the establishment of a Royal Commission under the most ill-starred circumstances. It would have been preferable for the Royal Commission to have been established as part of a carefully thought out proposal by the then Government to seek radical reform and improvement of the Health Service. When one looks at the history of events, it is obvious, however, that it was set up as a matter of expediency because of the widespread concern—indeed, uproar—in the medical profession at the activities of the then Secretary of State, Mrs. Barbara Castle. Like my right hon. Friend the Secretary of State, I, too, cannot wait for the next few Sundays to complete reading, over the breakfast table, her account of those exciting days. It would, therefore, be surprising if the Commission, which was set up in those circumstances, provided any fundamental answers to the problems that we are all aware exist in the National Health Service.
In a report of this length it is inevitable that there are matters with which few of us would disagree, but there is also an absence of positive contribution to solving the problems that all our constituents experience with the Health Service today. This is partly due to its terms of reference, which greatly tied the hands of the commission. They were:To consider in the interests both of the patients and of those who work in the National Health Service the best use and management of the financial and manpower resources of the National Health Service.485 The hands of the Royal Commission were tied merely to consider improving the present system. The commission was not to be permitted to cast its net wider and consider whether, having regard to the water that has flowed under the bridge since the Beveridge report and the events just following the war, there might be a need for a new ideal in deciding what was the best Health Service for the 1980s.
§ Mr. Clinton Davis (Hackney, Central)
Is the hon. Gentleman suggesting that the members of the Royal Commission objected to the terms of reference? It is not unknown that where members take a strong view on such a matter they make representations to the Government or allude to the matter in the report.
§ Mr. Mellor
I do not suggest for a moment that they objected. If I am driven to say so by the hon. Gentleman, one of my complaints—and I believe that a number of my hon. Friends will agree—is about the ease with which the commission seemed able to accept some of the propositions advanced by the Labour Party about matters such as charges. That, to me, indicates an ideological inclination on the part of members of the commission that might have something to do with the fact that a Labour Government set up the commission.
§ Mr. Ennals
The hon. Gentleman is casting aspersion son the balance of the commission, but it was extremely well balanced. It consisted of people with experience from within the Service and from outside. No one from the Government Front Bench has critcised its nature, structure or balance.
With regard to the commission's terms of reference, the hon. Gentleman cannot have read paragraph 1.6, which says:It would have been possible to have interpreted our terms of reference in a narrow financial and administrative context and written a straightforward technical report along these lines, but it would have been wrong to do so.The commission went on to say how widely it had interpreted its terms of reference. The hon. Gentleman cannot get away with the arguments that he is putting forward.
§ Mr. Mellor
It is a long report, and we can all fling pieces of offal from the carcase into each other's faces. The com- 486 mission says that it was unable to come up with more fundamental proposals for reform or a new look for the Service. I suggest that that has a great deal to do with the basis on which it was set up.
The right hon. Gentleman suggests that my hon. Friends do not share my views, but I do not see any obvious sign of dissent from my hon. Friend the Minister for Health. The right hon. Gentleman has his story and he is sticking to it. Equally, it is wrong for him to think that there is not a formidable body of opinion within the medical profession and outside the Conservative Party that certain of the ideological convictions that underlie the report are not the most persuasive to many of those who have to try to make the Health Service work.
A further problem derives from the statement of the objectives of the National Health Service on which the commission based its work. It was:We believe that the NHS should: encourage and assist individuals to remain healthy; provide equality of entitlement of health services; provide a broad range at services of a high standard; provide equality of access to these services; provide a service free at the time of use; satisfy the reasonable expectations of its users; remain a national service responsive to local needs.It is all very well setting out these grand and, indeed, proper considerations, but I do not believe that the commission considered in any fundamental way the practicality of those objectives while tied to the present system. It is merely repeating the underlying basis on which the Health Service was set up in the 1940s, without recognising the extent to which some of those ideals have been undermined by the passage of time.
I have before me paragraph 437 of the original Beveridge report, which sets out the fundamental ideal behind setting up the Health Service, and very good it sounds. However, at that time there was a total failure to appreciate the inordinate cost to the State ofa health service providing full preventive and curative treatment of every kind to every citizen without exceptions, without remuneration limit and without an economic barrier at any point to delay recourse to it".The Beveridge report goes on to express a suggestion that underlay the setting up of the National Health Service. With the passage of time it now seems naive, but it was that the effect of setting up the National Health Service in 487 that form should be to reduce progressively over the years the volume of use of that Service, since an effective medical service has its impact on the health of the nation. We have seen quite the contrary, and we are facing a situation today where more demands are being made on the Health Service than ever before.
We on the Conservative Benches should like a fresh look at, perhaps, a partnership between the present basis on which the Health Service is run and more private intervention. That would assist in creating the sort of service that would give everyone in the country the treatment that he or she requires.
The right hon. Member for Salford, West (Mr. Orme) was a member, or supporter, of an Administration that looked after the affairs of the Health Service for almost 12 of the past 15 years. The Health Service was run during that time on exactly the basis set out in the amendment to the motion. It is fair to ask what has been achieved by running the Health Service in that way. What sort of Health Service did this Administration take over?
The Royal Commission commented on that, but its comments are not such that they can be unreservedly accepted by the Conservative Party or those who work in the medical profession. The commission does not say that it is the finest health service in the world—and in these days we do not even hear that from the Labour Party—but it rightly pays tribute to its emergency care and says that it is splendid. However, people are not looking only to emergency services. A hernia can have an intensely debilitating effect on one's ability to lead a full life, to work and to contribute to society. During the time that the right hon. Member for Salford, West and his right hon. Friends were in office, people suffering from such painful conditions had to wait longer and longer for treatment.
On its view of the morale of Health Service workers, the commission totally underestimates the blow to morale, particularly of professional workers, of deteriorating working conditions and remuneration.
Whether one likes it or not, doctors, nurses, pharmacists and dentists are in no way satisfied with the conditions under 488 which they operate within the National Health Service. Very little attention is paid to the debilitating effect of conditions in the Health Service on the willingness of qualified personnel to work within that Service.
I have extracted some figures about the number of doctors who have left this country over the past 15 years. In 1964 more than 1,000 doctors left Britain, and that figure was repeated throughout the next 11 years. Therefore, up to 1975 we had a total outflow of 11,000 doctors who qualified in England—
§ Mr. Mellor
Even if the hon. Gentleman is right—andI do not know about that—it still means that there was an outflow of nearly 7,000 doctors who qualified in England. That is hardly a satisfactory state of affairs in which Labour Members can take any pleasure. How many of their constituents in the inner city areas have complained about GP care? How many of them would have been much happier had all those doctors stayed and worked in the National Health Service?
The figures from 1975 are not available because they have not been collated. Is that because the Department is embarrassed about collating the figures of doctors who have left the country? There can be little doubt that the figures would show a dramatic increase as a result of the malignant interference in the affairs of the medical profession by the former right hon. Member for Blackburn, Mrs. Barbara Castle.
When one considers the number of doctors who have come to this country, one is still left with a dramatic shortfall in staff, particularly when one takes account of the recent regulations on the re-examination of doctors coming from overseas. The position is hardly satisfactory. I am sure that Labour Members, who care so much about the Third world, do not really think that it is right that we sohuld have to rely so extensively on doctors from the Third world to keep our Health Service going. The fact is that we are unable to provide a Health Service in which thousands upon thousands of our doctors, qualifying in England, are prepared to work.
489 How can we rectify that position? The right hon. Member for Salford, West talked about more money. He said boldly—as Labour politicians always do after an election—that this meant increased taxation. Yet he fought the election alongside his right hon. Friend the Member for Leeds, East(Mr. Healey), who claimed that Labour, too, could cut taxes.
When in the last 11 years of Labour Government was there ever satisfactory funding of the National Health Service totally from the State? When did we have adequate funding that enabled nineteenth century hospitals to be cleared away and provided nurses to staff all wards? I remember wards in hospitals in my constituency being operated at 75 per cent. capacity because the nurses were not available to staff them. When will we reach that golden age when funds will flow from the Treasury to enable us to do all the things that appear in the windy speeches of Labour Members?
The answer is, of course, not until the economic base of this country has been restored. We all know that that is never likely to happen under a Labour Administration. Even under this Administration it will take a long time to achieve because the rot has set in so far.
What are we left with? How can we restore our constituents' belief that they will get a Health Service worthy of them in every respect? The answer must be that people should be encouraged to recognise that while they make their contributions to the Health Service through taxation, the prudent ones among them will ensure that they are protected against the sort of illnesses with which the National Health Service, as presently constituted, cannot deal. I am referring not to emergencies, with which the Health Service deals adequately, but to debilitating long-term conditions. A person suffering from such a condition may find, if he is not properly insured, that he will have to wait for a year, two years, three years or even more before a necessary operation can take place.
§ Mr. Reg Race(Wood Green)
Will the hon. Gentleman tell the House how this insurance system would deal with people who were totally uninsurable? One example is my wife, who is a chronic 490 diabetic and must have two injections a day. How would he deal with her?
§ Mr. Mellor
The hon. Member erects a haystack and then fires his rather rusty blunderbuss at it without paying any attention to the point that has been made. I am not suggesting that everyone would necessarily want or be able to afford insurance. But those who can afford it should do so, and by affording it and taking themselves out of the system they make it easier for those who cannot afford any additional contribution to get treatment. Obviously, there are some darknesses that no light could ever penetrate, and from the look on the hon. Member's face it is obvious that my argument does not persuade him. But we live in hope.
In this country now, private insurance companies are capable of providing additional cover for the vast majority of working people at prices they can afford. If only the TUC would take a more sensible attitude to such negotiations forming part of wage negotiations, it would give a lot more benefit to its members, particularly those who, while protesting loudly, have access to a private hospital when it is needed. For the cost of a holiday in Majorca, any family can obtain the best insurance policy from either BUPA or Private Patients Plan.
In a civilised society, it is the height of irresponsibility to encourage members of the public to throw away their money on bingo and gambling and not to encourage them to use it on the provision of elementary health cover for their families against the evil day that may dawn. I hope that during the course of this Government's tenure of office it will be possible to evolve successful partnerships between the private medical insurance companies and the National Health Service, with, perhaps, the shared use of smaller hospitals.
§ Mr. Haynes
Has the hon. Gentleman considered seriously the question of insurance? Let us consider motor insurance, for example. Each year costs rise and the cost of the premium rises in proportion. That will happen in the same way in the kind of scheme that the hon. Member is suggesting.
§ Mr. Mellor
I suspect that I have considered it at least as seriously as the hon. Member has. I can obtain private 491 health insurance for myself and my wife for £150 a year. I do not think that there are all that many people, considering present industrial wages, who could not contemplate that amount, provided that they thought it important enough to let it take precedence over certain other things. I am saying to people "For heaven's sake be responsible about your health, because nothing is more important."
It is very important, notwithstanding the enormous difficulties facing Ministers in trying to bring the Health Service back to acceptable standards after a substantial period of Socialist Government, that we should look creatively at the possibility of recognising the truth of the proposition that, essentially, health care in the future for the vast majority of people must depend upon their paying taxes and dealing with the NHS to some extent, and also on making creative use of the private insurance companies and their facilities. I hope that the use of shared facilities will be examined, because this represents a way forward which will enable us to get out of the cycle which enabled a Labour Government—notwithstanding all the cant and hypocrisy that they bring to bear on this subject—to close no fewer than 280 hospitals during their last five years in office.
§ Mr. Deputy Speaker (Mr. Bernard Weatherill)
Order. There can be no 10-minute limit on speeches because this is not a Second Reading debate, but many right hon. and hon. Members wish to take part. Therefore, I appeal for short contributions so that Members are not disappointed as we approach 9 o'clock.
§ 6 pm
§ Mr. David Ennals (Norwich, North)
I wish that I could make some complimentary remarks about the speech which has just been delivered by the hon. Member for Putney (Mr. Mellor). Because he disagreed with so many of the Royal Commission's conclusions, he decided that he would disparage those who had reached those conclusions. That was absolutely without justification.
I quote the views expressed by Jean McFarlane, who has subsequently been ennobled in another place. She pointed out that some people who did not like the 492 conclusions had referred to the commission as an unbalanced or a Socialist commission. She said:Members had a wide experience of the service as consumers, members of health authorities, health professions and trades unions and there was a full spectrum of political allegiance.The allegation that it was in some way an unbalanced commission simply does not stand up to examination.
In my period as Secretary of State, I very often heard the present Secretary of State—I am sorry that he is not now in the Chamber—talk of low morale in the NHS. He was not entirely wrong. As part of our struggle to bring down inflation, which the present Government have obviously totally given up, I was obliged to run the NHS on a tight financial rein. In recent months I have had many frank and informal discussions with people working in all fields in the NHS—not least in my own hospital, which I have to visit far too often for my liking. I tell the right hon. Gentleman and his hon. Friends, who may be misled by their pundits, that morale is now much lower than it was.
I find that people in the NHS deeply resent the failure to adjust cash limits to cover the penal level of value added tax, with all its consequences. They face with horror the misery of grossly inflated gas prices. I hope that when he replies to the debate the Minister for Health will tell us what estimate he has of the effect on the NHS of the announcement of gas price increases over the next two years.
People in the NHS resent the new levels of prescription charges. Also, they face with horror the Chief Secretary's proposals for new charges, which would undermine the principles upon which the NHS is based.
I saw what was said by the Prime Minister yesterday, but I know what she said during the election campaign. She was asked about prescription charges. She said:I have no plan to increase prescription charges.She then worked out a plan and increased them twice. I hope that we shall press to ensure much fuller certainty that we shall not see new charges introduced.
I support the Royal Commission almost entirely in its conclusions. I merely say that I wish that it had been able 493 to report 12 months earlier. It would have meant setting it up 12 months earlier in order that it could have reported in July 1978 rather than in July 1979. From my point of view when Secretary of State, it was intensely frustrating to be constantly waiting for this report and to be held back from some actions that could have been initiated earlier.
I should have liked to set out, well before the election was upon us, our Labour proposals for structural reorganisation to undo some of the damage of the Joseph L. McKinsey reorganisation, on which eventually we shall see legislation. Some people have said "Why did you not do it when in Government?" We set up a Royal Commission for that purpose. If anyone thinks that we ought either to have stopped the decision already taken or in mid-term, before the Royal Commission had reported, thrown the NHS into another reorganisation, clearly he does not know what he is talking about.
For all those reasons, I should have liked to have also the commission's robust defence of the NHS and its principles and achievements, as outlined by my right hon. Friend the Member for Salford, West (Mr. Orme), before the nation in 1978 to set in some balance the sort of criticism that we have now from the Conservative Party. I should have liked to see the proposal that the TUC should initiate discussions for a procedure for dealing with national disputes in the NHS. That might have influenced the situation of a year ago. I wish that that proposal had been made.
No less do I wish that the Royal Commission's clear, concise rejection of proposals to finance the NHS by insurance payments had been published before the present Secretary of State and his Conservative colleagues became as committed to that concept as they were before the election and as they are clearly committed now.
The commission was set up by a Labour Prime Minister, and it reported to a Conservative Prime Minister —one who is in principle dedicated to private enterprise as opposed to public enterprise and private expenditure as opposed to public expenditure. The report has come at a difficult time, when the squeeze is 494 on and is affecting the health authorities, faced with the dramatic implications of VAT at 15 per cent. and cash limits tied to a long-past 8½ per cent. inflation rate. It has come at a time when social services are being slashed by local authorities, all of them putting new pressure upon the NHS.
Speaking consciously as one who carried the responsibility of Secretary of State for three years, I want to comment on four aspects of the report: the state of the NHS, its structure, its source of finance, and finally—it will have to be quickly—industrial relations.
Naturally, of course, I profoundly agreed with the commission's conclusions about objectives, which my right hon. Friend the Member for Salford, West outlined. I thought that it was the best possible definition of how our NHS should be structured and of its aims and objectives. I am glad, therefore, that we tabled the amendment to the motion. With no less conviction, I agree with the commission's careful assessment thatalthough there is room for concern we do not believe that the NHS is on the point of collapse as many of our witnesses would have us believe.Let us note that most of the gripes came from those who worked in the NHS. I do not blame them all. They were perfectionists. They wanted to see the NHS improved. The gripes were not mainly from the public. There never has been a more popular public service than the NHS.
I also shared the views of the right hon. Member for Down, South (Mr. Powell)—it is easier to say it out of office than in office—when in his book "A New Look at Medicine and Politics", published in 1966, he said that those who worked in the Service hada vested interest in its denigration",presenting what must bethe unique spectacle of an undertaking that is run down by everyone engaged in it.I hope that some people will learn some lessons from this.
I think that the Royal Commission did a good job in speaking up for the general quality of service provided by the NHS. That is not to say that many criticisms are not justified. There are strong feelings that we must find ways to improve 495 industrial relations. There are the under-financing of the NHS and the feeling that it is over-administered and that too often decisions are taken by people who do not really know the issues at stake. Those are issues which we shall try to put right as we work our way through the Government's proposals.
However, the report puts many of the moans into proportion by showing, first, what very good marks the NHS gets from its consumers and, secondly, that we get good value for money as compared with what is available in most other advanced industrialised countries, some of which—the United States and Germany are good examples—spend much more and in many important respects do less well.
That does not mean that the quality of our NHS is the envy of the world. It is not. But the principle still is the envy of the world—the principle so clearly set out in the report. The commission concluded that there was no need for Britain, as the Secretary of State said, to feel ashamed of its Health Service—nor should we. There are many aspects of it of which we should feel justly proud.
The report says:we must say as clearly as we can that the NHS is not suffering from a mortal disease susceptible only to heroic surgery".I think that what was in mind was some of the heroic surgery of the present Secretary of State for Industry, the right hon. Member for Leeds, North-East (Sir K. Joseph), when he created so many of the problems that we are now trying to put right.
That brings me to the central issue—the structure of the NHS. Merrison examined and discarded a number of heroic ideas—for instance, that there should be a public commission to run the NHS and that the NHS should be put under the direction of local authorities. I think that the commission was right to reject these conclusions. It was rightly convinced by the massive weight of evidence that the 1973–74 reorganisation created, in most places, one tier too many. But, thank heavens, the commission was not as dogmatic as the Secretary of State, who, when in Opposition, talked about abolishing the area tier as if there was not to be flexibility. I am glad that he has learnt some lessons.
496 Professor Kogan's research paper, commissioned by the Royal Commission, got the mood right when he reported that there wasa great deal of anger and frustration at what many regard as a seriously over-elaborate system of Government, administration and decision making. The multiplicity of levels, the over-elaboration of consultation machinery, the inability to get decision making completed nearer the point of delivery of services…were current themes in most of the areas where we worked.These are problems that have beset the Health Service during the whole of the last five years. They will go on besetting the Health Service until we have got its structure right.
Regions have to start looking as quickly as possible at improvements that they can make in the creation, for instance, of single-district areas. Some two-district areas were merged into single-district areas with my approval as Secretary of State. When it became clear that the Royal Commission was to report in a few months—and it was not known what it would say—I had to stop taking some of the actions that it has recommended. It commended the methods that I was using at that time. Some flexibility is needed. It makes no sense to have five separate districts in Birmingham without some co-ordination at city level. Flexibility will need to be considered carefully in dealing with structural points.
I was disappointed that the Government rejected so many of the methods put forward for achieving savings. A lot of savings could be made on drugs. The recommendation of the commission for a selected list to try to ensure that too much is not spent on drugs is important. I am sorry that the Secretary of State seems to have pushed the recommendation aside. I am sorry, too, that the right hon. Gentleman has turned down the proposal to end the separate family practitioner committees. I am sure that his action followed pressure by the medical profession, which has never understood the problems of financing the National Health Service. The profession has always believed that it has total freedom and that it is the task of others to show responsibility in terms of saving. This is a responsibility of all who work in the National Health Service.
The most acute subject of controversy in the debate and in the Merrison report itself is the financing of the Service. The 497 commission has made many recommendations which, both in the short and the long terms, may have results. I was disappointed at the attitude that the Government took today to fluoride. People ask why I took no action. The answer is simple. It became clear only a few months before the election that area health authorities had the power to require water authorities to do what health authorities had decided. It became clear only at a late stage that legislation was required. The best time to take controversial bold decisions is during the early life of a Government. Such a decision could be taken on fluoride, on smoking, on drinking and driving, and on the wearing of seat belts.
There are further methods of saving with which I do not wish to deal at this stage but which must be examined on another occasion. The real argument about financing relays not to charges—a minute part of NHS revenue—but to whether the Government are to make a fundamental change in moving to a two-tier service by introducing a scheme of medical insurance.
Almost two years ago, the right hon. Gentleman who is now the Secretary of State asked:Must we cling dogmatically to the concept of a service always free at the point of use?The commission gave its answer unanimously. It said "Yes. We must stand by that principle." It warned the Government bluntly against any attempt to introduce a health insurance scheme. I add any weight that I possess, small though it may be, to the recommendation of the commission that if the Government proceed down this road it will lead to great problems and big dissensions in the National Health Service. As proposed, health insurance would be bought in the same way as people buy houses or motor insurance. There would be competition between companies. There might be a compulsory minimum level of health insurance, much as owners of motor cars are obliged to take out third party cover. There would be good risks and bad risks among users, and premiums might vary accordingly.
We know that those who look to the Health Service most are the bad risks—the elderly, the disabled, the chronically sick and children. They are the bad 498 risks. They are too poor to pay the high premiums. Sixty per cent. of National Health Service expenditure is currently accounted for by the elderly, the mentally ill, the mentally and physically handicapped and children.
Any insurance scheme that offered a range of benefits according to ability to pay would inevitably favour the wealthier members of society. This is the fundamental principle. Facing up to this principle, the Royal Commission, consisting of people of different parties and backgrounds, business men as well as those in the National Health Service, said unanimously to the Secretary of State for Social Services "That is not the route down which to proceed." If the Secretary of State discards the main recommendation of the Royal Commission and introduces the insurance principle, he will plunge the National Health Service into a new, tragic, unnecessary and agonising conflict.
I turn now to the difficult issue of industrial relations. This was examined closely by the Royal Commission. It saw that the issue was closely linked with the whole question of morale and identified four factors which, to a varying extent, influenced the attitude of workers in the National Health Service. First, it identified the short-term effects of reorganisation. There is no doubt that morale was affected by the tragedy of the reorganisation forced upon the Health Service by the previous Conservative Government.
Secondly, the country's economic difficulties had an effect on the pay expectations of staff. Public expenditure restraint had implications for staffing levels and buildings. That applies even more now than during the past four years. People are asking whether their jobs will be safe and whether the hospital in which they work is to remain open. They wonder whether the hospital will be able to provide a casualty service. The uncertainty in the Health Service is greater than ever.
Thirdly, there is the changing attitude of Health Service unions. Apart from the increasing use of industrial action by several different groups, there has occurred what the Commission callsthe growth in influence of nurses and other groups in decisions about the management of services and the treatment of patients.499 Fourthly, there is the continuing criticism of the National Health Serivce, which feeds on itself, panders to the press and makes people feel insecure and unsettled but determined in the sense that they intend to prove themselves.
The commission welcomed the proposals that I had made for dealing with local disputes. I hope that the Minister for Health will explain what has happened to those proposals in the last six months. They were carefully worked out in my room, around my round table, with leaders of the medical profession, leaders of the medical unions and management. We had started discussions on how to improve industrial relations at national level on issues related to Whitley and general conditions of work. What progress has been made? What consultations has the Minister been holding?
I am glad that the TUC has responded immediately. I wish to know whether the BMA and other bodies have responded and whether the Secretary of State has taken any initiative. It is my view that the decision of the previous Government to establish a system of comparability, so that nurses, as well as doctors, feel that their interests are properly looked after, will improve their feeling of confidence in the National Health Service.
It might be worth reflecting what might have been the effect on subsequent events if this recommendation of the Royal Commission had been made 12 months earlier. The commission said:We think it essential that a procedure should be worked out for resolving national disputes about pay. This will involve a review of existing pay arrangements, including the role of the Whitley Councils. It will take time and patience. We think the initiative can best come from the TUC. In due course proposals should be put to the Secretaries of State and the NHS management interests.If that proposal had been made a year ago, and if the TUC had responded as generously as it has today, we might have avoided some of the miseries—and perhaps the Secretary of State felt the hurts even more than anyone else—of what happened just a year ago.
Inevitably, when in Opposition, the right hon. Gentleman formulated many ideas of his own, and he has got himself stuck on the belief that one can create an insurance base for the National Health Service, in the face of all the evidence 500 against it. I hope that he will take seriously the recommendations of the Royal Commission and the advice of my right hon. Friend the Member for Salford, West not to proceed down that route.
I believe that if the Secretary of State were not to be so persuaded he would make the biggest single contribution to the breakdown of morale in the National Health Service. So long as morale is as low as it is, we shall inevitably find difficulties that blow up into issues that cannot easily be resolved. Let the Secretary of State and his ministerial colleagues not be so doctrinaire as they are now proving themselves to be in terms of the financing of our National Health Service.
§ Mr. Nigel Forman (Carshalton)
I share the view that it is broadly right to finance the National Health Service mainly out of taxation and that, when somebody is really ill, there must be no means test effectively on essential treatment. To that extent, I agree with the right hon. Member for Norwich, North (Mr. Ennals).
But there are many run-of-the-mill cases where people feel the need for medical treatment or medical consultation of some kind or require drugs, and in these cases I think it fair and right for the community to expect that a certain portion of the money involved in meeting those costs should be raised directly from the people so applying. That is the argument for prescription charges, and it is the argument for seeking to keep them at realistic and sensible levels at times when inflation is taking its toll of charges which are in no way indexed.
We can readily envisage what would happen if the right hon. Member for Salford, West (Mr. Orme) were free to put his first principles into effect. I refer to his first principles when in Opposition rather than to his second thoughts when in Government. If those first principles were put into effect and all such charges were abolished, the right hon. Gentleman, were he in a position of responsibility, would have to find roughly an extra £200 million to meet the cost.
Furthermore, there is no evidence from public opinion—in fact, quite the contrary—that the public as a whole in this country are necessarily frightened of the principle of contributing directly themselves to some of the costs of medical 501 care. One has only to look at the figures for BUPA and other such organisations to see that there are now more than 1 million subscribers, representing a total of nearly 2½ million people in 1978, who in some way or other are involved in schemes, whether private or group schemes. I am sure that the Opposition recognise that this is a strong growth area now in general health care.
In my view, our response on this matter should be non-dogmatic. The Opposition should realise that there is a place for sensible and realistic charging, just as I and, I am sure, others of my hon. Friends will agree that the vast basis of the NHS must continue to be financed out of taxation. That is not only the humane way to do it, but there is some evidence from other countries that one gets better value for money and a better chance of containing overall health costs if one proceeds in that way rather than by placing excessive reliance or relying almost wholly on an insurance basis. For those reasons, I hope that hon. Members on both sides will look at the matter in a balanced fashion.
I agree with those who have said that this is a useful report—it is certainly a large one—and I agree with the view expressed in paragraph 22.4 thatthe NHS is not suffering from a mortal disease susceptible only to heroic surgery".I noticed that the right hon. Member for Norwich, North quoted those words, and I also picked them out. I believe that that point is worth stressing.
It is well for the House to remember that the Health Service—the point is made in paragraph 22.7—reflects the society around it—both society's aspirations towards good health and its careless attitudes towards bad health".I shall have something to say later about my view of the importance of preventive medicine in all its forms.
The background which my right hon. and hon. Friends have to consider when pressing for an efficient and effective Health Service is bleak. The objectives set out in paragraph 22.10 of the report have to be fulfilled, or the Government have to attempt to encourage the various health authorities to fulfil them, against a fairly bleak economic background, which, I hasten to add, is largely the legacy of the previous five years of 502 Labour Government. However, whatever the history of the matter may be, I hope that this Government will strive to protect what I would call the solid core of the National Health Service, however bleak the economic climate may become over succeeding months and years.
I am sure that hon. Members will agree that Britain is still a good country in which to live, and, to my way of thinking, one of the reasons is that we have the National Health Service. I put that on a par with our system of justice, with all its faults, and I always think that the way to put the question to oneself about other countries is to ask "Is this a country in which I would not mind being critically ill or standing trial?" If those questions can be answered in the affirmative, one can take it that any such country is a fairly good place in which to live. As I say, on those two important criteria Britain still does rather well.
I said that I would touch on the importance of preventive medicine. I am glad that the Royal Commission laid such stress on the importance of sensible measures against smoking, measures to help smokers kick the habit, on sensible measures for the prevention of road accidents and on measures to combat and control the growth of alcoholism, and called for more emphasis generally on health education. I am delighted by what my right hon. Friend said about health education and his determination to safeguard the Health Education Council from the effects of any quango hunt.
I think it particularly important to give priority to those preventive measures which the Government can support and which could be done in such a way as to reduce the overall NHS costs. It is freely admitted in the report that the bulk of its recommendations would entail increased expenditure were they to be implemented, but there are some measures, such as vaccination on the preventive side, which could be strongly backed by the Government and which would have the effect of reducing costs overall. In this context, I commend paragraph 5.12 to my right hon. Friend. I hope that we shall hear something positive about that in the winding-up speech from the Government Front Bench.
It is important also for Government policy in other respects to be supportive 503 of preventive medicine and not to undermine it. There is a lot that we can learn in this respect from the Norwegians and what they practise rather than what they preach in agriculture and food policy. The Norwegians are well aware—there have been articles in New Scientist about it—of the links between agricultural policy, food policy and diet and the effects which they can have on people's health. They are well aware that the way people live and the signals which they get through the price mechanism in respect of different forms of food can have an influence on their state of health.
If the House asks me for a specific example, I point out that Norwegian agricultural policy includes a deliberately calculated price policy which is biased to discourage the consumption of, for example, saturated fats, which, it is well known—I see the right hon. Member for Norwich, North nodding in agreement—have some connection with various forms of circulatory and heart disease. I commend the Norwegian system to my right hon. Friend. I hope that he will ask his officials to look into it.
Moreover, I stress the broader point that if the Government's policy is to be serious about preventive medicine, they should look not just to health policies but to policies in other areas as well.
§ Mr. W. R. Rees-Davies (Thanet, West)
Does my hon. Friend agree that, whether it is in the field of dietetics, dentistry, acupuncture or a number of other important matters to add to those that we have catalogued, a valuable aid would be to use the media to present short films and items of interest to the public? To use the media outside would cost nothing. The Minister should be encouraged to bear that in mind.
§ Mr. Forman
I entirely agree with my hon. and learned Friend. I am grateful to him for strengthening my argument.
I turn to the question of the mentally ill and the mentally handicapped. As a Member of Parliament, I am especially concerned about that issue as many of those who attend my constituency surgery every fortnight have told me of a number of disturbing cases of inadequate treatment. I am delighted that the report paid sufficient attention to that previously 504 Cinderella aspect of the NHS. I hope that my hon. Friend, when he replies, will say something positive about the Government's intentions to support a sector which has previously languished.
Those working in that sector are entitled to ask for better treatment and more recognition of their important work. In return, their patients need to be treated in a more humane and understanding manner. Having been told of some examples of treatment, I hope that it would be possible to achieve less over-administration of tranquillising drugs in knockout doses. I hope that there would be less frequent recourse to electro-convulsive therapy and that we arrive at a stage where it will not be used at all.
I hope that there will be a less cavalier attitude from general practitioners towards the use of section 25 of the Mental Health Act 1959. I hope that any inadequate forms of nursing and supervision in mental wards and mental hospitals will be dealt with and rectified as speedily as possible by the health authorities and the Government. I shall be writing to my hon. Friend on the matter, and I hope that he will be able to give a satisfactory answer.
§ Dr. Roger Thomas (Carmarthen)
I remind the hon. Gentleman that the great difficulty in the care of psycho-geriatrics is that those who are not totally cured, but partly cured, cannot be discharged into the community. They cannot be discharged into social service homes because of cutbacks in social service expenditure. With nowhere for these patients to go, the consequence is a cluttering up of our psycho-geriatric hospitals. It is not the over-use of tranquillisers or the over-use of ECT that is the problem but the cluttering up of psycho-geriatric beds because of cutbacks in social service expenditure.
§ Mr. Forman
I agree that the psycho-geriatric services should receive a higher priority within the total provision available for the Health Service. I shall not make a recommendation to my right hon. Friend that there should be more health spending because of that particular cause, however worthy it may be. If the Government are honest with the country, they have to state their priorities. I wish that the Government would give a higher priority in the order of batting to mental health.
§ Mr. Ennals
I have great sympathy with many of the arguments deployed by the hon. Gentleman. Does he not agree that it is unfortunate that the Government have decided to abolish, as one of the quangos, the National Development Group for the Mentally Handicapped, which has been performing an invaluable service in giving advice to mental hospitals and area health authorities on how to improve their services? Perhaps he will ask his hon. Friend, when he replies, to deal with that question.
§ Mr. Forman
There is an argument for every quango. If I were forced to choose between quangos in this sphere, I would rather preserve—and I am glad that my right hon. Friend has done so—the Health Education Council. I do not think that the absence of the quango to which the right hon. Gentleman referred would invalidate or prevent my right hon. Friend, health authorities or anybody else from taking the necessary measures to give the whole sector of mental health a higher priority.
I turn to the important issue of the attitude of those working in the NHS towards patients. I hope that the hundreds and thousands—indeed, I believe it to be more than 1 million—who work in the Health Service always remember the admonition in paragraph 1.7 of the report that the NHS is a service to patients. I hope that that is engraved over all the mantelpieces concerned.
Patients must be given fuller information about their condition. They should be allowed to see their medical records, with proper safeguards for the privacy of records in the light of the use of computers in that sector. They should be treated as individual human beings and not as mere numbers in some data bank. We all remember the recent tragic case in Coventry of somebody dying as a result of an operation that he should never have had because he was confused with another patient.
There should be more certainty and clearer explanations to patients about waiting times. Waiting lists for hospitals—always a politically sensitive issue—can be a red herring. They can be as much of a red herring as council house waiting lists. It all depends on how people are 506 placed on the list, how they come to be there and the precise reason for that. As the report points out, it is the waiting times that matter. It is important that people on waiting lists should have some degree of certainty about how long they will have to wait. The health authority concerned should be able to give them promises that can be delivered.
It is vitally important to do everything possible to preserve small community hospitals where both patients and their relatives feel at home and confident of the atmosphere. One of the better aspects of these hospitals, such as the Carshalton War Memorial hospital in myconstituency—and I pay tribute to my right hon. Friend for his constructive and positive reply about that hospital in November 1979, to which I intend to hold him—is that they are run and supervised by the matron and doctors concerned. Worried patients and their relatives feel that when they go to these hospitals they can speak to the people who really matter.
I put in a plea for small hospitals throughout the country. I was delighted to hear the remarks of my right hon. Friend the Secretary of State on this subject this afternoon.
I welcome the Government's intention to concentrate on the regional tier of administration of the NHS and to move towards a slimming down of tiers beneath that level. I hope that that will happen. I was as alarmed as anybody by the 28 per cent. increase in administrative and clerical staff between 1973 and 1977. I note the remark of the Royal Commission that that was not necessarily related to the 1974 reorganisation of the NHS by the last Conservative Government and that there may well have been other factors that contributed to the increase.
I hope that the Government will learn from experience and take on board the lesson that, whereas there may be economies of scale when making plastic ducks, there are seldom economies of scale in administration. It would be an advantage to find means of directly controlling administration which could be implemented by those responsible for giving the services to the patients.
507 It is obviously disturbing, as paragraph 22.83 of the report makes clear, that the NHS will haveto spend about I per cent. more each year merely to provide its existing standard of servicebecause of demographic projections and the growing number of elderly people. In those circumstances, and bearing in mind the bleak economic climate to which I have already referred, I suggest that the flexibility of response, which is one of the last points which is made in the report, should be one of the key elements of the Government's policy in future. That implies the encouragement of units of various sizes and categories within the Health Service, not all constructed on the principle that larger is better. It should also imply the judicious use of volunteers in the Health Service wherever and whenever that is appropriate.
The events of last winter showed us what a fund of good will exists at all levels of the voluntary sector to help the NHS. I hope that we shall be able to introduce some of that voluntary effort in quieter times, not when industrial disputes are taking place, so that those who work in the Health Service can get used to the idea of working alongside these well-intentioned people who want to help, often in a part-time capacity.
Fundamentally, the NHS will be only as good as it can be made by the dedication of those who work in it—I pay my warm personal tribute to them—and by the Government's success in creating the necessary climate for future economic growth in which we can pay for, and make realistic, the aspirations that I am sure all hon. Members share.
§ Mr. Cyril Smith (Rochdale)
I welcome the Royal Commission's report. There are many items in it that one would like to discuss. First, however, I place on record my belief in a taxation-based NHS. Indeed, it is for that reason that I shall support the Opposition amendment, because it is wise to place on record our belief in such a Service.
I should like to discuss prescription charges. If we cannot have their abolition, I plead with the Government at any rate seriously to consider extending the 508 exemption list from those prescription charges. I have recently had correspondence with the Minister about cystic fibrosis, which requires the use of many drugs. One hopes that that sort of disease, even at this stage, may be granted exemption from prescription charges.
I could comment at great length about the fluoridation of water. Frankly, I welcome the Minister's statement today on that subject because I am against the compulsory fluoridation of water. That does not mean that I am against the fluoridation of water. However, I believe that those who are to be subject to the treatment ought perhaps to be consulted first. If a local referendum, or something of that type, took place which indicated that it was the will of the people that the water should be so treated, I would go along with it.
I could also comment on smoking and industrial relations. I want, instead, to confine myself to one aspect of the report. Indeed, it is an aspect that has hardly been touched upon as yet. That is the section of the report dealing with the allocation of resources which begins on page 344, paragraph 21.38 onwards. I do so because this is important from a constituency point of view. It is even more important from the point of view of residents in the North-West region, in which my constituency is based. So far as I am concerned, that is the most important aspect of the report, because the North-West region is undoubtedly in need of special help and special allocation of finance even within the existing finance that is available. In other words, I am saying that the Minister should discriminate positively in favour of the North-West.
Paragraph 21.35 of the report speaks ofour belief that the NHS ought to aim to provide equal access to health services for those equally in need"—and these are the words—irrespective of where they lived".I hope that the Minister will note those words in particular.
On 21 March 1977, I initiated an Adjournment debate on this very subject. The debate is fully reported in the Official Reportfrom column 1042 onwards. Frankly, I could make almost the same speech today. The aim is to ensure that Ministers continue to make the same response as the Minister made to that 509 Adjournment debate. At that time the Minister was the right hon. Member for Lewisham, East (Mr. Moyle), whom I am glad to see in his place.
I concede that this afternoon the Minister gave some indication that it is the Government's policy at present to continue to have some regard to the principles of the RAWP in the allocation of finance. I welcome that statement. I am not exactly sure what 0.3 per cent. means in terms of money, but 0.3 per cent. is better than nowt. One hopes that, as the economic climate improves, more money will become available and that 0.3 per cent. will represent even more money.
§ Mr. Smith
I am grateful for that interjection. I was not sure of the figure and was frightened that if I went out to get it I would lose my speaking place in the queue. I suspected that it was much greater than 0.3 per cent., and I am grateful to the right hon. Gentleman for his interjection. I must tell the Government that while the North-West is always grateful for small mercies, we believe that a much greater share of the cake must go to that region.
Even taking into account the increases that have been made over the last three years, the present allocation to the North-West is still grossly unfair to that region and discriminates against it. That even takes into account the increased allocations that have been made since 1977. For a few minutes I should like to give some illustrations why I believe that to be a statement of fact.
The RAWP report clearly showed that the North-West region was the most deprived region of the country, and in a moment I shall try to give some statistics to prove that. Before doing so, I should like to make one other point. Rumours are floating around—I accept that at the moment they are no more than rumours—that a move is afoot by the Government to switch from capital expenditure some of the finance to cover revenue expenditure items. If that course of action takes place, it would also add to the discrimination against the North-West. I do not accept, nor do members of the North-West re- 510 gional health authority, of whom I am not one, that that is a solution, even a temporary one, to the region's present difficulties.
§ Mr. Lewis Carter-Jones (Eccles)
I am following the hon. Gentleman's argument on behalf of the North-West. Will he take it from me that with the current rates of increase it will be the year 2000-plus before the North-West achieves anywhere near equality?
§ Mr. Smith
That is certainly the fact. Perhaps I can now give some statistics to try to back it up. For example, the scars of the Industrial Revolution are there to be seen. Many of the buildings, including hospitals, date back to the period of the Industrial Revolution, and that includes some hospitals in my own constituency of Rochdale.
In the North-West region, 35 per cent. of Health Service buildings were built before 1900. A further 40 per cent. were built between 1900 and 1948. Therefore, the switch from capital to revenue expenditure would discriminate against the North-West. The North-West needs revenue cash but it also needs capital expenditure. The strategic plan for the North-West, published in 1974, pointed out that for the region as a whole the quality of life was notin balance with the rest of the country".A person living in the North-West has an expected life span of at least two years less than the average for England and Wales. He will be more at risk from certain diseases. Statistics indicate that the North-West region experiences more deaths from all causes than any other region, and the North-West certainly has the highest ratio of diseases of the circulatory and digestive systems. Perinatal mortality rates in the North-West region have been consistently worse than the average for England for each year from 1973 to 1977. My hon. Friend the Member for Colne Valley (Mr. Wainwright) received disturbing and revealing answers to parliamentary questions on the infant mortality rate when he raised the matter in November 1979. It might have been expected that a realistic attempt would be made to compensate for the high incidence of disease by allocating to the region a higher proportion of the resources available, in order to try to maintain and improve health.
511 Life in Rochdale is just as precious as it is in Redbridge. The revenue expenditure per head of population for the Rochdale area in 1978–79 was £91, compared with £136 for Redbridge. There can be no argument that the Health Service should provide the same health cover for people in Wigan as for people in Westminster, yet the revenue expenditure per head of population was £90 in Wigan and £287 in Westminster.
Even as late as 1979–80, the North-West region is still funded to only 91.95 per cent. of the target allocation which was postulated in the RAWP proposals. I referred to the need for adequate capital expenditure as well as for revenue. That is obvious, because buildings need to be improved. It is essential that the increased capital allocations notified for planning purposes should be maintained. Any attempt to switch from capital to revenue expenditure will be disastrous for the North-West region.
I mention that again because it leads me to my last point—the inadequacy of existing buildings and its effect on staff recruitment problems. It is particularly difficult to recruit paramedical staff, such as physiotherapists and occupational therapists. But the situation is even worse in the North-West. There are 35 consultant posts vacant, 19 of which are due to retirement and resignation. Six consultant posts are filled by consultants who have agreed to stay on beyond retirement age because replacements have not been found.
Last November my hon. Friend the Member for Colne Valley pressed for statistics about people on waiting lists in his constituency. The figures were alarming. The hon. Member for Carshalton (Mr. Forman) said that numbers did not matter; what mattered was how long people had been on the waiting list. The waiting time for many people is 12 months, two years or three years. Many people in my constituency are receiving cards giving them appointments to see consultants—for a diagnosis, not for treatment—in 1982. That is what is happening in the North-West region. People who live in the North-West believe that that is partly due to the poor conditions of the buildings, which can be remedied only by a special allocation of capital re sources.
512 The Royal Commission, in chapter 7 of its report, deals with the role of the general practitioner in the provision of primary care. It stresses thatIt is impossible to over-rate the importance of the quality of and easy access to services of this kind.Even in that field, the North-West region lags behind. In 1977 there were 2,415 patients per general practitioner in the North-West, compared with an average of 2,331 patients per general practitioner for England as a whole. In the North-West, 46 per cent. of general practitioners have list sizes of over 2,500 patients, whereas the national average is 38 per cent. It does not matter what criteria are used, the North-West is disadvantaged. It deserves a fairer deal.
The Royal Commission focused attention on the particular problems of inner cities and on the issue of urban decay. The right hon. Member for Salford, West (Mr. Orme) referred to it. The North-West experiences real problems in that connection. I echo the sentiments of the Royal Commission that added incentives should be provided to improve the relatively poor standard of health care provisions in these areas and give impetus to the development of services.
It may not be possible to increase the size of the Health Service cake, in real terms, because of cuts. I was intrigued to hear the Minister say that the Government had had to fund many wage increases. I spent a considerable time in the Christmas Recess meeting many representatives of the Health Service, including the chairman of the area health authority and its officers Because two hospitals out of four in my constituency are to be closed at the end of March I went into the statistics at great length. I was told by area health authority officials that last year, if additional wages as a consequence of national wage negotiations and the increase in VAT payable by the health authority were taken into account, Rochdale was short-funded by £70,000.
It is not sufficient for the Minister to say that the Government have funded many wage settlements. They have not done so. Some area health authorities have not had the extra money given to them in order to pay those increases and are, therefore, faced with hospital closures as the only way in which to finance the Service in its present state.
513 I very much hope that, even if it is not possible to increase the size of the cake, and even if there are cuts in real terms, resources which are available will be directed towards the areas of greatest need. One of the objectives of a National Health Service, as defined by the Royal Commission—that there should be equality of access to health care—will then become a reality.
The North-West region has been deprived for far too long. It must now be allowed to make real progress towards the standard enjoyed for many years by other regions. I therefore urge the Government to think seriously about their allocation of funds and to use on the basis of need the funds that are available. The North-West region is undoubtedly at the head of the league table of need, regrettable though that is to those of us who are Northerners. I look for some positive response to my plea when the Minister replies to the debate.
§ Mr. Deputy Speaker
The House should know that 17 right hon. and hon. Members wish to catch the eye of the Chair before 9 pm.
§ 7.1 pm
§ Mrs. Sheila Faith (Belper)
I welcome many of the recommendations of the Merrison report. I am fortunate enough to be a member of the new Select Committee on Social Services. I know that the Royal Commission recommended the setting up of such a Committee, and I hope that we shall live up to its expectation.
I welcome also the suggestion that increases should be made in preventive medicine and health education. I hope that the Select Committee will do valuable work in these areas. I particularly welcome the fact that the Commission believes that bureaucracy should be streamlined and that the Minister is sympathetic towards this suggestion.
However, I must oppose the Opposition amendment, because the most glaring weakness in the report is that, while it suggests increased spending in many directions, including increased hospital building and more help for inner city areas, it does not say where this money is to come from. Increased life expect- 514 ancy means an increased need for services for the elderly, and yet I know that in my own constituency a hospital is threatened with closure before there is adequate replacement. This is not a new phenomenon, for throughout the National Health Service the total number of hospital beds has been reduced since 1965 by about 44,000.
We have heard this evening about the North-West region, but my Derbyshire area is also a Cinderella of the Health Service. In fact, it would seem that the commissioners live in a dream world with regard to economics. They even recommend the abolition of all Health Service charges. Even more importantly, they rule out any alternative funding of the National Health Service. They say that all finance should come from taxation and that the Government should not look at other methods of raising funds. They take no account of the fact that Government funds are stretched to the limit and that no country can afford a totally free and comprehensive service from direct taxation. No other country, apart from Italy, attempts to provide a service in this way.
I welcome the idea of holding lotteries, in spite of the reservations in the report, in aid of the Service. I hope that this will prove popular and will harness the British people's gambling instincts to this worthwhile cause. But, of course, no lottery can raise the vast amount of money required by the National Health Service. Even before 1976, when the International Monetary Fund ordered that economies should be made to bring sanity to our economy, the Health Service was in severe financial difficulties.
Britain spends less on its Health Service than do most Western industrial nations. For every £100 spent per head in Britain, the Netherlands spends £147 and West Germany £158. The report states—and I think everyone would agree—that in spite of this the National Health Service gives as good a service as anywhere in the world for acute illness. This has been mentioned already in the debate. It was also stated that anyone with a hernia, varicose veins or osteo-arthritis of the hips has to join a long queue for surgery. Waiting lists have risen by 50 per cent. to over 750,000 in the last five years. As has already been said, this uncertainty is very unsettling for people.
515 The public feel that the money paid in taxes goes into a pool and is not being allocated to improve our depressing, outdated and shabby hospital buildings. Studies have suggested that two-thirds of our hospitals should be replaced.
The Government should ignore the advice of the Royal Commission and continue to investigate ways of raising money by other methods, possibly by the introduction of a national insurance fund. Note should be taken that this is the way in which most other countries fund their health service and that they have had better results and are able to spend more money per head. The Government must, of course, still accept the responsibility of ensuring that people with low incomes can afford their contributions.
The Royal Commission places much stress on the fact that an expanding economy will give increased resources for health. The aim of the Government is expansion, but this may take some time to achieve as the first priority is to control inflation. During two of the four years in which the commission sat, there was no growth.
The commissioners have not taken into account that insurance schemes are able to increase their revenue more easily than Governments can because the people who put up the premiums do not have to be re-elected. Nor have they recognised that people will be prepared to give a larger share of their income if they know that it is going directly to health care.
We know, as the right hon. Member for Salford, West (Mr. Orme) said, that the heaviest users of the Health Service are the old, the poor and the chronically ill. They will still have to be provided for and the Government will have to take responsibility for them. But that is not a good enough reason for allowing the present position to continue unchanged.
The level of expenditure on health, as a proportion of total public expenditure, has hardly risen over the last few years, and yet people are spending more of their income on holidays, entertainment and consumer goods. If this situation is allowed to continue, people will take the law into their own hands and decide that 516 they will give a higher proportion of their income for health provision for their families. This is already reflected in the increasing number of people joining private insurance schemes, the number of which increased to 2,388,000 in 1978.
The Royal Commission has underestimated this phenomenon. People are joining these schemes so that they can choose the time of their entry into hospital and have a choice of surgeon. As I have already said, while they know that National Health Service treatment may be as good as any in the world while they are acutely ill, they do not want to recuperate in overcrowded wards in old buildings or to seek to regain their health on what is very often unappetising food.
The 2 million people who are joining the schemes are not necessarily wealthy. Firms are taking out insurance cover for their members because they cannot afford to have their employees losing working time. Indeed, 40,000 members of the Electrical, Electronic, Telecommunication and Plumbing Union have negotiated with the British United Provident Association to provide medical care. Even more surprisingly, 1,300 members of the Transport and General Workers' Union at Bass Mitchell and Butlers have defied their union and joined a scheme. The commission is blind to the fact that the discomfort and inconvenience in our National Health Service will result in our having two completely different health services. In that way, dissension will be caused in the country. In a free country, we cannot and must not stop people spending their money as they wish. The standard of comfort and care that people give their families in time of sickness is of great importance to them.
Medical science and techniques have developed at a rate never envisaged when the National Health Service was founded. We have the best trained doctors, the best trained dentists and the best trained nurses in the world. We must also acknowledge the work done by the auxiliary services. But none of those groups is satisfied with its present remuneration or conditions.
I urge the Minister to ignore the Royal Commission's financial directives and to continue to look at and examine new ways of financing the National Health Service.
§ 7.9 pm
§ Mr. James Molyneaux (Antrim, South)
For the sake of brevity, I shall deal mainly with those aspects of the report which relate to Northern Ireland, although the lessons to be derived there from are not of exclusive interest to Northern Ireland.
It is very interesting to see how much has changed since the Royal Commission was established, and even since we put forward our own views in the form of a submission almost three years ago. The hon. Member for Carshalton (Mr. Forman) may be interested to read the paragraph relating to the subject of voluntary help in the Health Service and in hospitals, in which we said:The present complicated organisation is not clearly understood by the general public and the process of making contact with the appropriate section is a hit or miss affair. As a practical step we suggest that in each unit, however small, there should be one member of staff who, in addition to basic (or normal) duties, would be charged with channelling and encouraging voluntary aid and clearly identifiable to the general public as the individual responsible.I am not sure that the Royal Commission paid any great attention to that suggestion. Perhaps we could, with the help of the hon. Member, persuade the Secretary of State and the Minister of State, Northern Ireland Office, who are present this evening.
Chapter 16 of the report, entitled "The NHS and Local Authorities," and particularly paragraphs 26 to 28, is, I believe, worthy of special attention. Those paragraphs concern Northern Ireland Members but they should not be overlooked by the House in general. They must also concern many members of local authorities and others who are interested in the relationship between the National Health Service and local authorities.
Paragraph 26 sketches the history of the integrated structure in Northern Ireland embodying health and personal social services. I shall not rehearse the reservations that we expressed in debates in 1972 and 1973. The House will recall many of them. Paragraph 27 admits that at that time there was criticism. It says that there was a fear that there would bea de-personalisation of social work.The Royal Commission, unfortunately, does not say whether that fear was justified.
518 In my view, the fears expressed in 1973 were based on far wider considerations. The fears of "de-personalisation" were not confined to the social work sector alone. Most people in the integrated structure, at various levels, would today confess that "de-personalisation" has to a great extent gummed up the works, slowed up decision-making and damaged communication between those who eventually take decisions and those who execute those decisions.
The report makes the point that the full potential of this experiment in Northern Ireland had not, when the commission considered the matter, been fully realised. It quotes Professor Rea and Dr. O'Kane in paragraph 28. They found thatWhile some respondents considered that the system was not working as well as it should, nevertheless, the impression gained was that integration was inherently beneficial with, at its best, an improved continuity of care between hospitals and community for all patients and special care groups.Right hon. and hon. Members will have noted the words "at its best". On those three words depends the beneficial result which might be expected to flow from the change to an integrated structure. Since perfection in this wicked world—as implied in those three words—is unlikely ever to be achieved, I am afraid that we must be content with something less than what the report refers to as "improved continuity of care".
Only when the system is working at its best—I use those three words again—can it be considered superior or even equal to the present system in Great Britain. On that ground alone, this Government—indeed, any Government—ought to distinguish between the recommendation in the report thatin Northern Ireland the present integration of the health and personal social services should be encouraged and further developedand any step which would tend to make permanent the integrated structure without modifications in Northern Ireland in contrast to the pattern which the report has recommended for Great Britain.
Those who take an interest in Northern Ireland affairs will wish to give some thought to the problems which will have to be faced—sooner rather than later—when local government is restored to Northern Ireland. There will be great difficulty in putting the NHS elements 519 under local democratic control as opposed to appointing local representatives to hospital boards.
In such a situation there would be no financial responsibility. All net expenditure would be borne by taxes. It would be desirable, on the other hand, that there should be, as in the rest of the United Kingdom, a local democratic responsibility for the personal social services which are partially borne by the rates. That might be a powerful reason for the Government not to accept uncritically the recommendation of the Royal Commission. The Government ought not to suggest that it should remain permanent without modification.
The amalgamation in 1973 did not derive from Health Service considerations. It was a by-product of the centralization of nearly all local government functions in the hands of the Northern Ireland Government. That almost accidental development has over the years aggravated the defects and the teething troubles inherent in the changes within the original structure.
There is the completely separate consideration that there ought to be reforms of social security. Such reforms should produce advantages, both of centralisation and decentralisation, which are presently lacking. District managers are excellent at handling and advising on supplementary benefits. But when other benefits—for example, the family income supplement, attendance allowances and other benefits—are considered, the picture becomes confused. A bewildering variety of central agencies becomes involved.
The Social Security Bill now before the House will help by restoring ministerial responsibility for supplementary benefit. It could be argued, however, that the process should go further. I should like to see the link between personal and environmental health matched by a social security structure which would enable all the circumstances of a family—mental, physical, environmental and financial—to be examined by officers operating at the same level.
It will be noted that the district general hospitals—or, as we would refer to them in Northern Ireland the area general hospitals—are dealt with in chapter 10. In paragraph 41 of that chapter attention is drawn to the contrast between England 520 and Wales, on the one hand, and Scotland and Northern Ireland, on the other. In that paragraph the report appears to indicate that the flexible approach in Scotland and Northern Ireland to this question is to be deplored. It seems to indicate that in Northern Ireland and Scotland we should be expected to fall into line.
I understand that in England and Wales a good deal of flexibility has crept into the original 1962 hospital plan. We hope that flexibility will be maintained and encouraged. For that reason, the Ulster Unionist Party welcomes the Secretary of State's announcement that there is to be a review of the role of small hospitals.
We shall work closely with the Northern Ireland Office. We shall co-operate and contribute to the review to ensure that a sensible balance is achieved between the need for general hospitals, which provide a full range of specialist treatment, and the equally important but not conflicting need for small local hospitals with a limited range. We shall bear in mind that our objective is not to produce a master plan which looks impressive on paper but to provide an efficient service for patients—the most important factor in our calculations.
§ Mr. Richard Alexander (Newark)
As I listened to the hon. Member for Rochdale (Mr. Smith) saying how the North-West was the worst-funded area, I thought that that was rather odd, because I have always believed that the Trent regional health authority was the worst funded of the RHAs and that the central Nottingham district was the worst-funded district. We all believe that our own area is the worst funded. Surely, the Trent regional health authority is the worst funded.
§ Mr. Alexander
I agree. I was making a debating point. We all feel that we are deprived.
The Merrison report is thorough and workmanlike. It has come up with no shattering conclusions, but that does not diminish the effort involved. It is a commentary on there being nothing fundamentally wrong with our National 521 Health Service. All hon. Members who visit the hospitals in their constituencies will have that impression. We have the finest generally available health service in the world. The dedication of the doctors, nurses and anciliary staff is beyond praise. It cannot be bettered.
Those who awaited the report with bated breath were unrealistic to expect radical recommendations for a shake-up in the Service. The issues remain as they were before the report was published. The better organisation of the patients' comfort and personal arrangements when in hospital and reorganising the structure and management of the Health Service are of prime importance.
On page 2, the report states:Our work has been informed throughout by the idea that the NHS is a service to patients.The December consultative document is called "Patients First". Many hon. Members wish to speak in the debate, and I shall comment briefly only on one or two aspects of the report which strike me as important and which have not been dealt with in the debate. I was glad that the report devoted a section to wakening times. Anyone who has been a patient in a general ward of a hospital, as I have, knows that wakening times are a prime example of the philosophy of "patients last". The report states that 44 per cent. of patients are wakened before 6 am and 76 per cent. before 6.30 am. That borders on the inhumane.
By definition, a patient is a sufferer and finds it difficult to sleep at night at all. He has no exercise during the day. He is in discomfort and cannot get to sleep until the small hours unless he has the benefit of sleeping pills. By the time he drops off, he has only an hour or two's sleep before he is awakened again. He is not refreshed, dozes fitfully through the day, and by night he cannot get to sleep. Lack of proper sleep during normal sleeping hours cannot be in the best interest of a patient who is recovering from an illness. I hope that all health authorities will review their practices, as recommended in the report.
The report also deals with the question of privacy. Mixed sex wards do not appeal to most people. Least of all they appeal to the middle aged and elderly, who were brought up in an era when modesty was more the order of the day 522 than it is today. In hospital things are done to, and by, a patient which, ideally, should be done in total privacy. They can be done—but only just—when people of the same sex are around. For the elderly it is humiliating and degrading if they are done in the presence and hearing of people of the opposite sex. Mixed wards should be a rarity. As the report recommends, patients should be given the choice before they are put in such a ward.
Mental health was mentioned by my hon. Friend the Member for Carshalton (Mr. Forman). The commission deals with mental health in some detail. However, it does not mention housing the mentally ill with the mentally handicapped. There is a proposal to erect a medium secure unit for the mentally-ill at the Balderton complex for mentally handicapped people. Such a development would be a disaster for a hospital for the mentally handicapped such as Balderton.
The proposal is causing alarm to the parents of mentally handicapped children who are patients at that hospital. It cannot be in the interests of mentally handicapped people. Nearly 100 per cent. of the people living in the area are against the proposal and are alarmed about it. I am sorry that the commission did not find time to deal with that recent development, but we shall hear a great deal about it in the coming months.
The report contains a section on complaints within the National Health Service. It states that in England and Wales complaints about general practitioners, dentists, opticians and pharmacists must be made in writing to the family practitioner committee administrator within eight weeks of the event which gave rise to the complaint. Hands up those hon. Members who know that. I warrant that possibly only 50 per cent. of hon. Members know of that requirement.
If only 50 per cent. of Members of Parliament know what to do—and, by definition, they are people who go about the world and understand what should be done—how can people with no great education or influence know what to do? Not one person in a thousand has ever heard of a family practitioner committee, and not one in ten thousand knows where the administrator operates from. Even if a person knew both those things, he could not know that there was an eight-week time limit from the date of 523 the event which gave rise to the complaint. Sometimes we in this place overestimate the ability of the ordinary citizen to find his way through the web of bureaucracy to get his rights. This is so also in the National Health Service.
§ Mr. Ronald W. Brown
The hon. Gentleman has just made an important point. When the patient finally knows that he can go to a family practitioner committee to complain, he has to present his own case. He can take a friend, as long as that friend is not legally qualified, but the friend has to whisper in his ear to tell him what to say in answer to any questions. Therefore, even if the patient understands the procedure, it is made difficult for him.
§ Mr. Alexander
I thank the hon. Member for that helpful intervention. I entirely agree with him.
The way in which we deal with complaints can be considered at a later date. If we must have a complicated and obscure system of complaints through family practitioner committees, we should at least extend to six months the time limit for making the complaint, as recommended in the report.
I have adhered to the instruction to be brief. I trust that my remarks will fall on receptive ears and will be dealt with by my right hon. and hon. Friends.
§ Mr. Laurie Pavitt (Brent, South)
I hope that the hon. Member for Newark (Mr. Alexander) will forgive me if I do not take up his points, but I also want to be brief.
I am not without a little knowledge of the National Health Service. I believe that the Merrison report is a truly great report. Since the inception of the Health Service we have had dozens of reports. I believe that this report compares favourably with the report of a quarter of a century ago—the Guillebaud report. That report was commissioned by a great Conservative parliamentarian, the late Iain Macleod. I say that Iain Macleod was a great parliamentarian because he was prepared to accept the recommendations of that report, and until 1976 the Tory Party followed the general consensus of opinion that came out of that report. I hope that the present Government will follow that 524 example. The pattern set by Iain Macleod was a good one.
This report gives a number of signposts which are the result of careful study. Athough the commission gives no answers, it at least has charted the way for a Government to move forward. The House knows how complicated the NHS is, because it has so many sectors. The commission has gone into each of those sectors in depth. So, whichever sector of the NHS one looks at—I am not talking here about geographical regions—it has been studied in depth by the commission. The report will be a valuable source of information for action by all Governments of the future.
The course has to be followed by the Government. Priorities for action have to be selected by them and the responsibility is theirs. Nevertheless, the Merrison report will go down in history and could well shape what happens during the next two decades. The most important aspect of the NHS with which the commission dealt, which overshadowed even the reorganisation and almost every other aspect of the Service, was resources. This has again emerged in the debate in practically every contribution.
The value of the Merrison report is that it shoots down a lot of the fallacies, false dawns and things that were thought possible. What the report does so effectively is to show why such matters were peripheral and did not deal with the basic problem. There is no other alternative than that a public service such as the NHS should be paid for by the public. Whatever form of semantic labels we may choose, whatever pattern we like to put forward, it boils down to a system—or systems—of taxation. The Government have no money. They have only the money given to them by the taxpayers. If the NHS is to be a comprehensive service, the public must provide the money.
Present funding, under which 87¾ per cent. of the cost of the NHS comes from rates and taxes in the year 1977–78, is social justice. The higher taxes a person pays, the more he pays for the NHS for the benefit of his fellow man. The poor and the elderly pay nothing at all. Surely there is not a more humane way of funding NHS resources. However, a massive increase in funds is now urgent and vital. Unless the Government do something to 525 provide additional finance, many of the recommendations of the report will be impossible to fulfil, even with the best of intentions.
The Secretary of State might consider approaching Saatchi and Saatchi, which has some fame in the selling of products. The NHS needs to be sold to the general public instead of being denigrated in the newspapers day after day. It is about time someone started shouting about what is right with the NHS. If the public are to be asked to pay more, they must know what they are paying for. The NHS is the best bargain in the world for a family. It is worth paying for.
I recently had the opportunity to study the health service in France. I know that the Minister of State is keen on that country's system. I can assure the Minister that we are still head and shoulders above the French when it comes to health care.
§ The Minister for Health (Dr. Gerard Vaughan)
Does the hon. Member for Brent, South (Mr. Pavitt) accept that in France there are no waiting lists for hospital treatment, whereas we have the longest waiting lists in Europe?
§ Mr. Pavitt
I looked not only at the hospital service but at domiciliary care. Additionally, the French did not have a consultants' strike as we did a few years ago, which added to the waiting list. The French do not have the same system of employment. The Minister knows that if one is seriously ill there is no waiting and one is admitted within 24 hours. As I told the House last time I spoke on the subject, there is no waiting list for an urgent case in this country any more than there is in France.
The first thing I urge the Secretary of State to do is to make a clear designation of the payment we make to the NHS through taxation as distinct from national insurance and the social security scheme. Most of my constituents are of the opinion that a deduction is made from their wages for the NHS. In fact, only a small percentage of that deduction goes to the NHS. It is almost negligible. If the public are to be expected to pay more—as I believe that they should—they will do so more generously if they know how much they are paying and what their 526 payment buys. Perhaps the door may be opened to more generosity.
I have time only to touch on three of the particular points of the report. The first is one that has dominated this debate so far, and that is the question of NHS charges. Many hon. Members will remember that the greatest vote against my own Labour Government was when I divided the House on this issue some years ago and took most of my hon. Friends on the Back Benches into the Lobby with me.
Incidentally, may I put the record right on some of the dates that have been bandied about today regarding prescription charges? These charges were not imposed by a Labour Government. They were imposed by the Conservative Health Minister in 1952, the late Iain Macleod. I do not know that this is relevant, because had the Labour Government won the election they might well have done the same. However the Labour Party did not win the election. The Shadow Opposion spokesman at that time was the late Hilary Marquand, who gave a pledge on behalf of the Labour Party that when it returned to office it would do away with prescription charges. That pledge was honoured on 1 February 1965 by the then Minister, Mr. Kenneth Robinson.
There were no prescription charges for a year. Exactly a year later, on 1 February 1966—I know the date, because 1 February happens to be my birthday—under the pressure of the Treasury, as ever, they were reintroduced by Kenneth Robinson. The various changes in prescription charges since then have occurred under both Governments. The report states that there is a good case for their gradual but complete extinction, and the commission so recommends.
Prescription charges remain economic, ethical and clinical nonsense. If I had more time, I could show precisely why. I quote as my authority a previous Secretary of State, the late Dick Crossman, who declared in a Fabian lecture that the first thing he would do in 1970 was to eliminate prescription charges. I regret to say that it was not because of the eloquence of my arguments or those of my colleagues on Socialist or ethical principles that he did so. It was purely because of economic facts. He found that charges were nonsense. They cost more 527 to collect than they were worth and involved a great deal of trouble. Every year that prescription charges have risen, so has the pharmaceuticals bill, for some of the reasons already given in the House. Of 296 million prescriptions last year, 63 per cent.—188 million—were free.
What is so unjust is that the charges mean double taxation. Everyone pays once, but only the sick pay twice. Only those whom a qualified doctor declares to be in need of medication pay a second tax. The average taxpayer pays 80p a week, year in and year out, for medicines whether he consumes them or not.
Let us take a hardy and healthy group, such as the Lobby correspondents, who are probably rarely ill and who probably pay higher taxation than most. They are paying all the time, but if their wives or children want medicine they pay a second time. That is unjust in terms of taxation, because the whole purpose of the Health Service is that the healthy pay for the sick. The prescription charges and other Health Service charges mean that those who are sick contribute to the healthy.
The greatest sin of the Secretary of State and this Government was their Scrooge act of last July, when they decided that all those under 60 who suffered from Parkinson's disease, congestive cardiac complaints, hypertension, arthritics, thyroid sufferers, those with emphysema and all other chronically sick people entitled to a season ticket should pay an additional charge. The six-month season ticket was doubled in price, by £2.50, and the 12-month season ticket went up by £4.50.
Do the Government really need to tax the chronically sick to raise a total of £670,000? Do thy need to tax the sick to the extent of 0.007 per cent. of the NHS finances in order to find more money to give away for tax relief for the wealthy? I cannot conceive that that is in any way compatible with a humane society.
My second point has also been covered by the hon. Member for Carshalton (Mr. Forman). I refer to the holy grail that we are everlastingly pursuing, and on which the Royal Commission has a first-class chapter—prevention rather than cure. Paragraph 22.14 of the report says:government action could produce rapid and certain results: a much tougher attitude towards 528 smoking…a clear commitment to fluoridation and a programme to combat alcoholism".The Secretary of State has already told us that the negotiations with the tobacco industry will be completed by March. I urge him to be really tough. If he wants further factual information about the way in which he could get tough, I ask him to look at the article in the Financial Times of 17 January.
We assume that when the present negotiations with the tobacco industry finish we shall have a statement. I urge that it should be made not on a Friday but when hon. Members have a chance to discuss it.
The right hon. Gentleman has backed down on fluoridation. I do not believe that he wants to introduce it. As it is a controversial issue, and as hon. Members on both sides of the House may have reservations about it, would it not he possible for the Leader of the House to find time for a Private Member's Bill on the subject, letting the House decide? If the Government cannot, and if the Opposition have no right to decide, why not let the House decide?
My third comment is mixed with gratification, in that the evidence that I submitted on possible radical changes within the dental service has been the basis of many of the recommendations in the report. Paragraph 9.73 says:The prevention policies which we recommend for the future offer a real and attainable—perhaps unique—improvement in public health.The country spends £238 million a year on dental treatment, yet toothache, caries and the use of dentures could be as extinct as the dodo by the end of the century. We now know how to prevent dental decay, yet, in spite of the comprehensive dental service, the incidence of oral diseases has risen dramatically. In 1969 there were 19,430,000 courses of treatment. In 1976 the figure had risen to 26,277,000. We know how to stop putting china into people's mouths and how to preserve their teeth, but it means spending a little more money. It means an increase in public expenditure, but services for the people in need can be increased only if that is done communally, by the country at large. Public expenditure on these matters means a long-term saving. It is an investment. It does not mean that we are throwing money away.
529 The second paragraph on the dental services to which I draw attention is paragraph 9.75(b), which responds to some of the suggestions made to the Royal Commission that there should be an experimentwith alternative methods of paying general dental practitioners".I believe that dental graduates could be given a choice of two kinds of career structure. One would be precisely as it is now, with a Dental Estimates Board and all the present complications.
If a graduate wished to keep to the present old-fashioned system, he should be allowed to do so. But he should be offered the alternative of a more rational approach, in which prevention takes its full part in the service that he gives. Unlike the present system, under which he earns his maximum income at the age of 30 and receives less the older he becomes, this approach would make it more likely that his experience would be well rewarded, as it is in every other profession, including the medical professions, the older he became. The Secretary of State could well experiment with other systems which could overcome the difficulty that the more teeth the dentist fills, the more money he receives—the greater the incidence of illness, the higher the income. That leads to all kinds of problems.
I offer the Secretary of State and the Minister of State my sympathy. Thinking voters will add to their judgment of this Tory Government an assessment of their compassion and humanity. I believe that the right hon. Gentleman is a lone voice crying in the icy wastes of the Cabinet against all the economic, financial and selfish interest that seem to motivate the present Government. I wish him well in what he is trying to do but feel sure that he will be outgunned. I look to the next Labour Government to use the Merrison report—paragraph 22.2—it is invigorate the NHS and to restore morale, particularly of nurses, doctors, ancillary workers and those to whom all of us owe such a great debt.
§ Mr. Den Dover (Chorley)
In the conclusions and recommendations of the Merrison report to re-enliven and restated that 530no matter what the topic",the commission examined it and asked itselfWill our recommendations help the patient, and help those who serve him to do so more effectively?It is against that background that I shall speak for a few minutes.
Is the Health Service responding in too much of a big brother manner, a bureaucratic manner, to local demands? The Secretary of State and the Minister for Health have made it clear on many occasions that the Government want to respond to local demands to provide a local service.
I shall describe briefly some local matters in Chorley that raise doubts in my mind whether we are providing a locally responsive service. I have written to and spoken to my hon. Friend the Minister for Health about the casualty service at Chorley hospital. It has been the subject of a petition containing 20,000 names and a march by 7,000 people in pouring rain. There is tremendous local demand. All that is wanted is one senior registrar, one consultant or one house officer to supervise the extension of casualty hours beyond the nine-to-five five-day service that is now provided. Surely that is not asking too much.
I direct my remarks, secondly, to the local ambulance service. A few years ago the casualty service was restricted. A Lives in Danger organisation was established. It ran an ambulance service by means of voluntary help. It operated a car that carried specialist equipment. The car was used to take people to hospital. Among other things, it carried resuscitation equipment.
We were supposed to have an extension of two ambulance bays as a step towards an expansion of the hospital service. That has now been turned down. Did we respond to the show of voluntary service? I do not believe that we did. Has the National Health Service taken advantage of that voluntary effort?
Pat Seed has been present in the Strangers' Gallery for most of the debate. In the North-West she has raised about £2 million towards the provision of an all-body scanner at the Christie hospital, Manchester. Within that funding she has paid for 10 years of its operation. My hon. and learned Friend the Member for 531 South Fylde (Mr. Gardner) and I have been pressing the Minister to ensure that the unit will operate. It has taken several weeks or months for the regional health authority chairman to urge that on the Minister. It has been necessary to make those representations even though funding has been available. I am pleased to announce that in the past 24 hours the Minister has relented. It has been made possible to man the scanner outside the NHS by something to do with the University of Manchester medical school. That is the first sign of a chink of light. It is the first sign that perhaps we are not too much of a bureaucracy.
I sympathise with the Minister for Health and the Secretary of State because they are responsible for a huge number of people throughout the country. However, I ask them to ensure that we carry out our policies of responding to local demands and combining the best of voluntary help and funding with the provision of the NHS. Surely it is best to carry both forward and thereby improve the NHS.
§ Mr. Lewis Carter-Jones (Eccles)
I shall be brief, because I hope that all my colleagues will have a chance to participate in the debate. I identify myself with the hope that has been expressed by several hon. Members that the deprived areas will be given much greater resources. If greater resources had been made available to such areas, the appeal made by the hon. Member for Chorley (Mr. Dover) would not have been necessary on behalf of the North-West. I commend Pat Seed on her wonderful and valuable efforts.
I was delighted to hear the Secretary of State say that the Government would be giving priority to perinatal care. The campaign was led by the Spastics Society. I have been actively involved. Since the campaign was launched, the figures have tended to improve. I feel that they have improved primarily because people have become aware of the problem. It is significant that those who now occupy the Front Benches are among those whom I have plagued over the past two and a half years on the issue of perinatal care. The first results are appearing, but they are the results of awareness and not so much those of extra funding.
532 I give notice that I intend to make the Minister aware of another problem. However, with his background the hon. Gentleman does not need me to do so. We should devote much more time to the rehabilitation services. In the decade that has recently ended, we had four reports on rehabilitation, namely, the Tunbridge, Mair, Sharp and Snowden reports. In the commission's report there is an appendix on rehabilitation.
I shall speak briefly on rehabilitation and its impact upon the elderly. There is an assumption that we grow old and that there is not much that can be done for us. It is assumed that at the end of the day we shall be tucked away in a geriatric ward to absorb vast quantities of National Health resources. That is a fallacy. I ask the Minister to consider allocating extra funds to the rehabilitation of the elderly.
We make an assumption that as we grow old there is not much that can be done for us. That is unfair to those who work to rehabilitate, such as the staff at the Lady well hospital, in my constituency, and Dr. John Wedgwood, the consultant physician in geriatric medicine at the Middlesex hospital. These people prove conclusively that there is a tremendous amount of rehabilitation that can be done. It requires team work and the efforts of those in the medical profession who want to specialise in that sector. It requires the efforts of nurses and those in the remedial profession, such as occupational therapists, physiotherapists and social workers.
Much has been said about queues. When considering the elderly, the problem that we must face is the immobilisation syndrome. I shall give a classic example of the syndrome as an illustration before returning to the elderly. Dr. Wedgwood, in an illuminating address to NAIDEX, referred to the man aged40 who, at the request of his parents, was visited by a geriatrician. The geriatrician found that the man had had his appendix removed when he was 19. Apparently he had been told to go to bed. He did so, and he stayed there until he was 40. The geriatrician and the rehabilitation staff worked hard on that man, and after five years they succeeded in making him only partially mobile.
That is an unusual and exaggerated case, but I am sure that it falls within 533 the experience of the Minister that an elderly person in need of treatment for a disease who has to wait for treatment and has to stay within his home, or in bed, quickly becomes highly immobile. The initial cause of the immobility, coupled with the delay in treatment, leads to a person going into a geriatric ward much earlier than would otherwise be necessary.
On the evidence that I have, tens of thousands of NHS beds are occupied by elderly people who have not received treatment early enough and are suffering from the immobilisation syndrome. If resources could be devoted to intelligent rehabilitation in our society within the NHS, I am sure that many of those now in hospital would not be there. That would result in substantial savings to the Health Service, better living conditions and better standards for those involved, and fewer demands being made upon our social services. It is right to do that. To use a phrase that is often quoted,The intelligent use of rehabilitation will not of necessity add years to the life of people, but will add life to their years.That is the function of the National Health Service when caring for the elderly.
§ Mr. Anthony Grant (Harrow, Central)
I hope that the hon. Member for Eccles (Mr. Carter-Jones) will forgive me if, in view of the time, I do not take up his speech.
The Royal Commission was charged with the task of finding better uses for the financial and manpower resources of the National Health Service. The Government were elected—and pledged in their manifesto—to find a better use for existing resources. I can suggest one way in which millions of pounds might be saved each year for our hard-pressed National Health Service. My suggestion does not involve recourse to the taxpayer. I suggest the greater use of private contractors and private enterprise in the ancillary services that hospitals require.
I declare an interest in the Pritchard Services Group, which is a large company operating in a number of fields all over the world. Until recently the company was sited within the boundaries of my constituency. The Crothall company is a subsidiary of that group and it offers 534 domestic and ancillary services to hospitals throughout the world. Most of that company's work is carried out abroad, where there is a much greater use of private contractors, who compete with each other within the health services.
According to figures that I obtained from the Ministry under the previous Labour Government, about £250 million a year is spent by the Health Service on domestic cleaning services. That figure may be higher now because of inflation. Of that sum, about 1½ per cent. is undertaken by private contractors.
I approach the issue in three ways. First, there is a question of standards. Some people believe that the standards rendered by private contractors would be lower than those of direct labour. However, that is fallacious. The right hon. Member for Lewisham, East (Mr. Moyle) is on record as saying that the services rendered in one particular hospital—where services had been criticised—were of the highest order. In 1980 the standards in the hospitals where direct cleaning labour is involved are deplorable.
Close to the boundaries of my constituency lies Northwick Park hospital, which was built in 1971 and was opened by Her Majesty the Queen. It was intended that it should be one of the best hospitals in Europe. However, some time ago I went to visit constituents in that hospital. I got into the modern lift, which had been built only in 1971, and I found graffiti all over the walls, cigarette ends in the door runners and stale food on the floor. Months later, I visited the hospital again and I used the same lift. The food had gone but the graffiti remained. As far as I know, the same cigarette ends were there. I was told that it was almost impossible to keep such places clean and to remove such dirt. If that is the standard in our hospitals, something must be done.
Secondly, it has been suggested that industrial relations are worse in hospitals where private contractors undertake ancillary work. However, that can be disproved by the last winter of discontent. During that period, industrial unrest was worst where labour was carried out directly by the hospitals. There was virtually no trouble in hospitals that had used private contractors.
535 Finally, I turn to the question of saving resources. Where private contractors have been used for ancillary services, it has been found that a saving of nearly 10 per cent. has been achieved without any diminution in standards. I have given documentary evidence of that to the Minister and his Department is aware of it.
Let us assume that, without any reduction in the labour force and without any reduction in wages—because the same firms and unions are involved and the same negotiations take place—savings are achieved by skilled management. If private contractors were used throughout the whole of the Health Service—as other countries use them—on the basis of a cost of at least £250 million each year and on the basis that a 10 per cent. saving can be achieved, there would be a saving to the National Health Service of about £25 million a year. An even greater saving might be achieved if greater competition were allowed.
§ Mr. Ronald W. Brown
A new hospital is being built in Ealing by private contractors. Its cost has increased because of delays and the absurdity of the contracts that were made. As a result, the district has lost a lot of money.
§ Mr. Grant
I am not concerned with that, because it concerns the building of a hospital and does not involve the supply of ancillary services. I am not associated with any firm involved with that hospital, and my constituents do not go into that area.
It would be possible to achieve savings of £25 million on the basis of figures that I have given to the Minister. I urged the Labour Government to encourage the use of private enterprise, but the answer was always that this was a matter for the health authorities. That is fair enough, but it does not go far enough. In November. I asked the Minister what action he had taken to encourage greater competition in the supply of ancillary services. He replied:Health authorities have discretion to put a wide range of services out to contract, and it is for them to decide in the light of local needs and circumstances whether services can be provided more effectively and cheaply by this means. I should be glad to see them use this discretion more freely"—[Official Report, 5 November 1979; Vol. 973, c. 52.]536 That is progress in the right direction, but it does not go far enough.
What can the Minister do to push the authorities—I am not suggesting legislation—into the greater use of private enterprise? Private enterprise would lead to higher standards and to a substantial saving of money. It would be possible to buy a lot of kidney machines and essential medical equipment with that money.
§ 8.8 pm
§ Mr. Ronald W. Brown (Hackney, South and Shoreditch)
In many regions private contractors are used for a whole range of work, and their track record shows why their work is poor. They have to undertake fixed contract prices, and the Minister knows that. As long as fixed contract prices remain, there will be a problem. When hospitals employ labour to do a job, that labour is under better control. The building management may be wrong. It is up to the hospitals to find better building management. That does not alter the fact that it is not correct to say that private contractors would bring about an improvement in the Health Service. That does not accord with the facts.
I support the general theme of the commission's report. The reorganisation of the Health Service in 1974 produced the chaos and difficulties that we are now in. We opposed the reorganisation and tried to point out to the "Mad Mullah" who is now the Secretary of State for Industry that he was on a mistaken course, as he was in 1962 when he destroyed London, but he would not listen. We tried to explain that, with his restructuring, unless the Health Service continued to be funded on a growth rate of 4 per cent. it was bound to be destroyed. He would not listen and argued that as long as the structure was changed the money would take care of itself. We are now in the position that we warned him about many years ago. It was an inevitable consequence. The previous Conservative Government caused the problem, and they are now trying to tell us that they do not want to put it right but want to bring in private enterprise as an alternative.
Between 1956 and 1974 the National Health Service enjoyed an annual growth rate of about 4 per cent., whereas it now absorbs only about 5.5 per cent. of the gross national product, compared with 5.6 per cent. in 1975 and 1976. It is 537 clear that the proportion of the nation's wealth spent on the National Health Service has been effectively frozen for five years.
It is impossible to freeze the NHS. It moves backwards. It cannot stand still. The Secretary of State talked about increasing problems. He mentioned the burden that elderly people put on the Service. To countenance a freeze is to say that the Health Service will grind to a halt.
It was the limit when the Secretary of State said that the problem with the Service was the patients. In identifying the problems of the Health Service, he said that it was all down to the patients. That was his first point. He did not go on to say "By the way, we shall have to re-educate patients." The main thrust of his argument was that the patients were the real problem. If the Government could get rid of the patients and their demands, they would have a wonderful Health Service. It is scandalous that that was the sum total of the Secretary of State's contribution.
The Secretary of State's skill was that he enunciated that fact as if it were some new dream—this is the millennium. It was in the Conservatives' manifesto. He is right, but it was their nineteenth century manifesto. That was what they did in those days. Even after the war we had the HSA, the HSF and the Manor House hospital. People could not afford to pay for hospitals and doctors, and because they could not afford to buy them they used to make up their own treatments for coughs. That was how it was. It would seem that the Government would like to wipe the slate clean and return to that position. When people were poor, the Tories were compassionate. They built a home and called it a workhouse.
In my constituency the other day I was delighted to see one of the DHSS buildings being painted. I thought that rather strange. It looked as if it needed pulling down, but it was being painted. I suddenly realised why. Over the entrance it said "Office for the relief of the poor". Having listened to the Secretary of State this afternoon, I am sure that the order has gone out to repaint those offices. The right hon. Gentleman will not get a very 538 good reception from the people in Hackney for the idea of having an office for the relief of the poor. No doubt he calls that forward planning, but he is arguing to turn the clock back.
Patients are demanding. The Secretary of State claims that old people do not visit a doctor so often. They are more discriminatory. It is the young people who use the Health Service more frequently. However, the young people are told by the medical profession that they would rather they came to see them earlier, before it was too late. If a young mother worries about her baby and does not go to see a doctor for a long time, when she eventually goes and the doctor finds that there is nothing wrong he does not tell her that it is marvellous that she has saved the Service a bit of money. He tells her that she is a silly girl and should have come earlier. He tells her that he is there to give advice. The Secretary of State is wrong to suggest that the young mother is a disgrace to society because she takes her child to see the doctor when she is unsure about what is wrong. Young mothers should not listen to the Secretary of State. They should go to their doctor and see that their child is properly cared for. It is outrageous for the Secretary of State to argue that it is an exercise to save tax.
The right hon. Gentleman mentioned drugs but said not a word about the pharmaceutical industry and the vast sums of money that it milks from the Health Service. He appeared only to be saying to doctors that they should not prescribe these drugs because they were too good for the workers; they should be saved for those cared for by private enterprise. I hope that he will produce a circular that can be handed to all my constituents by their doctors. It will say to the patients that they should have a certain drug to help them get better but that the Secretary of State says that it is too expensive. The right hon. Gentleman cannot leave it to the doctors. If he gives that instruction and takes away a doctor's clinical judgment, he must put it in writing so that we know at whose door the blame rests.
The right hon. Gentleman's advice to doctors is that under the National Health Service they must not prescribe drugs 539 that ought to be prescribed. He says that they are too expensive. If people have sufficient money for private medicine, he will allow them to have whatever drugs are available and the necessary help. People can have good help if they pay for it, but if they cannot pay for it it is the knacker's yard for them. That is the point made by the Secretary of State.
Years ago, before he was Secretary of State, I told the right hon. Gentleman that one of the greatest problems in the Health Service was that the largest part of the bill in a teaching hospital in London was for drugs. No matter what measures are taken, the pharmaceutical industry will always get round them. The Secretary of State should have told us what his proposals are to cope with that problem.
The Secretary of State, as a London Member, acknowledged that London had problems, but he went no further than that. He leaves it to three highly specialist inquiries, one of them by a university and not even by his Department. He said that he would examine the London problems in the light of those specialist investigations. He knows that that is wrong. Until we have an independent inquiry to examine all the facts, we shall never get it right.
As I have said before, the hospital service in my constituency is in a chaotic state, and we shall not solve the problem unless we have an investigation. A teaching hospital in the district covering my constituency takes about 65 per cent. of the district money. To find that money, four hospitals in my constituency are being closed. That would not be so bad if all the people in that hospital came from my constituency, but only 15 per cent. of the patients in that teaching hospital come from the district, even though they pay 65 per cent. of the charges. The other 85 per cent. come from all over the country—from the North-West, the North-East, the South and Scotland. Therefore, it is quite unreasonable to close all these hospitals in my constituency simply because of the money needed for the teaching hospital. I underline the fact that these hospitals are not being closed for medical reasons. They are being closed on a financial basis, namely, that £1.5 540 million must be found, and the only way that this can be done is through closures.
I am staggered to hear the Secretary of State gloss over the London problem. The Royal Commission felt that the problem was too big even for it to handle. That was why it recommended an urgent inquiry. There is a definite problem here which must be resolved. Certainly the funding of teaching hospitals is an issue which must be resolved. It is not sufficient for the Secretary of State to leave it alone.
§ Mr. Brown
I am grateful for that assurance. I should like to discuss this matter in depth. It is a tragedy that we have so short a time in which to make our contributions on this excellent report. My right hon. Friend the Member for Lewisham, East (Mr. Moyle) has just thrown down a challenge to the Secretary of State. If we are prepared to do it, why will the Secretary of State not review his position and undertake an urgent look at the London situation—not because the Government are bureaucrats, but because people are suffering?
In my constituency, people are not getting treatment. I was assured by the Minister for Health, who was kind enough to come to my area, that Hackney people would have prior rights to go into the teaching hospital. That assurance was given in front of the consultants of the teaching hospital. Last week one of my constituents was referred to the teaching hospital by her doctor, but when she was seen at the hospital the doctor there told her that she was not really serious enough to be in that hospital and he suggested that she should go elsewhere. Therefore, there is clear evidence that the teaching hospital will not be used as a district hospital.
I hope that the Secretary of State will really pull his socks up. He was a pretty poor performer today. A real difficulty faces us, and we want a man-sized answer to the problem.
§ Mr. David Crouch (Canterbury)
The hon. Member for Hackney, South and Shoreditch (Mr. Brown) knows much more about the Health Service than he has revealed tonight. He ranted and raved in a way that really does not become his expert knowledge about the Service. He and I are the only two hon. Members who for the past five years have served on regional health authorities. I am sorry that he injected so much politics into his otherwise sober and sensible reflection of the real problems facing the Health Service. The real problems are not political but economic. There is a shortage of money. The real problem is finding enough money by some means or another. That is really what my right hon. Friend the Secretary of State has tried to do, and the Opposition, for quite good and fundamental reasons, object to it. I do not blame them for arguing on that score.
The hon. Member for Hackney, South and Shoreditch spoke about people coming into his area to go to one of the London teaching hospitals. In the jargon of the Health Service, this is called "cross-boundary flow". There is an advantage in being able to go to hospitals in my area, for example. I have an interest to declare in that I am a member of my regional health authority. Also, I have an interest in the pharmaceutical industry. That would come out—it always does—but am not worried about it because everyone knows. I believe that there is a real advantage in being able to go to one's GP and say "I want to go to Bart's" or King's or Guy's. There is a great advantage in the GP being able to say to a patient who lives 70 miles from London "The best man for you is at Guy's".
§ Mr. Crouch
I do not want to dwell too long on that point. I agree that there is a case for the teaching hospitals, whether they are in London or in any other great city. Merrison did not spend long enough looking at the problems of these hospitals. He quite properly described the teaching hospitals as "centres of excellence". That is true.
542 They are seen to be such, not only in this country but abroad as well. I am glad that they sustain and maintain their excellence. But that costs money. I liked Merrison's suggestion that there should be an inquiry—at least in London.
I go along with the hon. Member for Hackney, South and Shoreditch in believing that there is a strong case for an inquiry into the situation in which the 12 teaching hospitals are concentrated—unnaturally in this day and age—in a small area around London with its diminishing population in the centre. Nevertheless, to let these hospitals wither in any way at all would be a disaster. Also, to let them become so involved with other NHS responsibilities of primary healthcare that their specialist provision was diminished in some way would be a tragedy. These hospitals are in such a special position that they merit a further inquiry.
The House knows that I have never descended to the argument about the sale of drugs in the Health Service. It would be almost improper for me to do so. However, as the matter has been raised, I should like to comment on the cost of drugs. Let us get this in perspective. Out of a total cost of the NHS of £8,000 million, the total cost of drugs is £500 million. The real cost of the Health Service which comes from taxpayers' money is the 70 per cent. of £8,000 million which goes in wages and salary.
Merrison mentioned drugs in his very thorough report. He examined health services around the world and ways in which we could keep down the cost of drugs. He pointed out that in some countries—in Australia, New Zealand and Denmark—there is a limited list of drugs recommended produced by the Governments of those countries. The drugs that are recommended by bureaucrats and officials are prescribed free. If a consultant thinks that there is another drug which is an advance on the limited list, that drug must be paid for at the going rate. I do not deny that drugs are very expensive. I think that the limited list idea is appallingly bad—not for any vested interest of mine, but because some people might be denied the best drugs and the best developments in medical science. That would be terrible. The Health Service was set up in 1948, and 543 ever since it has maintained the free availability of the very best—of surgery, medical treatment and drugs. We must never lose that in this country, because it is important. I mention it only because it is mentioned in the report.
§ Mr. Haynes
The hon. Member has ranged across the spectrum concerning drugs, and he has mentioned particularly the high cost of wages and salaries, but he forgot to mention something very important—the massive profit that is being made by the pharmaceutical industry.
§ Mr. Crouch
In a way, it is almost helpful that the hon. Member has mentioned that, because all of us in this House have to learn that the profits are determined by the Minister. They were determined by the hon. Gentleman's right hon. Friends until a few months ago. Now it is the turn of my right hon. Friends on the Front Bench. The profits of the industry and its costs are determined. No industry in Britain is more closely controlled by the Government than the drugs industry. I would be the first to support that Government action in so controlling profits. It is absolutely right.
I say one special thing to my right hon. Friend. This afternoon he talked about regional health authorities, saying that they would remain and would have a strategic planning role. It is important that they continue to have that role rather than lean over the backs of the stronger district authorities that are to be established, telling them what to do in the tactical sense. They are allocating their resources and letting district authorities get on with the job, and the delivery of the health care and the decision on the spot is up to the people nearest the point of delivery of health care.
As regards membership of the authorities, here I speak with a vested interest. My right hon. Friend should look very carefully into his thought that he might seek to pack RHAs in future with district membership, and no more than district membership. Certainly let us have representation on the RHAs of the district team view, but let us also have some other voices there that are not at the district level and are thinking strategically as well. In that way, I think that my right hon. Friend would get what he really wants—the best decisions.
544 I want to speak on only one subject that arises from Merrison. Merrison has commented that the NHS is a service for consumers and that we must always start by considering the patient that it is intended to serve. But for once I want to speak not of patients but of the workers in the industry—1 million of them. I want to deal with one aspect of the report which is very important indeed. That is chapter 12 concerning the industrial relations problem.
We have seen emerging in the last few years, particularly since 1973, strangely—although perhaps it is not so strange—an industrial relations problem in the NHS which was almost foreign to the Service hitherto. We have not expected to see certain reactions on the part of people in a dedicated Service. Be they consultants, nurses, ancillary workers, porters or whatever, we have expected them to be so dedicated that they would not react in a way which would do anything to injure their own dedication to their patients. Yet that situation has arisen. In the NHS, industrial relations are as important for the patients as they are for the workers.
We should also be reading, in conjunction with Merrison, Lord McCarthy's report on the working of the Whitley Councils. It is absolutely essential reading, together with the report we are debating. Lord McCarthy carried out a review of the work of the Whitley Council system. He then said that what the Government needed to do was to ensure that the review recommendations were carried out. It is one thing to write a report; it is another to see that a review—and that means a change—takes place.
Another thing which arises from the Merrison report is appendix H to chapter 12—the evidence of ACAS. I go along with every word of that evidence. I quote from paragraph 39 of the ACAS evidence:Unless effective remedies are introduced urgently, we can see little prospect of avoiding continued deterioration in industrial relations…and noticeably poorer quality patient care.ACAS has been called in far too much to put out the fires in the Health Service in recent years to treat the symptoms. But no one has got down to treating the causes of the problem. Where we have industrial relations problems in the NHS 545 and disgraceful occasions such as we saw at the Charing Cross hospital—behaviour which we all condemn—there is something more than a symptom; there is always a cause. We must find out the cause and devise policies to put matters right.
A better system of industrial relations management is needed. Is the Whitley Council system good enough? Lord McCarthy asked this question. Are the reforms that he suggested good enough? Lord McCarthy, like the Merrison report, suggests that the Whitley Councils are never independent of the Government. The commission says in its report:the government apparently acts as both judge and prosecuting counsel in such disputes".The question arises whether an independent commission should be established to help solve industrial disputes in the Health Service. Should there be a review helped them very much. What about body? One element, the doctors and the dentists, have a review body. It has others who work in the Health Service? Do they need help from someone like Clegg? Or must they rely on a rather antediluvian Whitley Council system? The commission says:We hope that Lord McCarthy's review will lead to improvements. As pay negotiating bodies, the Whitley Councils are weakened by being insufficiently independent of government.Health workers, like anyone else, are affected by the disastrous impact of inflation. They are also affected as employees of the biggest employer in Britain, a massive, impersonal organisation called the National Health Service. Those workers—whether they are consultants or porters—have grievances from time to time. They feel that the system for dealing with such grievances is, to say the least, a bit sluggish. It does not always appear to hear them, let alone understand them. In short, the system for coping with their problems is inadequate. ACAS has found this to be so. Its report referred to a lack of industrial relations expertise in management. It found that personnel officers had no past experience in industrial relations. Even more startlingly, it found that there is no statutory duty for personnel officers to be appointed, let alone have a voice in the decisions of the district management teams. Those personnel officers tend to be non-committal. They tend to have little effect.
546 Management must show its readiness to listen and its competence to make decisions in industrial relations matters. Another fault in the management structure is failure to operate effective line management. Decisions in industrial relations are all too often passed upwards. That is a sure recipe for dissatisfaction and frustration. Problems should be settled at the point where they arise—on the shop floor, at the point of delivery. There must be more delegation and decentralisation. There also needs to be clarification of who manages whom.
There are too many separate organisations within the Health Service. The man or woman with a grievance does not know who can settle the question. Lord McCarthy was concerned about the absence of professionalism in industrial relations at the grass roots. So am I. Lord McCarthy thought that Whitley Councils could still do a useful job if they were reviewed. I believe that they should be reviewed. I am not sure that they should not be replaced by something better.
§ Mr. Reg Race (Wood Green)
I should be glad to take up the remarks of the hon. Member for Canterbury (Mr. Crouch) on industrial relations if I had more time, but in the circumstances I shall concentrate on certain specific questions to the Minister and raise one matter which, I believe, was not covered by the Royal Commission in any satisfactory fashion.
First, I put my questions to the Minister. In the so-called trade-off between the level of service which the patient can expect and the level of wages which employees in the National Health Service can expect, what absolute level of wages is he prepared to allow the employees to sink to in order to preserve the structure of the NHS? That question arises at once from the logic of what Ministers are saying, and I shall be grateful if the hon. Gentleman will be more specific about it in his reply tonight.
Second—very much on the same issue—there is the financing of the nurses' pay settlement arising out of the Clegg recommendation. Will the Minister give a specific assurance that the Government will finance every penny of whatever settlement is negotiated on the Nurses and 547 Midwives Council and give that money to the area health authorities to pay out? The answers on that question which we have had so far have not been entirely clear.
I come now to the big problem with which the Royal Commission did not deal, namely, the problem of control and of power within the National Health Service. Who controls the National Health Service? Is it Parliament? We vote the money for the Service, but in no sense do we control the day-to-day delivery of the services. Nor do we control the level of aggregate spending, since that is the job of the Executive and, in particular, of the Treasury.
Does the DHSS itself control the National Health Service? Again, I think that the answer must be "No" because of the way in which the Treasury dominates macro-decisions about the level of health spending. The DHSS has some power over internal relativities and over internal methods of allocating resources to different sections of the Service, but again there is no real power over day-to-day delivery of health services.
Is the Treasury in control? This is the crunch question in the context of public expenditure. The Treasury controls in direct fashion all the spending in the NHS, and hon. Members need no reminding of that.
Are the area health authorities and regional health authorities in control? I argue that they, too, have no direct control over delivery of services, which are primarily the responsibility of doctors, whether in hospital or in the community, and aggregate spending at that level is determined by, so to speak, social factors through RAWP and other mechanisms.
Is it the doctors who control the NHS? My answer is "Yes, partly it is", because they control the day-to-day delivery of services through key aspects such as prescribing habits.
Is it the public who determine policy in the National Health Service? Again, I say that it is not, since the public have no direct control over the membership of the area and regional health authorities as they are at present constituted.
Finally, one must put a big negative against the possibility that control is exer- 548 cised by workers employed in the National Health Service, whatever their level or responsibility may be.
The real power structure of the National Health Service is therefore poly-centric, with power being exercised by the Treasury on macro-issues, by the doctors on day-to-day delivery aspects of the Service, and by Civil Service mandarins in the DHSS and elsewhere over the internal shares of the NHS cake.
The distribution of power within the Service is profoundly unsatisfactory, and the Royal Commission did not address itself to this issue in a realistic fashion. There are no recommendations for democratising our National Health Service, and I regard that as a deplorable failure on the part of the Royal Commission.
In company with many hon. Members—the point was made by the hon. Member for Rochdale (Mr. Smith) earlier in an intervention—I believe that there should be a more direct method of election by which people at the community level could determine for themselves who would sit and represent them at district health authority level and regional health authority level. Only in that way will the system really serve the purposes of the NHS by reflecting the needs and aspirations of the public as a whole in the 1980s.
From the point of view of a Labour Back Bencher, therefore, I believe that we must do more than just regard Merrison as defending the National Health Service at this time and defending it against the iniquities of the present Government's policy. We have to strike out in advance of the Merrison proposals and argue for fundamental democratic changes within the NHS to make possible greater control by the public, by health workers and by the House of Commons. These changes are necessary because of the manner in which the Treasury, the Civil Service mandarins and the doctors presently control the NHS.
There is another argument to support my belief that the Royal Commission is important but not crucial. What would happen if all the commission's proposals were implemented overnight? There would be high public expenditure and a great improvement in the Service in many areas. However, the crucial test is that 549 the implementation of the report would not protect the NHS one iota from monetarism, control by the Treasury or domination by the doctors.
The debate, important though it is, has to be set in that wider political context. The implementation of the report's recommendations would not protect the NHS from the problems foisted on it by the policies of the Treasury, the Prime Minister and the Conservative Party.
When discussing the need for fundamental changes of that character in the scope of the NHS, it is important to recognise that the NHS will never be the same again. Following reorganisation in 1974 and the imposition of public expenditure cuts by successive Governments, in no way would the public or the workers in the NHS accept continued domination of the Service by those presently in control. Nor will they accept, on a continuing basis, the method of financing that is presently ruining the Service. I am referring not to the basic principle of financing by general taxation but to Treasury control.
We need to open out decision making to a broader, democratic group of elected representatives. We must return to the House a number of important decisions about aggregate spending in the NHS that are currently glossed over.
The position is clear. As the hon. Member for Canterbury intimated, in no way can the industrial relations position return to what it was before 1973. We must determine that there will be better industrial relations within the NHS based on clear integration of ancillary and nursing staff in decision making. If we ignore that, we will be putting forward a prescription for total disaster inside the NHS, which is something that no hon. Member would wish to see.
§ Mr. Ivan Lawrence (Burton)
The saddest part of the Merrison report is its unequivocal endorsement of compulsory fluoridation of the public water supply. I wish to devote my short speech to that subject because, as hon. Members will know, I am chairman of the all-party Anti-Fluoridation Committee.
We are committed to stopping the artificial fluoridation of public drinking water, and 83 hon. Members have signed early-day motion 93 to that effect. No 550 doubt a number of my right hon. and hon. Friends who are in the Government would sign the motion but for the rule of practice which prohibits the signing of early-day motions. I hope that a number of hon. Members will still sign it.
It is well known that the reason why no Government have legislated for fluoridation is that such legislation would not get through the House. The majority of hon. Members on both sides feel strongly that, whatever the medical argument for or against fluoridation, to force every citizen to drink water that has been medicated in accordance with the wishes of so-called experts, whether or not they need it and wish for it, would be a gross deprivation of personal liberty. It would be a betrayal of one of the fundamental justifications of our presence in this place, namely, to protect the individual against the insidious incursions of the collective State and its bureaucracy, especially since that State's record of being right in things medical is not entirely without blemish.
Those who advocate mass medication do so in contempt of individual freedom. I can understand why some people in power or influence think that freedom is less important than saving life, which is why I can understand the argument for stopping cigarette smoking or making seat belt wearing compulsory. But I find great difficulty in understanding their preoccupation with fluoridation, which does no more than delay the onset of dental caries in children's teeth by a year or two. It does little or nothing to stop the decay once it has started. A reduction of dental decay in one tooth for a year or two is no solution to the problem of tooth decay and is certainly not worth mass medicating for. The authority for that is the Department of Health's own report in 1969 on "Fluoridation studies in the United Kingdom and the results achieved after 11 years". That report is available from Her Majesty's Stationery Office.
Quite simply, I want to demonstrate to the House not the question of freedom but the scientific aspect of fluoridation. I want to show how grossly irresponsible and misleading the Merrison report is in recommending fluoridation on the assurance that it is completely safe. I do not know whether it is endorsing fluoridation safety in ignorance of the evidence or with knowledge of it and in order to 551 deceive. Of course, I prefer to believe the former, although I fail to understand how the Merrison Commission can possibly be ignorant of the evidence as it is now receiving such widespread circulation.
Either way, no credit is due to that body for its irresponsible judgment in that regard. The apt slogan is perhaps that none are so blind as those who will not see. The commission relies upon the 1976 report of the Royal College of Physicians, which said that there was no relationship between cancer mortality or cancer incidence and fluoride levels in water supplies. To ordinary people, those words mean that no one has come forward with any evidence. If that is too narrow an interpretalion of the phrase, at any rate ordinary people would understand it to mean that there is no reputable evidence of any harm from fluoridation. Either way, that assertion is bogus and it is quite terrifying, as the evidence is that many people may be dying from drinking artificially fluoridated water.
Let me present some of the evidence. My point is merely to show that there is a doubt about its safety so that the House can consider whether that is so and whether there is justification in the sentence in the Merrison report on page 119, paragraph 9.59, thatthe safety of fluoridation in recommended quantities is no longer in doubt.To begin with, there is the evidence and studies of Dr. Aly Mohammed, professor of biology at Missouri university, that sodium fluoride in a concentration of one part per million produces genetic damage to mice. There is the evidence of Dr. Donald Taves, associate professor of toxicology at Rochester university, that if it is shown that fluoride is a mutagen, it would increase the probability that there is a causal connection between it and cancer.
There are the studies of Drs. Hershkowitz and Norton, of the department of St. Louis university, that fluoride induces tumours in fruit flies. There is the evidence of Dr. Marvin Schneider man, chief statistician of the National Cancer Institute in America, that a substance tending to cause tumours would probably be a "red flag" for cancer. There are the studies of Drs. Taylor 552 and Taylor of Texas university showing an increase in tumour growth rate in mice fed on one part per million of fluoridated drinking water.
There is the evidence of Dr. George Waldbott, an eminent United States physician, who has personally examined 400 patients suffering from fluoride poisoning, that fluoride in drinking water at one part per million gradually causes cancer death in sensitive individuals. There are the studies of Okanura and Matsuhisa showing positive correlations between food fluoride levels and stomach cancer. There are the studies of Litvinov and others, showing a possible correlation between airborne fluoride and lung cancer. There are the studies of Klein and others indicating that fluoride at one part per million interferes with the repair of DNA and the availability of the chemical-building blocks of DNA and RNA.
There is the evidence in 1975 and 1976 of Messrs Burke and Yiamouyiannis in the United States that the 10 largest fluoridated cities in America compared with the 10 largest unfluoridated cities show such a sharp increase in cancer mortality after a period of fluoridation that between 10,000 and 35,000 people may be dying each year as a result of drinking artificially fluoridated watered. Yiamouyiannis has compiled a collection of studies, 12 of which show a possible relationship between fluoridation and cancer once they have been corrected for errors and omissions.
Most of that evidence was considered in a court case in the United States last year. The decision of the judge, after hearing five months' evidence, was:Point by point, every criticism that the defendants made of the Burke Yiamouyiannis study was met and explained by the plaintiffs.The plaintiffs were the citizens of the town trying to stop the fluoridation. The judge went on to say thatoften the point was turned round against defendants. In short, this court was compellingly convinced of the evidence in favour of the plaintiffs".He went on to refer to significant evidence. The climax of that evidence was the answer by one of the witnesses, Dr. Taves, on behalf of the defendants, to the question whether it was his testimony that he would recommend fluoridation in public water supplies. He said:I do not want to state on that.553 How can it possibly be said, by any stretch of reasonable analytical objectivity, that there is no evidence? That there is evidence that is disputed is one thing, that there is no evidence at all is quite another. But when a court of law considers both sides of the evidence—witnesses giving evidence on oath—and reaches the conclusion that, point by point, all the anti-fluoridation arguments have been upheld, how can it still be said that there is no evidence?
When the Sub-Committee on Social Services and Employment considered the question of preventive medicine, we received a letter from a university lecturer who said that he had been growing watercress in fluoridated water. He said that the fluoride concentrated in the watercress, putting man at the end of a poisoned food chain. There is much evidence, stretched across the continents of the world, to the effect that fluoridation is a dangerous way of curing anything.
A professor of chemistry at Kansas university, having reviewed the evidence of fluoride's contribution towards kidney disease and bone disease, concluded:Despite whatever reduction in tooth decay can be achieved by fluoridation, there is a steadily growing amount of solid evidence showing that fluoride in drinking water at the officially recommended concentration of 0.7 to 1.2 parts per million causes serious harmful effects to its users.That is not all. In 1977 the government of Quebec, before fluoridating their water compulsorily, set up a high-powered committee to look into the subject. It was not made up of cranks. It was made up of high-powered scientists, upon whom the government of Quebec placed their reliance. On the question of the effects of fluoride upon the ecology, the committee concluded:Although there is a lack of information regarding the effects of accumulation of fluorides along the food chains, there is enough evidence to conclude that the actual presence of fluorides above certain levels in the aquatic environment is causing important biological damage to both the plant and animal systems.On the question of cancer it concluded:What is implicit in this study is that fluoridated organic compounds and the fluoride ion may be as potent carcinogens as chlorinated organic compounds.It went on to say:The possibility of formation of fluoridated organic compounds either during the water 554 treatment process in public waterworks or during later use by industry…should be of utmost concern to all who are interested in public health.The decision of the Quebec government was to recommend an indefinite moratorium on water fluoridation for the province, that there should be basic and applied research in the area of fluoride intoxication, that the fluoride levels in the environment should be monitored, and that fluoride levels in food should be monitored to determine the exact level that is digested by people. It is no use adding one part per million to the water supply if one has not the faintest idea how many parts per million the ordinary individual has in his system already.
Recently the figures for Birmingham and Manchester have been published. An analysis shows that for the period 1953 to 1963, before fluoride was added to Birmingham water, the cancer death rate had risen more slowly in Birmingham than in Manchester. But Birmingham water was fluoridated in 1964, whereas Manchester water was not fluoridated, and during the period from 1965 to 1967 there was an 8.2-fold increase in the cancer death rate in Birmingham as against only a 1.5-fold increase in Manchester.
How can it possibly be said that there is no evidence and no doubt? If responsible scientists are in dispute, there is a doubt, regardless of which side is right. It is, therefore, of small wonder that practically every other country in Europe, with the exception of Ireland, has either stopped fluoridating its water or has never fluoridated.
For goodness sake, let the Government stop saying that they support fluoridation. For goodness sake, let them remove from their mind any possibility of legislation. For goodness sake, let us have a moratorium on fluoridation until the matter has been more thoroughly investigated. If we cannot trust the scientists to make an unbiased judgment, let us have a proper committee, supervised by a High Court judge.
The British people do not want fluoridation. They can remember how they were betrayed on numerous occasions, and most significantly on the question of thalidomide, by the scientists. I earnestly ask the Government to reconsider their whole attitude to this subject, whatever their scientific advisers may say.
§ 9.2 pm
§ Mr. Clinton Davis (Hackney, Central)
I want to return to the problem of the inner city, because it was that which the Royal Commission report described as deserving of the most immediate and urgent attention.
As an inner city Member, I am dismayed by the Government's indifference to the problem, as revealed by the Secretary of State's speech today and in their document "Patients First". Perhaps they spelt "patients" wrongly, because what they are asking us to do is to wait and wait and wait. My feeling is not just one of dismay; it is one of great disappointment that I express on behalf of people in an area such as mine who are having to face tremendous misfortune and hardship.
I should like to illustrate, as quickly as I can, some of the problems as they have been presented by the community health council in my area. The Secretary of State has put great emphasis on the need to develop community care. I agree with that, but we need more than words.
There should be 66 health visitors in Hackney; there are 41, and 10 students. There should be 79 district nurses; there are 46, plus six in training. There should be 17 community midwives; there are only 11. General practitioners are expected to maintain in Hackney a list size of 2,500, so technically Hackney is over-doctored. It is, therefore, extremely difficult for new GPs to work in Hackney and no allowance is made for the fact that in a district of high morbidity and poor social conditions 2,500 may be too big a list.
I ask the Minister whether he will consider trying to work out a system of payments which takes account of the difficulties of inner city areas. It is one very good reason why urgent attention should be given to the problems of London.
When we turn to the maternity service, we find another sad and sorry state of affairs in Hackney. I illustrate it by reference to a submission made by the community health council to the area health authority and to the regional health authority about the inadequacies of the maternity service. At the Mothers' hospital, clinics are grossly overcrowded. There is no privacy in the booking clinics. Mothers, many of them suffering from high blood pressure, must wait far too 556 long. Indeed, a two-hour wait is common at the antenatal clinic.
The district management team considers that seven minutes is adequate for first appointments and five minutes for follow-up appointments. Doctors must see between 80 and 100 women in a morning, and no effort is made to ensure that patients see the same doctor on each visit. Those problems are faced not only in Hackney. They are faced in many inner city areas but particularly in London. There is need for an urgent inquiry into these matters.
The Minister should know that Hackney has a poorly developed community midwifery service and that there is a particular problem affecting Asian mothers. There are no facilities for interpretation, although almost 25 per cent. of births are to Asian mothers at the Mothers' hospital. It is not good enough to tell those mothers that they must bring an interpreter with them. It is often the husband, who has to take time off work, or an older child who has to interpret. How embarrassing that must be for those Asian mothers. I believe that interpreters should be made available at clinics at certain times. Those are some of the practical problems.
The members of the community health councils are dedicated and caring people who express great concern for our problems and have done an enormous amount of valuable work in alerting our communities to these problems. They have tried to find solutions. Yet there is a guillotine poised over the heads of community health councils, as we note from the document "Patients First". The Government say that authority members will be less remote from local services than many of them necessarily are today and that the need for separate consumer representations in these circumstances is less clear.
There is no evidence to support the proposition that community health councils should go. They are an invaluable watch-dog, and that has been proved in practice. I believe that, although this Government may be afraid of the role played by community health councils, the case for keeping them is overwhelming.
§ 9.7 pm
§ Mrs. Elaine Kellett-Bowman (Lancaster)
I was pleased to hear my right hon. Friend the Secretary of State say 557 that he will continue with the redistribution of health care resources and that he will give twice those increases to the less-well-off than to the better-off. That is of tremendous help to the North-West. Our region is at the bottom of the poll if we consider all health items together and has been so for many years.
At the rate of redistribution of resources under the last Government, it would have taken the North-West a quarter of a century to catch up with the South-East. The announcement, in July, of a £172 million hopsital—the biggest hospital programme ever undertaken in the North-West—will accelerate our rate of catch-up.
I always believed that coterminosity in health care anywhere was a mistake, but in my area it was a disaster. Until 1974, hospital services in Kendal and Lancaster were integrated, and despite reorganisation nobody has succeeded in reversing that happy relationship. Senior medical staff in Kendal are appointed to the Lancaster group of hospitals and the majority of their contracts oblige them to work both in Kendal and in Lancaster. There has been a history of affiliation between our hospitals for many years and the flow of patients is naturally between Kendal and Lancaster. There has been a close relationship between the hospitals, and even the plan for a new 300-bed hospital in Kendal—costing £11 million—still envisages that 50 beds will be provided in the Lancaster hospital for the treatment of patients from Kendal.
The towns are only 22 miles apart, which in rural terms is not much, and it is, therefore, quite easy to live between them and be within reasonable reach of either. Many of the consultants from Lancaster live across the Cumbrian border.
The Lancaster hospital pathology department provides a range of services unequalled anywhere in the North-West that is fully available to patients from Kendal. The Kendal service is completely integrated with that of Lancaster, and it is absolutely vital that this is considered when decisions about the structure are made. That is the natural patient flow, and we hope that the Secretary of State will take that into consideration when making his decision.
§ Mr. Roland Moyle (Lewisham, East)
I welcome back to our debates the hon.
I shall not deal with organisation or pay beds, because we gave those issues a good run when we discussed the Health Services Bill. We shall press for a debate on London's health services as demanded by my hon. Friends the Members for Hackney, South and Shoreditch (Mr. Brown) and Hackney, Central (Mr. Davis) and the hon. Member for Canterbury (Mr. Crouch), not only on teaching hospitals, but on the shape of the London regions and the inner city and other problems which must be discussed.
The Royal Commission did a first-class job. Most hon. Members agree with that. I thank Sir Alec Merrison and his colleagues. They have served the nation well. That does not mean that we agree with everything that they said. Their views on mental illness hospitals are controversial. I agree with my right hon. Friend the Member for Salford, West (Mr. Orme) and my hon. Friend the Member for Wood Green (Mr. Race), who said that the commission produced an "on the one hand, and on the other" approach to local democratic control. The idea of making regional health authorities responsible to a Select Committee is a little wide of the mark. The two Front Benches agree about that.
To the extent that Ministers agree with the Royal Commission, they will forge a health service which is of inestimable value to the British people. To the extent that they depart from it, they will run the risk of inflicting damage on one of our most highly regarded institutions.
I am pleased that the opportunity has been taken by hon. Members on both sides of the House to refer to prevention. The Royal Commission was clear about that. In chapter 5, paragraph 3, on page 41 of its report the commission states:it must be understood that many of the main improvements in the health of the nation have come not from advances in medical treatment, but from public health measures, better nutrition and improvements in the economic, social and natural environments.One of our most important tools in prevention is the immunisation programme. For years children and others have been immunised with increasingly 559 beneficial results. The trouble is that a decreasing number of children are being immunised because of parental anxiety about the possible detrimental effects of immunisation in a few cases. That anxiety applies in particular to the whooping cough vaccine. We should sympathise with and help to allay those parental anxieties.
There is little doubt that a proper compensation scheme has a part to play in restoring health and improving our immunisation programme. However, the Government have said that they will not introduce a proper compensation scheme for vaccine damage. That is appalling and regrettable. We support the sentiments of early-day motion 325.
[That this House deplores the Government's refusal to establish a compensation scheme for vaccine-damaged children; endorses the view of the Pearson Royal Commission that there is a special case for paying compensation for vaccine damage where vaccination is recommended by public authority and is undertaken to protect the community; recognises that the Vaccine Damage Payments Act does not purport to provide a compensation scheme; and calls upon the Government to introduce a compensation scheme as favourable to vaccine-damaged children as the industrial injuries and war pension schemes are to the industrially injured and war disabled.] We urge the Government to think again.
The Vaccine Damage Payments Act provides £10,000 compensation for vaccine damage to children as an interim measure.
§ Mr. Patrick Jenkin
I have checked carefully the exchanges between the right hon. Member for Norwich, North (Mr. Ennals) and myself, and he was most explicit and careful to say that he was talking not of compensation but of an interim measure.
§ Mr. Moyle
I am in total agreement with the Secretary of State. He must have misunderstood me. The £10,000 was an interim payment.
If the Government are not now to introduce a full vaccine compensation scheme, another issue arises. All those children who have been considered for the £10,000 scheme will have to have 560 their cases reopened and reconsidered with a view to the possibility of their receiving more compensation.
The honour of the Government, irrespective of party, is involved in this issue, and I hope that the Government will look into it. We believe that Mrs. Fox, in her campaign for justice, is entirely right and her case must be conceded.
The Secretary of State made a fairly pathetic contribution on the subject of fluoridation. He is obviously not going to do anything. This is a serious matter, and if we had been returned to office we would have legislated by now because there is a gap in the law. My right hon. Friend the Member for Norwich, North (Mr. Ennals) explained clearly that the law allows water authorities to fluoridate the water if the area health authority wants it done. The difficulty is that few water authorities believe that they have the power to do this without legislation. So legislation is required to solve this problem.
The Minister will find that if he does not legislate he will get nowhere. The minority represented by the hon. Member for Burton (Mr. Lawrence) will have won, once again, during another Parliament. I sincerely ask the Minister to take that matter in hand or to take up the idea of my hon. Friend the Member for Brent, South (Mr. Pavitt) and support a Private Member's Bill.
Smoking is another important issue. I accept that there are two major constraints on smoking policy. First, a number of people, in good faith, have put their skill into the industry in times past and they must be allowed to adjust to new Government policies. Secondly, smoking is a difficult habit to break, as I know, having been a smoker myself. This fact imposes its own restraints on any action. As the Secretary of State said, the biggest avoidable cause of ill health today is smoking.
The Government are now embarked on further negotiations with the tobacco industry aimed at restricting further the possibility of damage to the nation's health from this cause. As the Minister who negotiated the current agreement, I have no hesitation in saying that the new agreement must be tougher than the last, and each succeeding agreement should form part of a continuing progression of toughness in the future. I shall put for- 561 ward five principles on which I suggest the new agreement should be based.
First, cigarette advertising should be restricted as close to the point of sale as possible and should be aimed at giving information about tar content and other such matters.
Secondly, the health warning should be placed on the front of the packet and it should be tougher. What about "Danger. Government Department Health Warning. Cigarettes cause bronchitis, heart disease and lung cancer"?
Thirdly, no new brand of cigarette should be introduced with a tar content in excess of 15 milligrammes and a special tar-related tax should come in at that level. This means extending the two-year derogation from the EEC on tobacco taxation and increasing its scope. I believe that the Government must do this because the lives of our people are at stake. In this area, as in so many others, Common Market regulation is becoming the enemy of good government in this country.
Fourthly, why not make it compulsory to record on the packet the carbon monoxide emission of a cigarette? After all, we all want freedom of information these days, and that would be a contribution.
Fifthly, should not the same principles inspire the whole of Government policy, whether it be the Department of Industry's grants, the Department of Trade's attitude to exports, the Department of the Environment's sponsorship of sports, the Chancellor of the Exchequer's level of taxation or even the Prime Minister's attitude to recommending people for honours?
If we could get all this into the new agreement, there would be advantages in allowing it to extend to four years rather than the three years of the current agreement. This is a concession I would be prepared to make.
§ Dr. M. S. Miller
Would my right hon. Friend add one more principle, which is to make non-smoking the norm and smoking abnormal?
§ Mr. Moyle
That is so at present because only a minority of adults smoke.
I turn now to the question of the social services. So far this issue has not been mentioned in the debate, although it is crucial to any discussion of the Health 562 Service. The Royal Commission said at page 258 of its report at the beginning of chapter 16:it is essential to have the easiest and most efficient collaboration between the NHS and local authorities.But perhaps we have a straw in the wind. The Secretary of State is to close down the Personal Social Services Council from 31 March. I do not know why. It consists of eminent and respected people in the social services. Who on earth would not want the advice of Mia Kellmer Pringle, for example, on children in such a context? The council always gave me and my right hon. Friend the Member for Norwich, North very good advice. The Association of County Councils and the Association of Metropolitan Authorities both gave substantial support to the continuation of the council's work.
Is the council to be closed because it was monitoring social service cuts? If that is the object, it is a busted flush from the beginning, because the Social Priorities Alliance will be monitoring them. I imagine that the Association of Directors of Social Services will. In any case, we shall.
I hope that, as with the Central Health Services Council, much of the valuable work will be continued. I think of work on such matters as ageing in later life, collaboration in community care, intermediate treatment on which a consultative group has been set up, a code of practice for voluntary private boarding houses and fire precaution problems in the same sort of institutions.
Why should we look for the straws in the wind when the gale is already blowing? I have already said, when I spoke in the Budget debate last year, that the NHS was probably being undermined by cuts in the social services which were looming. Now, the Secretary of State for Social Services has made his own contribution. In a press statement of 1 November last year, he called for a 5 per cent. cut in the personal social services. He has been trying since to repair the damage done by that statement, saying that it is entirely up to local authorities where they cut.
But the message has gone out, and all the other departments in local authorities now realise that there will be no penalties to pay to the Government if they cut the social services budget by 5 per cent. 563 or more. So, when the NHS is under greater pressure than it has been under for years from the financial point of view, it is being put under increasing pressure again because the social service budget, which takes a great deal of the load off it, is also being savagely cut, more savagely than any other aspect of Government expenditure.
What will this mean? Elderly people will be unable to leave hospital—they will be left bed-blocking, which is more expense for the NHS—because there will be a lack of support for them in the community. There will be a lack of meals on wheels, or they will be more expensive, and a lack of home helps, or they will be more expensive. There will be a continuing dearth of day centres, my hon. Friend the Member for Eccles (Mr. Carter-Jones) might like to note. There will be a lack of home visiting support. Elderly people will also be retained in the community, unsupported, when they should be in hospital.
What is to happen to the mentally ill, left in the big isolated mental hospitals? That will be more expensive for the NHS. The hon. Member for Carshalton (Mr. Forman) mentioned the large mental hospitals. They will be around longer and will be under more strain. There will be less care of the mentally ill in the community.
What is to happen to the Jay report, with its carefully postulated scheme of community care?
I am sure that it is politically astute to cut social services. Their clients are the most inarticulate section of the community. That will also mute the people who speak on their behalf in social services departments. That is what the Government's policy will lead to.
I turn to the problem of charges. All the Opposition Members who took part in the debate referred to it. The hon. Member for Canterbury thought that it was not politics to talk about it. Of course it is. Raising money is bound to be politics. We are still left with the following problem. Will prescription charges be increased yet again beyond 75p in the coming year, and will the exemptions be restricted? The Financial Secretary to the Treasury has said that he would contemplate that. The Secretary 564 of State has not denied it, nor has the Prime Minister.
Why is this happening? The Royal Commission and the Government part company here. The Royal Commission has already said that it recommends the abolition of charges. Nevertheless, prescription charges are going up, by about 300 per cent.
On top of that, the road accident charges are going up by between 500 and 600 per cent. I have never heard of anyone volunteering to take part in a road accident.
Why are charges going up? Is it to educate the public on the matter of costs? It cannot be that, because the public use the Health Service only on the basis of professional judgment. If professional people do not recommend the public to use the Health Service, the public, generally speaking, will not make use of it. Is it a means of raising more money? It cannot be that, because we all know that to the extent that money is raised in that way the Treasury will reduce its central grant.
These are all reasons why I contend that charges are totally inappropriate. In addition, charges breach the principle of taking care of people free at the point of use. So long as we have a charge, that charge can be increased. We are receiving a first-class demonstration of that by the Government. The charge that was levied by the Labour Government, which was being phased out by inflation for over five years, has increased twice. There is a threat that it will increase a third time. It is proposed to levy a road accident charge. Once a charge exists, there is no argument in principle for not increasing it until the pips squeak. That is what the Government are doing.
The Secretary of State is advocating an insurance scheme. I do not have time to make detailed criticism. The right hon. Gentleman thought that he had pulled out a brilliant rabbit from the hat when he talked about going to a Belgian hospital and finding only two people in charge of issuing bills.
§ The Minister for Health (Dr. Gerard Vaughan)
There were only two people in charge of the accounting.
§ Mr. Moyle
If there were two such people employed in every hospital in 565 England, there would be an extra 5,000 Health Service employees at a time when we are trying to cut the cost of administration. If the right hon. Gentleman's example were implemented throughout the United Kingdom, there would be more people employed in Scotland, Wales and Northern Ireland on the same basis. That would add between £25 million and £35 million to the National Health Service's wage bill.
There is no point in commisioning a study of insurance funding of the NHS, because all the information is available to the Secretary of State. It is readily understood by even the simplest intellect. There are only two conclusions that the right hon. Gentleman can reach. He can reach them now without more ado.
If a patient is a drag on the economy—that is what the Government seem to be coming more and more to accept—he is no less a drag if the money for his treatment is raised by a source other than general taxation. If the country is to continue to care for the sick—no one has suggested that it should not—the economic burden must be met. If it is not met by general taxation, the cost must be met in some other haphazard and inefficient way. I take it that no one is arguing that we should stop looking after the sick.
On the basis of morality and efficiency, the best course for the NHS is to raise money by general taxation and to spend it comprehensively on a service for the nation that is free at the point of use.
For the reasons that I have outlined, I ask my right hon. and hon. Friends to vote in favour of the Opposition's amendment.
§ The Minister for Health (Dr. Gerard Vaughan)
First, I thank the right hon. Member for Lewisham, East (Mr. Moyle) for his kind remarks. It is good to be back in the Chamber again and good to be able to listen to the right hon. Gentleman's thoughtful comments. It will cause him no surprise when I say that I do not agree with the mojority of them.
The debate has ranged extremely wide. It is right that it should have done so. As the hon. Member for Brent, South (Mr. Pavitt) said, it is difficult to think of any aspect of health care that has not 566 been commented on in the report of the Royal Commission.
I add my tribute to that of my right hon. Friend the Secretary of State to Sir Alec Merrison and his colleagues for the work that they have done that went into the report. I do not think that our appreciation of the devoted work that is carried on day after day by NHS staff has come through in the debate to the extent that I know it is felt in the House.
My right hon. Friend the Secretary of State opened the debate with characteristic authority. He gave the Government's overall view on the Royal Commission's report, and particularly the Government's overall view of the financial situation. Therefore, I do not propose to go into that in detail again.
I shall concentrate almost entirely on the points that have been raised by hon. Members. I find it extraordinary that the Opposition have put down any amendment. It has at once introduced, once again, a quite unnecessary party conflict on the subject of the Health Service. We deeply regret that. I should have thought that we could have at least one debate on this subject without such an amendment. There is no escaping the fact that the Labour Party has used the Royal Commission as an excuse. Year after year it has used the Royal Commission as a cover for drift. It has regularly criticised the reorganisation of 1974, but it did absolutely nothing about those things that it criticised. When it was in power—
§ Dr. Vaughan
Not at all. We have had five years of drift and uncertainty, and that has been immensely damaging to health care. It is not surprising that the recommendations of the Royal Commission have come to us amidst a background of almost unbelievable mismanagement.
§ Mr. Ennals
Has the Minister met anyone within the Health Service who thinks that we should have made a snap change two or three years after the introduction of the monstrosity for which his predecessor was responsible? Does he not think that it was right to set up a Royal Commission? Was it not right to wait for its 567 report? We would have acted on that report. Has he met anyone who thinks that we should have plunged suddenly and irresponsibly, as his predecessor did?
§ Dr. Vaughan
The right hon. Gentleman must defend his previous inaction as he thinks best. However, we have seen five years during which capital investment was reduced by no less than £193 million a year—that is, by nearly 35 per cent. Capital investment was reduced from £559.3 million in 1973–74 to £366 million in 1978–79. That cannot have been good. We have also had five years during which the total number of beds available was reduced.
§ Mr. Pavitt
Does the Minister recall that from 1974 to 1976 the Government undertook that, as a matter of deliberate policy, because of nurses' pay, and so on priority should be given to people rather than to buildings and similar capital equipment?
§ Dr. Vaughan
I know that it is unpleasant and uncomfortable, but I am putting the facts as we have found them. Labour Members know that these facts are true. They are the unpalatable features that have led us to receive the recommendations of the Royal Commission. We have had five years during which waiting lists have risen by 170,000. We all know what that means in terms of personal tragedy for thousands of sick people. Nearly 750,000 people are on our waiting lists. That is the highest figure on record in this country. It is the highest figure for any part of Western Europe or for any civilised country. Those are the problems.
While the numbers of general staff within the National Health Service rose by about 12 to 13 per cent., the administrative staff were increased, under the previous Labour Government, by just on 30 per cent., from 90,712 to 117,743.
§ Dr. Vaughan
Many hon. Members have spoken and, as I said, I wish to take up the individual points that have been made.
During that period, morale in the National Health Service throughout the country fell to a level that we had never known before. That is so much so that various professional bodies find it necessary to draw special attention to it in their reports. We have had five years of a series of the most damaging industrial actions against patients, culminating in the appalling strikes of last winter. More recently, who can forget the horrifying spectacle outside Charing Cross hospital?
I hope that instead of scoring party political points Labour Members will recognise that health care should not be a battleground for political parties. We should work together to raise standards and bring about the kind of Service that we all want.
I was reminded just now that one in20 of our working people are employed within the National Health field. It is therefore not surprising that, as my right hon. Friend reminded us, even a 1 per cent. wage increase costs £37 million, which is equivalent to the treatment of 80,000 patients, 2,000 hospital beds or the dialysis machines that my right hon. Friend mentioned.
I was also astonished, on coming to office, to realise that over the past few years there have been procrastination, dither and delay in making decisions. I know it can be explained why that occurred, but it has been extremely damaging to the Service. That is why one of our first actions, for example, has been to issue a clear guide to management for handling industrial upsets. It is available to management and staff. We have sent it out with a request that all people working within the health field should have it available to them. It is most important for all the staff to know exactly where they stand. Unashamedly, we have said in that document that patients must be safeguarded at all times. That must come first.
That is the background against which we have received and examined the Royal Commission's recommendations. It is one reason why we have not come forward with detailed proposals for action on every one of the 117 recommendations, 569 even if we agreed with them all. We do not believe that at this stage the National Health Service can stand changes other than those that are essential. That is why in "Patients First" we have gone for a philosophy of making the Service more local—more responsible to local authorities within each individual unit.
The right hon. Member for Salford, West (Mr. Orme), in a rather passionate opening, made great play of prescription charges. He knows that every, time the Labour Party has been in Opposition it has promised to abolish those charges. Every time it has been in Government it has reintroduced them or put them up. We have already had information on that.
§ Mr. Speaker
Order. When I get to my feet I must say something, even if it is only to tell the right hon. Member for Lewisham, East (Mr. Moyle) that the Minister is quite clearly not giving way.
§ Mr. David Stoddart (Swindon)
On a point of order, Mr. Speaker. Is it in order for the Minister to mislead the House by saying that the Labour Party put up prescription charges every time it was in Government? The Labour Government did not put up prescription charges between 1974 and 1979.
§ Dr. Vaughan
Of course, it has never been my intention to mislead the House. We have been accused of having plans to introduce new charges—charges for visits to general practitioners, "hotel" charges. That is quite untrue, yet we seem to be accused of it over and over again. We have always made clear thatWhen the service is short of funds for priority tasks, there is no case for holding down prescription and other charges.That is a direct quote from "The Right Approach" in 1976. Let us hear no 570 more about all these hypothetical charges which people throw at us for party political purposes.
Let us recognise that there is a finite limit to the amount of money that any nation can make available for a health service. That has been said by Aneurin Bevan, by the right hon. Member for Huyton (Sir H. Wilson) when he was Prime Minister, and by the right hon. Member for Norwich, North (Mr. Ennals). It makes me very sad—
§ Mr. Ennals
Since the Minister has quoted me, perhaps he will tell us who has done most of the talking about new charges during the past few days? He knows as well as we do that it has been one of the Ministers on the Treasury Bench.
§ Dr. Vaughan
That is why I was so sad when I listened to the remarks of the right hon. Member for Norwich, North about private practice. Labour Members are still obsessed by the private practice aspect of health, even though the Royal Commission said that it is an insignificant part of health care in this country.
I make no apology for the fact that, although we see a need for a thriving and viable NHS which is available to everybody who needs it, we also feel that we must look at health care in this country generally. We see a need to bring extra resources into health from whatever source is willing to make them available. That is why we talk of developing the private sector in partnership, and not in conflict, with the NHS. That is why this morning at Stoke Mandeville I was with Jimmy Savile in his appeal for money to rebuilld that special centre for spinal injuries.
§ Dr. M. S. Miller
I have noted very carefully what the hon. Member, for whom I have a high regard, has said about the resources that a nation can spend on health being finite. He may believe that as a politician, but what does he believe as a doctor?
§ Dr. Vaughan
I quote from a speech made by the right hon. Member for Huyton in this House in October 1975 when the Royal Commission was being set up. He said that it was inevitable that there 571 were limits to what the taxpayers could provide, and later he said:I must also make it clear, as my right hon. Friends have already made clear, that the Government are equally committed to the maintenance of private medical practice in this country and we intend to guarantee this in the legislation we propose."—[Official Report, 20 October, 1975; Vol. 898, c. 36]The right hon. Member was quite clear on that, and so are we.
A number of hon. Members have spoken, quite rightly, of the problems of inner city areas, and the hon. Member for Hackney, South and Shoreditch (Mr. Brown) said that patients had suffered. This is something to which we are giving great thought.
The Royal Commission, while supporting, in a slightly lukewarm way, the concept of health centres, also said that it would be quite wrong to press doctors into working in health centres against their wishes. I would agree that that is wrong. It also pointed out that it is possible for doctors, nurses, health visitors and so on working in a community to work in close conjunction with each other—not in local authority planned centres but in group practices and the like.
Therefore, we have been looking very carefully at the way in which the health centre programme has been developing in this country. We have concluded that health centres should continue to be developed—for example, in some inner city areas in places where there is a clear benefit to the community by having a health centre—but not in the face of opposition by the local general practitioners. It is a disgraceful waste of resources to have, as we have now, at least two health centres which areempty because doctors will not work in them. That makes no sense to anyone.
We are, therefore, looking at the other tack. In the Health Services Bill, which is about to be considered in Committee, there are proposals for increasing the amount of money which can be loaned to doctors through the General Practitioner Finance Corporation, increasing the borrowing power by four times, to £100 million, and at the same time, for the first time—this is very important—enabling the General Practitioner Finance Corporation to lease premises to general practitioners. We are looking at the possibilities of extending the opportunities 572 to undertake some private practice from health centres—which is permitted at present but is not always easily available.
Finally, the right hon. Gentleman referred again to the problem of industrial relations. I was glad to hear what he said about the subject of industrial disputes holding back the regional secure units. This is something about which we, too, are very concerned. I am glad that there is agreement between the two sides of the House.
My hon. Friend the Member for Putney (Mr. Mellor) made a very constructive speech.
§ Dr. Vaughan
I happen to know that my hon. Friend is deeply concerned with a number of problems of health care in his constituency. No one could accuse him of not having a genuine anxiety to do what he can to help in the health field. He was talking about the value of insurance. We recognise this. My right hon. Friend has already referred to it.
I must be honest. It was very good indeed to see the right hon. Member for Norwich, North so obviously in better health these days. However, I was disappointed that he did not face more squarely the very difficult situation which developed under his hands. He talked about the need for better industrial relations. He asked what progress was being made on procedures at local level for handling industrial disputes. This matter is being pursued. The General Whitley Council is well advanced in its discussions between the management side and the staff side. We are looking forward to receiving agreed conclusions very soon. No doubt the right hon. Member will make comments on them when they come.
The right hon. Member also asked what effect on the NHS any increase in gas prices would have. All that I can say is that he has obviously forgotten the words in "The Way Forward", where the problems of fuel, fuel costs and the likely difficulties are examined on page 41, as are the difficulties ahead that we may well face. It is not only gas prices but increases in the prices of all kinds of fuel that have to be taken into account. It is sad for me to find these days the number of hospitals, newly built, that are costing over £1 million to heat and ventilate 573 because they were not designed in a way that is economic in fuel use.
§ Mr. Ennals
I was obviously referring to the recent Government announcement under which gas prices are to go up dramatically. The document to which the hon. Gentleman referred was published two and a half years ago. I am talking about decisions taken by this Government dramatically to increase gas prices.
§ Dr. Vaughan
That is a brave attempt to correct the situation. My hon. Friend the Member for Carshalton (Mr. Forman)—
§ Dr. Vaughan
I must move on rather rapidly. My hon. Friend the Member for Carshalton, in a most effective speech, talked about the value and importance of preventive medicine and the Health Education Council. We have been having discussions with Dr. Lloyd, chairman of the Health Education Council, to see how the council's work can be made more effective and whether it might be advisable to reduce the range of work it devotes to health education in order to increase its work in other areas. My hon. Friend also mentioned the question of vaccination. This was also raised by the right hon. Member for Lewisham, East. I shall return to the matter in a moment.
While on the question of preventive medicine, I believe that we could totally eradicate in this country the problem of rickets. It is a disease that is extremely damaging to young children and also presents a major problem to certain mothers when they are feeding their babies. This condition was virtually eradicated until the late 1960s and the early 1970s. At the moment, it is almost entirely a problem of immigrants. I shall not go into details. We are having meetings with the leaders of the immigrant community to see how best we can bring the education aspects of this matter to the attention of members of immigrant groups. I believe that this will be success- 574 ful and that we shall see the end of rickets in this country once again.
My hon. and learned Friend the Member for Thanet, West (Mr. Rees-Davies) made an important comment when he referred to the use of the media in carrying out this kind of health education. That, again, is a matter that we have been discussing.
My hon. Friend the Member for Carshalton also mentioned the subject of mental illness. We give it great priority. We hope to bring to the House shortly the long-awaited updating of the 1959 Mental Health Act. We hope to place provisions for the mentally handicapped in a separate section.
§ Dr. Vaughan
We are also working rapidly on that.
The hon. Member for Antrim, South (Mr. Molyneaux) made a short and constructive speech. My hon. Friend the Minister of State, Northern Ireland Office came into the Chamber to hear the speech and asked me to say that he will take up the points that were put. I cannot resist the comment that the hon. Member made on the importance of small hospitals, but I will not pursue that now.
§ Dr. Vaughan
I shall write to the hon. Gentleman.
My hon. Friend the Member for Newark (Mr. Alexander) referred to the problem of mixed sex wards. This practice has been spreading steadily throughout the Health Service. It is not a desirable practice. It is forced on hospitals by the difficulty which they sometimes have in making the best use of their beds. We are having discussions about it.
One thing that has been made clear to me—it is understandable—is that patients will come into hospital, they will not comment on what happens, but they resent it very much and will comment afterwards. We have been receiving a number of letters from patients who were apparently happily looked after in hospital but who were not in fact so happy. It is particularly the lavatory and bathroom provision which worries them. I assure my hon. Friend the Member for 575 Newark that we have taken the matter very much on board.
§ Mr. Cyril Smith
Has the Minister any message for the millions who live in the North-West, on whose behalf I spoke for over 20 minutes, pleading for an allocation of resources?
§ Dr. Vaughan
I should like to reply to the important points raised by the hon. Member in a written answer. I say that because they raise the whole question of RAWP and resource allocation and the way we propose to see that a larger allocation—not a very big one; I do not want to raise the hon. Gentleman's hopes—goes to the parts of the country which are in greatest need.
The hon. Member for Brent, South spoke about fluoridation, and I hope to come to that in a moment.
My hon. Friend the Member for Chorley (Mr. Dover)—I must refer to this in passing—spoke of what is happening in the constituency of my hon. Friend the Member for North Fylde (Sir W. Clegg). I pay tribute to the work which Pat Seed does there. It took a little while to arrange, but through the local health authority we have now managed to arrange for the staffing—that was the difficulty; the extra member of staff needed—to supervise the running of that important scanner.
A number of hon. Members have spoken about London, and I respond to them in this way. We have had a series of inquiries on London. What we need is some action. There are at present two inquiries in progress—the university inquiry under Lord Flowers and the
§ departmental inquiry, the London Planning Consortium—and they will be reporting within a few weeks.
§ Our view is that, rather than have yet another inquiry, we ought to examine those two reports and then, through a powerful London committee, put something into rapid and effective action. That is what the Government propose.
§ The right hon. Member for Lewisham, East made a very thoughtful speech, although I could not agree with all that he said. Without doubt, there is some misunderstanding over the vaccine damage scheme. I should prefer to deal with this on another occasion, but I must make clear now that at no time has the £10,000 payment been regarded by the Labour Government or by ourselves as compensation. In my view, that would be quite wrong. But the right hon. Gentleman is quite right in saying that this is a matter which we cannot brush on one side, and we are looking at it. More important, I think, is to ensure that the assessments and payments are made more rapidly than they are at present.
§ There is no escaping that a service free at the time of use is of little benefit if it is not an available service, and under the Labour Government we were moving steadily towards a service which was neither free nor available. That is why I ask my right hon. and hon. Friends to support the motion and firmly to reject the Opposition amendment.
§ Question put, That the amendment be made:—
§ The House divided: Ayes 159, Noes 191.579
|Division No. 144]||AYES||[10 pm|
|Adams, Allen||Crowther, J. S.||Evans, John (Newton)|
|Allaun, Frank||Cryer, Bob||Ewing, Harry|
|Alton, David||Cunliffe, Lawrence||Field, Frank|
|Atkinson, Norman (H'gey, Tott'ham)||Dalyell, Tam||Flannery, Martin|
|Barnett, Guy (Greenwich)||Davidson, Arthur||Fletcher, Ted (Darlington)|
|Beith, A. J.||Davis, Terry (B'rm'ham, Stechford)||Foot, Rt Hon Michael|
|Bennett, Andrew (Stockport N)||Dean, Joseph (Leeds West)||Ford, Ben|
|Bidwell, Sydney||Dempsey, James||Foster, Derek|
|Booth, Rt Hon Albert||Dixon, Donald||Foulkes, George|
|Bradford, Rev. R.||Dormand, Jack||Freeson, Rt Hon Reginald|
|Brown, Hugh D. (Provan)||Douglas, Dick||Freud, Clement|
|Brown, Ronald W. (Hackney S)||Dubs, Alfred||Garrett, W. E. (Wallsend)|
|Brown, Ron (Edinburgh, Leith)||Dunn, James A. (Liverpool, Kirkdale)||George, Bruce|
|Callaghan, Jim (Middleton & P)||Dunwoody, Mrs Gwyneth||Ginsburg, David|
|Campbell-Savours, Dale||Eastham, Ken||Golding, John|
|Carmichael, Neil||Edwards, Robert (Wolv SE)||Grant, George (Morpeth)|
|Carter-Jones, Lewis||Ellis, Raymond (NE Derbyshire)||Grant, John (Islington C)|
|Clark, Dr David (South Shields)||Ellis, Tom (Wrexham)||Hamilton, W. W. (Central Fife)|
|Cocks, Rt Hon Michael (Bristol S)||English, Michael||Haynes, Frank|
|Coleman, Donald||Ennals, Rt Hon David||Heffer, Eric S.|
|Concannon, Rt Hon J. D.||Evans, loan (Aberdare)||Holland, Stuart (L'beth, Vauxhall)|
|Home Robertson, John||Millan, Rt Hon Bruce||Silverman, Julius|
|Homewood, William||Miller, Dr M. S. (East Kilbride)||Smith, Cyril (Rochdale)|
|Hooley, Frank||Mitchell, Austin (Grimsby)||Smith, Rt Hon J. (North Lanarkshire)|
|Horam, John||Molyneaux, James||Soley, Clive|
|Howells, Geraint||Morton, George||Spearing, Nigel|
|Hughes, Mark (Durham)||Moyle, Rt Hon Roland||Spriggs, Leslie|
|Hughes, Robert (Aberdeen North)||Mulley, Rt Hon Frederick||Steel, Rt Hon David|
|Hughes, Roy (Newport)||Newens, Stanley||Stewart, Rt Hon Donald (W Isles)|
|Janner, Hon Greville||Oakes, Rt Hon Gordon||Stoddart, David|
|Jay, Rt Hon Douglas||Ogden, Eric||Strang, Gavin|
|Johnson, James (Hull West)||O'Neill, Martin||Summerskill, Hon Dr Shirley|
|Johnston, Russell (Inverness)||Orme, Rt Hon Stanley||Thomas, Dafydd (Merioneth)|
|Jones, Rt Hon Alec(Rhondda)||Palmer, Arthur||Thomas, Dr Roger (Carmarthen)|
|Jones, Dan (Burnley)||Pavitt, Laurie||Thorne, Stan (Preston South)|
|Lamborn, Harry||Pendry, Tom||Tinn, James|
|Lamond, James||Powell, Rt Hon J. Enoch (S Down)||Urwin, Rt Hon Tom|
|Leadbitter, Ted||Powell, Raymond (Ogmore)||Wainwright, Edwin (Dearne Valley)|
|Leighton, Ronald||Prescott, John||Wainwright, Richard (Colne Valley)|
|Lewis, Arthur (Newham North West)||Race, Reg||Walker, Rt Hon Harold (Doncaster)|
|Litherland, Robert||Radice, Giles||Welsh, Michael|
|Lofthouse, Geoffrey||Roberts, Albert (Normanton)||White, Frank R. (Bury & Radcliffe)|
|McCusker, H.||Roberts, Allan (Bootle)||Whitehead, Phillip|
|McDonald, Dr Oonagh||Roberts, Ernest (Hackney North)||Whitlock, William|
|McElhone, Frank||Rodgers, Rt Hon William||Willey, Rt Hon Frederick|
|McGuire, Michael (Ince)||Rooker, J. W.||Williams, Rt Hon Alan (Swansea W)|
|McKay, Allen (Penistone)||Roper, John||Wilson, Gordon (Dundee East)|
|McKelvey, William||Ross, Ernest (Dundee West)||Woodall, Alec|
|McMillan, Tom (Glasgow, Central)||Ross, Stephen (Isle of Wight)||Woolmer, Kenneth|
|McWilliam, John||Ross, Wm. (Londonderry)||Young, David (Bolton East)|
|Marshall, David (Gl'sgow, Shettles'n)||Rowlands, Ted|
|Marshall, Dr Edmund (Goole)||Sheerman, Barry||TELLERS FOR THE AYES:|
|Mason, Rt Hon Roy||Short, Mrs Renée||Mr. James Hamilton and|
|Maxton, John||Silkin, Rt Hon S. C. (Dulwich)||Mr. Walter Harrison.|
|Maynard, Miss Joan|
|Aitken, Jonathan||Emery, Peter||Lester, Jim (Beeston)|
|Alexander, Richard||Eyre, Reginald||Lloyd, Ian (Havant & Waterloo)|
|Alison, Michael||Fairgrieve, Russell||Lloyd, Peter (Fareham)|
|Ancram, Michael||Faith, Mrs Shella||Luce, Richard|
|Aspinwall, Jack||Fenner, Mrs Peggy||Lyell, Nicholas|
|Atkins, Robert (Preston North)||Fletcher, Alexander (Edinburgh N)||McCrindle, Robert|
|Atkinson, David (B'mouth East)||Fookes, Miss Janet||Macfarlane, Neil|
|Baker, Nicholas (North Dorset)||Forman, Nigel||MacGregor, John|
|Bell, Sir Ronald||Fowler, Rt Hon Norman||MacKay, John (Argyll)|
|Benyon, Thomas (Abingdon)||Garel-Jones, Tristan||McNair-Wilson, Michael (Newbury)|
|Benyon, W. (Buckingham)||Glyn, Dr Alan||McQuarrie, Albert|
|Best, Keith||Goodhew, Victor||Major, John|
|Bevan, David Gilroy||Gorst, John||Marland, Paul|
|Biggs-Davison, John||Gray, Hamish||Marlow, Tony|
|Body, Richard||Greenway, Harry||Marshall, Michael (Arundel)|
|Bonsor, Sir Nicholas||Grieve, Percy||Mawby, Ray|
|Boscawen, Hon Robert||Griffiths, Peter (Portsmouth N)||Maxwell-Hyslop, Robin|
|Bottomley, Peter (Woolwich West)||Grist, Ian||Mellor, David|
|Boyson, Dr Rhodes||Gummer, John Selwyn||Meyer, Sir Anthony|
|Braine, Sir Bernard||Hamilton, Michael (Salisbury)||Miller, Hal (Bromsgrove & Redditch)|
|Bright, Graham||Hawksley, Warren||Mills, Iain (Meriden)|
|Brinton, Tim||Heath, Rt Hon Edward||Mills, Peter (West Devon)|
|Brotherton, Michael||Heddle, John||Miscampbell, Norman|
|Brown, Michael (Brigg & Sc'thorpe)||Henderson, Barry||Mitchell, David (Basingstoke)|
|Bruce-Gardyne, John||Hicks, Robert||Moate, Roger|
|Buck, Antony||Higgins, Rt Hon Terence L.||Morris,Michael (Northampton, Sth)|
|Bulmer, Esmond||Hogg, Hon Douglas (Grantham)||Morrison, Hon Peter (City of Chester)|
|Burden, F. A.||Holland, Philip (Carlton)||Mudd, David|
|Butcher, John||Hooson, Tom||Murphy, Christopher|
|Carlisle, John (Luton West)||Howell, Ralph (North Norfolk)||Myles, David|
|Carlisle, Kenneth (Lincoln)||Hunt, David (Wirral)||Neale, Gerrard|
|Chalker, Mrs. Lynda||Hunt, John (Ravensbourne)||Needham, Richard|
|Chapman, Sydney||Jenkin, Rt Hon Patrick||Nelson, Anthony|
|Clark, Hon Alan (Plymouth, Sutton)||Jessel, Toby||Neubert, Michael|
|Clark, Sir William (Croydon South)||Johnson Smith, Geoffrey||Newton, Tony|
|Clarke, Kenneth (Rushcliffe)||Jopling, Rt Hon Michael||Normanton, Tom|
|Clegg, Sir Walter||Kaberry, Sir Donald||Onslow, Cranley|
|Cope, John||Kellett-Bowman, Mrs Elaine||Page, Richard (SW Hertfordshire)|
|Corrie, John||Kershaw, Anthony||Parkinson, Cecil|
|Cranborne, Viscount||Kimball, Marcus||Parris, Matthew|
|Critchley, Julian||Knight, Mrs Jill||Patten, Christopher (Bath)|
|Crouch, David||Knox, David||Patten, John (Oxford)|
|Dean, Paul (North Somerset)||Lamont, Norman||Percival, Sir Ian|
|Dorrell, Stephen||Lang, Ian||Pollock, Alexander|
|Dover, Denshore||Lawrence, Ivan||Porter, George|
|Dunn, Robert (Dartford)||Lawson, Nigel||Prentice, Rt Hon Reg|
|Dykes, Hugh||Lee, John||Price, David (Eastleigh)|
|Elliott, Sir William||Le Merchant, Spencer||Proctor, K. Harvey|
|Rathbone, Tim||Squire, Robin||Waldegrave, Hon William|
|Rhodes James, Robert||Stainton, Keith||Walker, Bill (Perth & E Perthshire)|
|Ridley, Hon Nicholas||Stanbrook, Ivor||Waller, Gary|
|Rossi, Hugh||Stanley, John||Ward, John|
|Sainsbury, Hon Timothy||Stevens, Martin||Watson, John|
|St. John-Stevas, Rt Hon Norman||Stradling Thomas, J.||Wells, Bowen (Hert'rd & Stev'nage)|
|Shelton, William (Streatham)||Tebbit, Norman||Wheeler, John|
|Shepherd, Colin (Hereford)||Temple-Morris, Peter||Wickenden, Keith|
|Shepherd, Richard(Aldridge-Br'hills)||Thompson, Donald||Wilkinson, John|
|Shersby, Michael||Thorne, Neil (llford South)||Williams, Delwyn (Montgomery)|
|Sims, Roger||Thornton, Malcolm||Winterton, Nicholas|
|Smith, Dudley (War. and Leam'ton)||Townend, John (Bridlington)||Wolfson, Mark|
|Speed, Keith||Trippier, David||Young, Sir George (Acton)|
|Speller, Tony||Vaughan, Dr Gerard|
|Spence, John||Viggers, Peter||TELLERS FOR THE NOES:|
|Spicer, Jim (West Dorset)||Waddington, David||Lord James Douglas Hamilton and|
|Sproat, Iain||Wakeham, John||Mr. Peter Brooke.|
§ Question accordingly negatived.
§ Main Question put and agreed to.580
§ That this House takes note of the Report of the Royal Commission on the National Health Service [Cmnd. 7615].