§ Motion made, and Question proposed,
§ That an humble Address be presented to Her Majesty, praying that the National Health Service (Determination of Regions) Order 1981 (S.I., 1981, No. 1836), dated 21st December 1981, a copy of which was laid before this House on 15th January, be annulled.— [Mrs. Dunwoody.]
§ Mr. Speaker
With this we are also taking the other two motions on the Order Paper:
That an humble Address be presented to Her Majesty, praying that the National Health Service (Constitution of District Health Authorities) Order 1981 (S.I., 1981, No. 1838), dated 21st December 1981, a copy of which was laid before this House on 15th January, be annulled.
That an humble Address be presented to Her Majesty, praying that the National Health Service (Determination of Districts) Order 1981 (S.I., 1981, No. 1837), dated 21st December 1981, a copy of which was laid before this House on 15th January, be annulled.
§ The Minister for Health (Dr. Gerard Vaughan)
It is with considerable pride that I rise to explain the orders and to invite the House to reject the prayers.
The orders are the legal instruments that fulfil our manifesto commitments to simplify and decentralise the structure of the Health Service, and by so doing to ensure a much better service to patients. That is what the orders are all about. We wish to see a considerable improvement in patient care following the rearrangement of the health authorities.
One of the main architects of the reorganisation was, of course, my right hon. Friend the Secretary of State for Industry. When in Opposition, he and I met a great many people in the National Health Service. There were very few areas of the country that we did not visit. Everywhere we heard the same observations—that the authorities were too remote, that there were too many committees, too much paper, that decisions were taking too long and that by the time they were made the circumstances had changed and the money was no longer available to carry a project through. The effect on morale was appalling. It was no longer possible to find anyone in charge in a hospital in a position to say "Yes, we will do it" or "No, we will not."
The Conservative Party took office in May 1979 determined to streamline the structure and reduce the cost of administration. In December 1979, we issued our proposals in "Patients First". We consulted widely and met a large number of bodies. We received no fewer than 3,500 comments from organisations and individuals. We found that there was widespread agreement with our proposals. Therefore, seven months later, on 23 July 1980, my right hon. Friend announced our policy to the House. That policy is now being carried out in these orders.
I ask the House to consider the urgency of the action taken by the Government. I do not believe that such fundamental changes, giving the opportunity for worthwhile improvement in the care of patients, have ever been proceeded with more rapidly and, at the same time, with such careful consultation.
My right hon. Friend the Secretary of State for Social Services also played a major part in the transition from ideas and proposals to reality. The orders are his responsibility and are in his name. We are privileged to be presiding over changes which sweep away not one, as is commonly thought, but two tiers of administration—the area and the sector tiers. They will provide a National 422 Health Service which is quicker on its feet and a 10 per cent. saving in expenditure on administration, which can be transferred to the care of patients.
I realise that the reorganisation has caused a great deal of uncertainty for many of the staff, because of the effect on their careers. However, we cannot have it both ways. We cannot have, on the one hand, truly local services able to make their own plans and meet their own needs and, on the other, the Government telling the authorities in advance exactly how they should organise themselves. Therefore, it has been necessary to wait for the boundaries to be settled, through these orders, for the chairmen and members of the new district authorities and the new chief officer teams to be appointed before the districts could decide exactly how they wanted to run the health services in their areas.
We appreciate that the price of local flexibility has been uncertainty for many of the staff. I pay tribute to them for their loyalty and the way in which they have continued the everyday running of the NHS while wondering about future.
The House will be pleased to know that most of the senior appointments have now been made. That means that the new district council authorities can now get on with the task of completing their management structures and filling the posts. Uncertainty is probably now at its peak. In the discussions that I have had with the people who will be running the new authorities I have sensed a desire to get on quickly and grasp the opportunity to improve the care of patients which these changes will bring about.
§ Mr. Nicholas Winterton (Macclesfield)
Does my hon. Friend realise that, although we are now in the last half of February and the new structure takes effect from 1 April, some of the areas have still not been finalised and that the guidelines given by the Ministry to the district health authorities have been somewhat lacking? Does he accept that that is causing considerable uncertainty, particularly to nursing management and the nursing profession within the hospital service? Will he give more attention to that problem? I have been told by nurses and the nursing management in my constituency that they are deeply concerned about their position, because of the current lack of guidelines regarding the system that is to be introduced in a matter of weeks.
§ Dr. Vaughan
With respect, my hon. Friend is trying to have it both ways. If we are to have a truly local service, as I believe we should, we should leave it to the new district health authorities to determine how they want to run their show. I shall return to this subject in a moment. I realise that this has caused some anxiety among the staff. I have had two meetings with the new district chairmen, and I know of the anxiety and the tremendous desire to get on with setting up the authorities and getting on with the tasks that lie ahead.
§ Dr. Vaughan
I shall give way shortly.
There are three orders. We propose to replace the present areas and districts by 192 new district health authorities. If the orders are confirmed, those new authorities will take over on 1 April. They will be much smaller and more local than many of the present area authorities, and we believe that as a result it will be 423 possible for their members to be in proper close contact with the communities that they serve and to know local needs.
I do not criticise the members of the existing area health authorities, but all too often they have been remote, as has been said by many of the staff employed by those authorities. There has been a feeling of frustration that it was not always possible to get to their authority members. Many members of the area health authorities have told us that they, too, had a feeling of frustration and said that there was a lack of contact with the people that they were serving and the professional staff that they were employing. The present system is faulty—not the members, who have been doing their best to make the system work.
§ Dr. Alan Glyn (Windsor and Maidenhead)
Does my hon. Friend agree that it is important to confirm these orders as quickly as possible so as to remove any uncertainty? Secondly, does he realise that this has been going on for some time and has worked well, but that in areas such as the Berkshire-Buckinghamshire overlap area there is considerable feeling—particularly in East Berkshire? Is he further aware that that overlap has worked adequately since 1974? Is it really necessary that the area should be coterminous with existing local authorities? Surely the most important consideration is the overall health care in the areas.
§ Dr. Vaughan
I am glad that my hon. Friend has drawn attention to the urgency to get on with the orders. That is one of the reasons why I have asked the House to reject the prayers. I suspected that my hon. Friend would raise the question of East Berkshire. I assure him that I know something of the circumstances there, and I know the strength of feeling in the area that the existing arrangements should continue. My hon. Friend has advanced a powerful argument in favour of doing that.
I certainly do not wish to see any increased anxiety or insecurity over the future. There are hon. Members—I shall be interested to hear their remarks—who want to put other views about this controversial issue.
§ Sir Ronald Bell (Beaconsfield)
My hon. Friend referred to the importance of having truly local administrations and the desirability of their not being remote. Is he not indicating that he will accept the prayer which I have tabled?
§ Dr. Vaughan
I am aware that my hon. Friend has tabled a prayer on this matter and that he feels strongly about it. I prefer to wait to hear his very powerful and reasoned speech later in the debate. However, that demonstrates the amount of local enthusiasm and awareness on the issues at stake and the desire among different parts of the community to start running their own local health services. We very much welcome that aim.
Hon. Members have raised the exceptional situation in Liverpool, which I visited on account of the problem. With that exception, each of the new district health authorities will have just one chief officer team holding a clear responsibility to advise the authority. In that way, we shall do away with the present confusing, inefficient and expensive situation found in many of the multi-district areas where an area team monitors the work of as many 424 as five or six different district teams, all directly accountable to the area health authority. As we discovered, that cannot be a sensible arrangement.
Such arrangements have turned out to be extremely costly and generated a great deal of unnecessary work. There have been too many teams and the cost of their salaries alone is about £100,000 a year. The proposals before us will reduce the number of teams by nearly a quarter—from the present 251 to 193. That is 58 fewer teams, with all the resulting benefits.
When these changes are fully implemented, we shall have not simply the establishment of district health authorities, but a much simpler and more effective management arrangement within each district. We judge that such authorities will be able to reduce the proportion of resources they spend on management by 10 per cent. Authorities presently spend about £320 million a year on management. That represents about 5.14 per cent. of their resources.
If the House agrees and these proposals are passed, we shall require authorities to limit their management costs to no more than 4.62 per cent. by the end of 1984–85. That will be a real saving and will provide resources which can then be transferred to other areas of the NHS.
§ Dr. Vaughan
My hon. Friend is always sceptical about how we organise these matters. I have no doubt that health authorities will achieve this reduction. I know that hon. Members will understand how surprised I was to read Mr. David Townsend's article in The Times Health Supplement last weekend. He said:Dr. Vaughan, although still cheerful, has stopped talking about savings. Indeed, it now seems likely that the net extra costs of reorganisation could be £30 million.That is absolute rubbish.
§ Mr. Winterton
While I respect my hon. Friend's sincerity in this matter, we were advised by a previous Conservative Government, who reorganised the NHS, that they would make it more efficient so that it would cost less. They said the same about local government. We know that both statements were untrue. Not only has the NHS become more inefficient; it costs a lot more as well. I hope that the Minister appreciates that some Conservatives are a little sceptical about the cost savings he has highlighted.
§ Dr. Vaughan
My hon. Friend again seems to have missed the point. That is exactly what we are attempting to cure and to put right. I can only say "Oh, man of little faith". He is talking to a Government, Secretary of State and Minister who have carried out more improvements in the National Health Service in the past two and a half years than any preceding Government.
To reinforce that argument, I have only to repeat David Hinkey's remarks in The Guardian when he quoted the facts issued from the Office of Health Economics. He stated:More resources have gone into the National Health Service in the past two and a half years under this Government than at any time since 1948 when the National Health Service was set up.We have reduced waiting lists, increased the amount of money, with a 5 per cent. increase in real resources, and there are now more nurses and doctors. My hon. Friends understand the situation.
425 Of course, I was slightly concerned to read that article in The Times Health Supplement, which I regard as a valuable and important source of information, until remembering that Mr. Townsend was an adviser to the right hon. Member for Norwich, North (Mr. Ennals) when he was the Secretary of State for Social Services. Perhaps it is not surprising that Mr. Townsend should now try to undermine our achievements.
§ Mr. Frank Haynes (Ashfield)
Mr. Townsend talks about an additional £30 million cost. Will the Minister refer to the £30 million reduction and savings that we were to make, as he said, in the National Health Service? I should like to know why he has not mentioned that aspect.
§ Dr. Vaughan
It is so difficult when people take a fixed view. In reality, we believe that there will be a proper saving of a 10 per cent. proportion in the management costs—about £30 million. We can use that money for the elderly, children and mentally sick—areas where extra resources are desperately needed. I ask the hon. Member for Ashfield (Mr. Haynes) to follow our progress on that because it may surprise him. These are the legal instruments necessary to effect changes——
§ Mr. Roland Moyle (Lewisham, East)
I remind the Minister that the £30 million savings figure was quoted in 1979, when inflation was much lower than it is now. May we take it that, as the figure is still £30 million, there has been a substantial erosion in the amount of money he intends to save?
§ Mr. Vaughan
I said that we were expecting savings of about a 10 percent. Proportion of the management costs. As the management cost rise, we would expect the proportion to rise as well, to about £30 million. Of course, as management costs rose a little, so did the proportion and that is now about 10 per cent.
These are the legal instruments necessary to change the present structure. They have been the subject of unprecedented public discussion and approval. The new structure really should enable the Health Service to be administered more responsibly, effectively, efficiently and at less cost.
The content of the orders fall into two parts. First, on the determination of districts order, No. 1837, articles 4 to 20 make various transitional and consequential provisions to cover the change from area to district health authorities. Second, the determination order and the constitution of district health authorities order between them set out the boundaries, names and memberships of the new authorities. Lastly, the determination of regions order makes some minor variations to regional boundaries. These are entirely consequential on the pattern of the new district boundaries.
I shall deal briefly with the transitional and consequential provisions because most of them are entirely technical. They ensure, for example, that trust funds will pass from the old authorities to the new and that the affairs of the old authorities will be properly wound up. They will ensure continuity in the exercise of functions. If the House agrees, I do not see the need to detain hon. Members with a more detailed explanation, but I shall be glad to deal with any points that are raised.
§ Mr. Laurie Pavitt (Brent, South)
The hon. Gentleman has referred to the transitional arrangements being made for trust funds which are at present the 426 responsibility of the area health authorities. Will he also deal with the residue of funds that are now totally the responsibility of the teaching hospitals? What will happen under reorganisation to those funds?
§ Dr. Vaughan
The hon. Gentleman may care to raise that matter in his speech. I shall be glad to deal with it.
I should like to turn to the issue of boundaries and membership which, I am sure, will interest hon. Members. The boundaries have been the subject of extensive discussions. The regions consulted locally. When their proposals were submitted, the Government saw numerous deputations and answered many letters from those who were dissatisfied in one respect or another. Finally, there was consultation on the orders themselves.
We realise in a matter of this kind that it is impossible to please everyone. I am conscious that some hon. Members still have reservations about what is proposed for their constituencies. In each case, where there has been opposition to the new boundaries, my hon. Friends and I have looked into the arguments carefully. It cannot be claimed, I believe, that we have not listened to all sides of each case. The yardstick that we have tried to apply has always been the health care needs of that community.
There have been arguments about coterminosity, local authority situations, and community services as opposed to hospital services. At the end of the day, we have tried to strike a balance between the health care needs and many of the administrative needs of the area. We have tried not to lay down rules from the centre but to adapt to local requirements. The extent of our flexibility is shown, I suggest, by the size of the population of the new authorities.
We set as a guideline a goal population of 300,000 to 500,000. We have ended up with a range of populations varying from Leicester at 836,000 to North-West Durham at 89,000 and Rugby, the smallest of all, at 86,000. If that is not flexibility and an attempt to consider the changes in the light of local feelings and needs, I do not know what is. Special problems arose in Liverpool. I spent three days in Liverpool examining them. We arrived at a solution that is unique—one authority for all Liverpool, which meets the wishes of those in Liverpool to keep a strong Liverpool identity and its community services, but with two chief officer teams, one for the east and one for the west. This solution, we hope, will help to solve the immense administrative and financial difficulties that faced the previous authority.
Many representations have also been received about the names of the new authorities. We are entirely flexible. We have already agreed to one or two changes. If a health authority wants to change its name and if other local interests, including hon. Members and local authorities, agree we shall be glad to allow this to happen. We wish to see the names that local people want, although this will mean laying further orders.
The constitution of district health authorities order contains details of the membership of the new district health authorities. Our proposals have been criticised. In "Patients First" we said that we wanted smaller health authorities consisting, in general, of 16 members. Many of the existing health authorities have proved too large. Many of those serving on the authorities have positively pleaded with us for smaller authorities. Most people have told us that a health authority consisting of 18 members is likely to be the most effective. In response to this, and also 427 because most districts will cover a smaller geograghical area than at present, we decided that 16 was the right number to bring before the House. There are, however, provisions for more members in special circumstances. If hon. Members have any worries, I shall be glad to discuss them.
Another controversial decision is the reduction in the proportion of local authority members on the health authorities. In 1974, area health authorities, in most places, had four local authority members. In 1975, the Labour Administration increased the number to one third of the total. This decision, on the face of it, appeared to be reasonable, but it had a number of undesirable consequences. It increased considerably the overall size of the authorities. There was also a ratchet effect. When it became necessary to add a member for any reason, an additional local authority member had also often to be added.
Nowadays local authority members face an increased load of commitments within their local authority work. They have informed the Government that it would be increasingly difficult for them not only to attend meetings but to serve on the working groups and carry out the visits to hospitals that are desirable. For the reasons I have mentioned, we propose that there should be four local authority members on each district health authority. However, we have not been completely inflexible. We have made arrangements, which I hope will be found satisfactory, for a small number of additional places to cover special needs and for people to be able to attend authority meetings as representatives of the local authority but not able to vote.
I have outlined the main points in the orders. There will be some corrections and amendments, I fear, involving at least one of the orders. One or two printing errors occurred after my right hon. Friend had signed the orders. One of these could have raised entirely false hopes of entitlement to appoint a member to a particular health authority. I refer to the appointment of an Inner London Educaton Authority member for the Richmond, Twickenham and Roehampton health authority. Those concerned have already been informed of the error. I can only repeat the apology that I have given to them. I assure hon. Members that procedures are already under review to ensure that similar errors do not arise in the future. Amendment slips have been prepared and are now available.
There are two errors in the orders as signed. Wards in two London boroughs were omitted from the relevant parts of the schedules to the determination of regions order and the determination of districts order. Unfortunately, these textual errors can be corrected only by making amending orders. These will have to be laid before the House in due course. If, however, that is bad news, the good news is that the amending orders will provide the opportunity to change the names of some district authorities following requests to which we have agreed. There is strong local support for the changes. In each case, it is clear that the proposed name is more closely identified with the whole of the district.
The changes of name that we have agreed are Aylesbury Vale instead of Aylesbury, East Yorkshire instead of Beverley and Mid-Downs instead of Cuckfield and Crawley. If hon. Members wish the Government to consider alternative names for other district authorities—I 428 hope not too many—I shall be pleased to hear them. Time is short. If we must make changes, and still have everything ready by 1 April, the new orders will have to be laid early next month.
I have deliberately kept my remarks short because I know that many hon. Members wish to raise questions about the orders and about their constituencies. With the permission of the House, Mr. Deputy Speaker, I shall seek to catch your eye and answer as many questions as possible at the end of the debate.
§ 5 pm
§ Mrs. Gwyneth Dunwoody (Crewe)
The orders relate to a matter of considerable importance. Recently, a national newspaper sought information from members of the public about their attitudes to the National Health Service. More than 80 per cent. expressed satisfaction with the NHS, although they felt that some areas needed improvement. The majority not only approved of the NHS but wanted it to remain an integral part of their lives as a State service to the community. Where there were criticisms, they were largely directed at the provision of specific services or the need for better communications between health professionals and the patient.
The orders, to reorganise the NHS for the second time in its 30 years' existence, provide a remarkable opportunity to redress the mistakes of the past and to lay down clear and attainable objectives for the future. The 1974 reorganisation did not achieve either the flexibility or the responsiveness to patients that should be the hallmark of a caring health service. Conservative Ministers came to office complaining bitterly about the deterioration of the NI-IS, the need to change it and the growth of the administration at the expense of other health personnel. They suggested that the creation of new and smaller district health authorities would provide not only a better but a cheaper service.
The Minister repeated today that £30 million, which was his original estimate, could be saved simply by changing the structure—although he was careful not to detail that supposed saving. He means that he has given instructions to the district health authorities to cut their management services by 10 per cent.—which is not the same thing.
§ Mrs. Dunwoody
I am grateful to the Minister, but he also said that he would appoint more consultants and that they would not cost additional money. I hope that he will forgive me if I find it difficult to accept his assessment of what "change" actually means. In my experience, there is little probability that the changes will cut the budgets or expenditure. Indeed, I suspect that they will have the opposite effect.
§ Mr. W. R. Rees-Davies (Thanet, West)
The Select Committee considered the matter in great depth. It reported that the Government and the medical profession wanted more consultants. Obviously that will cost more. However, it means that there will be fewer junior doctor and other posts, which would compensate for that. What we gain on the swings is "merried out" on the roundabouts.
Surely there must be a wide measure of autonomy for district councils to decide which appointments are 429 essential. We can give them only a general directive that they must make cuts of a certain percentage. We must leave them with a great deal of discretion.
§ Mrs. Dunwoody
As someone who has lived a large part of her life in hospitals, I find it difficult to conceive of a consultant who will not spend money on back-up services, will not require assistance, will not increase the drugs bill and will not increase the general services asked for by his department. I am happy to hear that such people exist, but I do not know where they are. We shall have to wait and see the effects of the changes on overall expenditure. I hope that the hon. and learned Gentleman will forgive me if I take up his point about finances later, as I wish to comment on it in some detail.
The public have the right to expect that, having learnt from their mistakes, the Government intend to create a better and more accessible service with greater accountability and with no unnecessary bureaucratic overlay. Indeed, Ministers repeat that constant theme in all their speeches. In fact, the opposite has been true. For two years the NHS has been thrown into complete turmoil, without any attempt to test the efficacy of the proposed schemes, either by setting up pilot management schemes or by any other means. Ministers have set about carving the country into new districts, often with scant regard for their own criteria.
The previous Secretary of State told the House that the Government's plan was to establish district health authorities covering populations of between 150,000 and 250,000. "Patients First" said that most districts would have more than 200,000, although a few might be below 150,000. The Minister today said that he takes pride in the fact that he has been so flexible. He has not stuck to his own criteria. He may call that flexibility, but some would call it indecisiveness.
There are 29 district health authorities with populations below 150,000. It is not clear whether the criteria took account of self-sufficiency in new districts. Some have been created in such a way that they are far larger than the target figure, whereas, at the other extreme, some will have considerable difficulty in providing comprehensive health care. When Ministers talk about the right of the district health authorities to make decisions and establish their priorities, they should make it clear that that requires finance. There is no point in creating a district health authority that is so small that it will find difficulty in providing a comprehensive health care system.
§ Dr. Vaughan
Which of the smaller districts does the hon. Lady wish to amalgamate with larger districts, and which of the larger districts does she wish to divide?
§ Mrs. Dunwoody
It is not for me to dictate to the people in the areas. The hon. Gentleman has made great play of his consultations with them. I shall soon refer to what happened in Liverpool when he took soundings and held consultations, and how much effect that had. It will show what actually happened, as opposed to what Ministers are alleging happened.
§ Mr. Nicholas Winterton
Does the hon. Lady believe that authority for the allocation of consultants' and junior doctors' posts should reside at district or regional level? The Select Committee felt that consultants should be appointed by the district authorities. The Government say that it is the responsibility of the regions. Which is right? 430 If the hon. Lady is arguing that districts need authority, which I support, they must have the resources to make the right appointments for the needs of individual areas.
§ Mrs. Dunwoody
I hope that the hon. Gentleman will contain himself with a little patience. He is developing the unlovable habit of intervening and making all the points that I intend to make. In a Health Service pledged to provide services in conjunction with local authorities, both through personal social services and the extension of joint funding, Ministers have wholly failed to face the problem of coterminous boundaries.
Instead of seizing the chance to integrate health districts with their most important partners in local government, Ministers have created yet another set of unrelated boundary lines on a national map already covered with different zones of demarcation. Should that result in greater problems, the same local authority is unlikely to be able to change the situation because it will have still fewer representatives on the district authority than it had under the old system. This will hardly ensure coordination of services at local level or the proper use of scarce local government resources, which are already under determined attack from the Secretary of State for the Environment.
The speedier treatment and discharge of patients from hospital has doubled the pressure on community nursing services, and the rise in the number of elderly and very elderly in the population will continue that trend. Inevitably, local authorities will bear the brunt of such demographic changes. They will have to know what provision they must make to meet these growing demands.
The Secretary of State should have sought to strengthen planning links with local users rather than paying lip-service to the ease with which smaller districts would in the future be able to respond to the needs of the community. Responsiveness to need is best demonstrated by taking the trouble to find out what the public really want, not by imposing yet another unaccountable structure in the name of progress.
Alas, it is not only local authorities that will lose representation on the new DHAs. The previous Secretary of State assured the TUC that although he had widened the definition for representatives of the trade unions to include organisations not affiliated to the TUC, nevertheless, appointments would not be made on a grand scale from non-affiliated bodies. That is important, given that the TUC represents 12 million workers and the non-affiliated bodies that he had in mind at most 150,000.
Nevertheless, the Managerial, Professional and Staff Liaison Group has succeeded in getting nominees appointed in seven different areas. As the BMA and the British Dental Association constitute two of the largest members of that organisation, one might be forgiven for thinking that the new extended representation will not necessarily bring in new revolutionary ideas to solve the problems of the Health Service. Those problems are real.
In some areas the RHAs undertook extensive consultations on the proposed reorganisation. That does not seem to have resulted in any great change in the Government's attitude or final conclusions. In Liverpool, for example, the suggestion that there should be two health districts was rejected by almost every organisation that responded to the consultative document. The city council, the Liverpool area health authority, the family practitioner committee, the Liverpool local medical committee, the 431 Liverpool university authorities, the Liverpool community health councils and the trade unions representing workers in the Health Service were all quite clear that they thought that the city should remain as one administrative unit.
The discussions went on for some months, but the final decision was to create what was called one unit with two sectors. It is still not clear how a city divided into two will operate efficiently. Liverpudlians, who are already among the most deprived and desperately in need of a high level of health care, may be forgiven for thinking that the Ministers who took the decision put the supposed interest of administrative convenience far above the interests of the inner city.
At the other extreme, the problem in the Trent area arises from the fact that the single DHA will be a jumbo organisation serving a population far exceeding the Government's maximum of 500,000. In Gloucestershire the chairman of the local AHA resigned, saying that the decision to split Gloucestershire was an administrative mistake causing unnecessary additional expense, which he calculated at about £500,000 a year. He said thatthe Minister and the Secretary of State made up their minds without the courtesy of coming back to me before deciding".Yet the Government have just been boasting about the amount of consultation into which they entered before making a decision. So much for consulting the people.
The new organisational arrangements are marked by a degree of muddle which will undoubtedly cause considerable difficulty for the incoming authorities. Why was the Minister not prepared to face the thorny questions? A senior administrator wrote in his professional journal that the Government seemed to have washed their hands of reorganisation and were not prepared to give any indication of the guidelines that the new authorities would be expected to follow.
Why were the Government not prepared to consider the involvement of teaching hospitals in DHAs? There is a real argument on both sides. When a senior teaching hospital is centred on a DHA, almost inevitably it sucks in large amounts of resources, often at the expense of other parts of the DHA. This was a good opportunity to consider the financing of teaching hospitals and how they could be incorporated into the DHAs around them.
This change is so extraordinary that in some London districts the Minister seems even to have applied different criteria to different areas operating side by side and containing similar teaching hospitals. This can only make the DHAs' job doubly difficult and will in no way resolve the age-old battle for resources between services such as those for the mentally handicapped and the more glamorous teaching hospital staff, represented, as always, by a powerful and articulate group of consultants.
The decision to deposit consultants' contracts with regional rather than district authorities shows the Government's real attitude towards devolving power downwards. The contracts should have been deposited with the district authorities, which in large part will be the direct employers. Even when two DHAs share the work of one consultant, it would still be better for the district authorities to hold the contracts. Yet the Government deliberately chose to place the responsibility on the regional authorities.
The Government have also gone ahead with the creation of an entirely separate structure for the family 432 practitioner committees, although it was clear that the new DHAs wanted to take this opportunity to gather the FPCs into their own organisation and provide better coordination for them.
There are already far too many barriers to good communications between one discipline and another, and between one group of workers and another, for decisions of this kind to be allowed to go ahead. Many of us foolishly hoped, and indeed believed, that reorganisation would provide a golden opportunity to improve relationships and consultative procedures within the NHS. It should be possible for health professionals to argue out their priorities in conjunction with their patients, and with one another, without resorting to entrenched enmities and old prejudices. Moreover, there is no sign that the Government have been prepared to give any lead in this matter or to issue any guidelines to assist the new authorities.
One element in better communications is knowledge. The community health councils have made a valiant attempt, with tiny budgets and virtually no staff, to help patients to understand how the Health Service works and, where necessary, to help them to secure redress for their complaints. The Government, however, have now decided that, although they will allow the CHCs to continue, they are not prepared to increase their budgets in line with inflation. What is more, the Government have unloaded the funding of "CHC News"—the councils' only means of passing information from one area to another—on to the DHAs, which are already burdened with very heavy costs. In the final analysis that can only mean that "CHC News" will find it extremely difficult to continue. The only tiny input of consumer attention that the Government have so far allowed will thus find it even more difficult to hand on its information to the general public and to provide a service.
My indictment of the Government's handling of the reorganisation of the Health Service is that they have failed singularly to grasp the challenge. It was a golden opportunity to ask the users of the service, who should most concern us, what they regard as being their first priority in the new district health authorities.
§ Mr. Nigel Spearing (Newham, South)
Is my hon. Friend aware that the Minister's failure to be firm about the future of community health councils and the question mark that stands over them, apart from "CHC News", has resulted in the complete bafflement of those who find it extremely difficult to obtain information? Whatever the Government's view about health and the Health Service, their attitude to the community health services is not understood.
§ Mrs. Dunwoody
The Minister has said that the reason behind the reorganisation is to bring the Health Service closer to the people. That being so, I do not understand why he is not prepared to allow the one organisation that helps in that respect to continue to provide assistance where it is most needed.
§ Mrs. Dunwoody
I am sure that the Government do not believe in giving the consumer more advice or help or in improving the Health Service. That has become obvious from the way in which they have handled the reorganisation.
433 The reorganisation provided a marvellous chance to stimulate the partnership between the National Health Service and local government, to improve the services in need of improvement and to respond to the rapid pace of change in the Health Service. It is an organisation that is much in need of a new beginning. It provides a tremendously important service at every level in our lives. It is admired throughout the world, because there is no comparable way of providing adequate health care.
The reorganisation bears all the hallmarks of the Government. In future, there will be far less planning, because the Government have done away with many planning positions. There will be far less co-ordination, because they do not seek to improve their relationship with local authorities. There will be far less exchange of information. Areas that are desperately in need of extra finance—caring for the mentally handicapped, the mentally ill and the chronically sick—will not benefit from the reorganisation. Many of them will find themselves in such small district health authorities that they will find it even harder to obtain a decent share of the resources.
The Government have not sought to improve local democracy or public participation in the NHS. There will be muddle, confrontation and a complete lack of encouragement for the staff. In a Parliament that has not even found time to debate the Black report on the inequalities of health care, we see increasing signs of the results of a negative Conservative health policy. There is no clear evidence of an overall Government strategy to improve and extend the service. Thirty years have passed since its inception and we have not even managed to redress the imbalance in health care between one region and another, one discipline and another and one inner city and another.
With all those major problems to face, the Government have run away from a true reorganisation. They have taken a large step in the dark and they are not even aware of what awaits them. They had to say that the previous NHS reorganisation carried out by Conservative Ministers was at best inadequate and at worst damaging, and I believe that they will have to return before the end of this Parliament to say that they made yet another mistake.
§ Sir Ronald Bell (Beaconsfield)
The motion in the names of my right hon. Friend the Member for Chesham and Amersham (Sir I. Gilmour) and my hon. Friend the Member for Wycombe (Mr. Whitney) relates to the determination of districts order. It does not envisage a wide-ranging attack on the concept underlying the order of the type delivered by the hon. Member for Crewe (Mrs. Dunwoody). We are concerned particularly with the so-called overlap area in the southern part of Buckinghamshire because the order proposes that the parishes of Burnham, Dorney, Farnham Royal, Fulmer, Hedgerley, Iver, Stoke Poges, Taplow and Wexham should all be incorporated with the East Berkshire health district.
I know that my hon. Friend the Minister is familiar with Berkshire, but I know also that he will not have allowed that to influence his judgment. My right hon. and hon. Friends are concerned that the wide process of consultation in which the Department indulged—I do not dispute that there was wide consultation—has produced such a result. 434 Everyone in Buckinghamshire who was consulted said that the southern part of Buckinghamshire did not want to be incorporated with the eastern end of Berkshire.
It is true that since 1974 the southern part of Buckinghamshire has been administered on an "agency" basis by East Berkshire. This is a good example of how one folly follows from another. My right hon. Friend the Member for Worcester (Mr. Walker), the Minister of Agriculture, Fisheries and Food, had a brainstorm in about 1974 and introduced changes in local government boundaries of an extraordinarily infelicitous sort.
§ Sir Ronald Bell
I am always guilty of understatement, as the hon. Gentleman knows, except on one or two particular topics, which, again, he will know about.
The result of my right hon. Friend's decision affected certain southern parishes in Buckinghamshire, which had been in the county for just short of 1,100 years, which is quite a respectable time—indeed, ever since the break-up of the kingdom of Mercia into the counties as we know them—but it was not a long enough pedigree for my right hon. Friend. We had a great deal of idle and pretentious cluck about social patterns and travel-to-work areas and all that sort of business, as a result of which the southern area was transferred to Berkshire. Instead of having a clear boundary at the River Thames, which for more than 1,000 years had been the southern boundary of Buckinghamshire, a part of the county was removed and became a part of Berkshire. That naturally led to the mix-up that we have now whereby the parishes south of the M40 in Buckinghamshire are administered for health purposes as part of East Berkshire although they are in the South Buckinghamshire district.
When it was proposed as part of the new determination of districts that the change of boundaries should be made permanent and that the southern parishes should be incorporated in the East Berkshire district, my right hon. Friend the Secretary of State and my hon. Friend the Minister for Health consulted everyone in Buckinghamshire. They were told by the regional health authority that the area should be administered as part of Buckinghamshire as part of the Wycombe district health authority. They were told by the South Bucks district council that it should be administered as a part of the Wycombe district. They were told the same by the community health council and the family practitioners committee—I could go through the list that the hon. Lady mentioned in relation to Liverpool—and by many others. Everybody gave that answer.
Incidentally my right hon and hon. Friends asked the Member of Parliament, myself, and I said that the area should be administered as part of the Wycombe district and not as part of East Berkshire. My right hon. Friend the Member for Chesham and Amersham, who is indirectly affected, as is my hon. Friend the Member for Wycombe, expressed the same opinion. No representative body, medical or administrative, expressed any other opinion. No representative body, medical or adminstrative, expressed any other opinion.
I have a letter from the family practitioner committee which states:The Committee like the Buckinghamshire Area Health Authority and the Buckinghamshire County Council,"—and it could have added all the other bodies that I have mentioned— 435are totally opposed to the transfer, and would be grateful if you would consider praying against the Order when it is laid before the House.The medical opinion, the local government administrative opinion, and the political opinion—I do not just mean my own; I do not know of any representative political body that favours it—are against the order. I congratulate my hon. Friend on the wide consultation, but is there much point in that wide consultation if it is then brushed aside and the opposite is done?
My hon. Friend could say that the East Berkshire area health authority, the existing one, advised him that it should continue to administer the area. It would have been surprising if it had not. People do not like parting with functions. It often results in a reduction of staff and importance. I am sure that it did say that I am sure that the officials, acting with the best will in the world, so advised him. But the East Berkshire health authority does not represent any of my constituents in the overlap area—they are in Buckinghamshire.
I realise that both my hon. Friend and his officials have looked at this from the point of view of health administration with the utmost sincerity. I am sure that my right hon. Friend the Secretary of State did the same thing. However, this is not just a matter of somewhat detached deliberations over an administrative network. One is dealing with actual people and what they want is very important. The Minister spoke of "truly local services" and emphasised the importance of "consultation with people in the area". That should be the criterion. What people want is not necessarily unrelated to administrative efficiency. People are not morons. Some of them are the medical people who operate the service and feel strongly about this. That is not just predilection; it has to do with efficiency. The people of the area are not incapable of knowing what is best for themselves so that they must be overridden by superior wisdom from somewhere else. Their wishes should weigh heavily in the balance.
It is not for me to discuss the importance of my view of the matter. I have no technical or medical knowledge. On the other hand, when one has represented an area for over 30 years one has at least begun to get the feel of it. One of the documents claims as justification that the shopping and social patterns or interests of the overlap area are centred on Slough. I hope that my hon. Friend will not think that Slough is regarded as a social centre by the people of the parishes that I have read out. I do not want to express a positive opinion on the subject but I shall confine myself to a negative one—they do not. Nor is Slough a shopping mecca for South Bucks. There is a certain difference between Slough and the somewhat conservative countryside of South Bucks. Its people do not have their social life centred upon Slough. If my hon. Friend has been told that by anybody, then he has been led into cloud-cuckoo-land. Nothing could be further from the truth.
The order creates another set of unrelated lines, as the hon. Member for Crewe pointed out. Councillors have said to me that the proposal is not only disagreeable but wasteful. Every time that they discuss health matters they have to have two community physicians present. Their officials have to attend two meetings with community health councils, area health authorities and so on.
436 There is merit in having medical and administrative boundaries coterminous. The primary medical welfare is done by local authorities and it is more convenient to have them coterminous with that part of the health services controlled by the area health authority, such as hospitals. My hon. Friend will tell me that my constituents in the overlap area are particularly concerned with the Wexham Court hospital which is in Berkshire by about 50 yards, and the Cliveden hospital which is in the overlap area. That cannot be accounted for by saying that it is in the overlap area and therefore should stay in it. If the overlap area stays in Buckinghamshire, so does the Canadian Red Cross Memorial hospital and the Wexham Court hospital.
As for the Wexham Court hospital, when Wexham was retained, at my insistence, in Buckinghamshire because that was part of the Minister of Agriculture's predatory intentions at the time, it was lassooed and held for Slough. The boundary looks like a lassoo. The hospital was specially put into an enclave and the boundary goes up and round it and back again because it was thought that it was important that the hospital, which took a lot of patients from Slough, should be in that area.
If that was so important as to produce that extraordinary contortion of the boundary, is it not important that the general body of the overlap area should be in the South Bucks district which is the administrative authority for it? Is it not the fact that, in any case, the patient is supposed to have a choice of hospital in the area? It is an important principle that consultants and medical advisers generally should have a choice, in so far as the facilities permit, among the range of hospitals in the area.
We are dissatisfied with what has been done. I accept a small share of responsibility in that when my hon. Friend had his final consultations at the end of last May I was hors de combat and in hospital. I was thus not able to consult widely and did not send him a rejection as emphatic as this rejection is today. Had I been in more robust health, I would have done so, I can assure him. He may thus have been slightly misled as to the degree of opposition that he would meet later.
Everybody is against this proposal. I do not think that it is too late for my hon. Friend to have second thoughts about it. It may be a bit much to ask him to withdraw the order when it has gone into print. There is probably a strike in the Stationery Office and he could not get it reprinted. In any case, reputations and prestige become engaged once a document is published. However, he must take into account not just my words but the fact that I am speaking on behalf of almost everybody who is articulate on this subject in my constituency.
I ask my hon. Friend to give this matter reconsideration which is not only early but significant and, if I may use a dreadful word, meaningful. He should consent to be persuaded, after a very short time, that this has been a mistake which ought to be rectified at the earliest opportunity.
§ Mr. Jack Dormand (Easington)
I shall be brief in raising a constituency matter arising from the orders. I hope that the Minister will not misinterpret my brevity as meaning that the problem is not of great importance either to myself or to thousands of my constituents. The hon. Gentleman will be aware that it concerns the representation of Easington district council on the proposed Sunderland and Hartlepool district health 437 authorities. I have been corresponding with the hon. Gentleman on the subject for some months, and he has also received strong representations from Easington district council.
I assume that the Minister has looked at the map. I do not believe that we have had the pleasure of seeing him in that delightful part of the world. From the map he will see that Easington is between Sunderland and Hartlepool. The main point is that thousands of my constituents must travel to those two adjoining areas for health services. The Government need not accept my word for that.
The Government, and certainly the Ministers this afternoon, have been at pains to point out how much consultation they have carried out in arriving at their decisions. That has included talks with regional health authorities. The northern regional health authority, in a document relating to representation on the two new health authorities, stated:Some two-thirds of the population of neighbouring Easington district will on present plans continue to look to Hartlepool for their District General Hospital services and future local hospital services within Easington will be linked with those in Hartlepool.As a result of that, the regional health authority suggested to the Government that an exception be made for Easington in the case of appointments. The proposal, as the Minister will know, is in accordance with the regional plan. In addition, that view is supported by Hartlepool community health council. Although I am laying stress on Hartlepool—the number will be less for Sunderland—the principle remains the same for both Sunderland and Hartlepool.
When I first wrote to the Minister about the matter, he said that he had not overlooked it but that, as a general principle, the Government wished to keep the membership of the new district health authorities to a manageable size. That is a laudable aim, but I interpret his words "as a general principle" as meaning that there must be circumstances that call for special consideration, and that there should be flexibility, not a rigid application of the letter of the law. There can be no other interpretation of those words.
There was a revealing error in the Minister's letter. He said that the Northern regional health authority had in any case appointed to the Sunderland district authority a member who lives in Seaham. I should explain to the House that Seaham is in Easington district. However, that person lives in Houghton-le-Spring, which is not in Easington district. We all make mistakes at times, but I mention this mistake to demonstrate how remote central Government can be in such matters. The hon. and learned Member for Beaconsfield (Sir R Bell) also made that point. It emphasises how important it is in making such appointments to listen to local views.
Is the Minister suggesting that one additional member, in the special circumstances that I have outlined, would cause the district health authority to be unmanageable? Such a suggestion is bureaucratic nonsense, and I ask him to reconsider the matter.
I remind the Minister of the declared aim of the Government to make the National Health Service more responsive and accountable to the people it serves. The best way to do that is through elected local authority members and by considering the special needs of each area. If a second examination of the needs of my area is 438 not undertaken, thousands of my constituents will be unable to have their voices heard, and for them accountability will be a mockery.
I said that I wished to raise a constituency matter and the House will now realise that it is a narrow one. However, I suspect that the rigidity being shown to my area by the Government is being repeated elsewhere. If nothing is done to correct it, it will be bad for the. Health Service and for the millions of old people who are so dependent upon it.
§ Dr. Vaughan
There are several different ways of achieving representation of a community. One way is to have a local authority representative and another way is to have a representative appointed by the region. I understand—I should be grateful if the hon. Gentleman will confirm it—that the Northern regional health authority has appointed to Hartlepool health authority a member who lives in Easington. That means that there is representation of Easington's interests.
§ Mr. Dormand
What the Minister says is news to me, but I hope it is correct. The hon. Gentleman made the same point about someone who was appointed by the regional health authority to the Sunderland health authority. He made that point in correspondence. However, that person does not live in the area. I shall be happy to check whether what he now tells me is true. If it is, that will take care of the matter. But the Minister is missing my point. The Government, my hon. Friend the Member for Crewe (Mrs. Dunwoody) and I have said that the best representation comes from elected members. I presume that the Minister is now talking about an unelected member. I hope that the matter will be re-examined.
§ Sir Ian Gilmour (Chesham and Amersham)
My hon. Friend the Minister for Health introduced the orders in a spirit of genial self-congratulation. In general, he made a very good case and deserves his own congratulations, but I take strong issue with him on the point raised by my hon. Friend the Member for Beaconsfield (Sir R. Bell) and the hon. Member for Crewe (Mrs. Dunwoody) about creating some new and unnecessary boundaries. That point is important generally, but I am concerned, as was my hon. and learned Friend the Member for Beaconsfield, with Berkshire and Buckinghamshire.
I appreciate what my hon. Friend said about it being impossible to please everyone. Equally, in present circumstances, he was wrong to take the credit for what he called "extensive discussions and deputations'', because, as has been pointed out, the extensive discussions must have shown a clear case for doing the opposite of what he decided to do. When we took a deputation to see my right hon. Friend the Secretary of State for Social Services the arguments were all one way. No argument was put against our case which, both now and then, seems overwhelming. I regret that my hon. Friend did not put forward a strong argument in his opening speech. No doubt he will do so later. Perhaps I may set out the case yet again?
§ Mr. Pavitt
What happened as a result of the representations that the right hon. Gentleman made to the Secretary of State? Did the Secretary of State accept or reject the case that was put to him so forcefully?
§ Sir Ian Gilmour
My right hon. Friend, who has only recently taken over the Department, very reasonably said that he wished to consider the matter. I have no complaint about that. His behaviour on that occasion was, as always, impeccable. My only complaint is about the final decision, which was entirely wrong.
First, it is generally agreed that the arrangement of the overlap area has not proved satisfactory. It has not served the people concerned. There was, therefore, prima facie, a strong case for change.
Secondly, as my hon. and learned Friend the Member for Beaconsfield pointed out, all those involved were against being allocated to East Berkshire. If we pride ourselves on paying attention to what people want from reorganisation, we should not ignore or flout the wishes of all concerned.
Thirdly, I understand that the cost of transferring contracts and patients' records will be high—about £80,000 to £100,000. That seems a considerable waste of money.
Fourthly, school health and social services will continue to be under the jurisdiction of Buckinghamshire, which will make liaison difficult, as it has in the past.
Fifthly, as has been said, the primary health care and other services provided by Buckinghamshire are the concern of patients.
Sixthly, not only all the organisations involved, but general practitioners—almost to a man and a woman—and the public, would undoubtedly prefer to be in a Buckinghamshire authority.
Seventhly, it is absurd to perpetuate such an anomaly when the county councils of Buckinghamshire and Berkshire, as well as the three new district health authorities in Buckinghamshire and those in Berkshire, are grappling with the problem of how to constitute the new district health authority and county-based joint consultation committees. Joint finance will be extremely difficult.
Finally, there is the difficulty of occupational therapy facilities. The Buckinghamshire social services committee has no occupational therapy workers, but it employs the Buckinghamshire area health authority as agent for occupational therapy work throughout Buckinghamshire, except for the overlap area. The Berkshire social services committee employs its own occupational therapy workers, but they operate only in Berkshire. Therefore, the 25,000 inhabitants of the overlap area are left high and dry.
The decision is unfathomable. It is inexplicable. Unless my hon. Friend can produce a serious argument to convince me—which is unlikely—or unless, as my hon. and learned Friend the Member for Beaconsfield said, he undertakes to see that this bad decision is genuinely reconsidered quickly, I shall have to oppose the orders.
§ Mr. Roland Moyle (Lewisham, East)
It is about 16 months since I took part in a Health Service debate. When I was transferred to foreign affairs, I had every confidence in the ability of my hon. Friend the Member for Crewe (Mrs. Dunwoody) to speak for the Labour Party on the Health Service. I have been subjecting myself to waves of nostalgia ever since the debate began about an hour and a half ago. A few moments ago I broke my resolution not to make comments on the general aspects of reorganisation because a wave of nostalgia overwhelmed me when I found our old friend the figure of £30 million being bandied backwards and forwards across the Chamber.
§ Mr. Moyle
As my hon. Friend says, I have seen it before. I think that I first heard it introduced in a speech by the Minister to the Conservative Party conference in 1979, and it has been with me ever since.
I promise that it is only the most powerful constituency interest that compels me to intervene this afternoon. I shall not talk about the general issues involved in the reorganisation of the Health Services. My views are on record of considerable length and I shall not elaborate my arguments. However, I reaffirm that, in general, the reorganisation of the Health Service is a good thing. Indeed, most of my constituents believe that that is so and will be only too happy to see the damage done by the Conservative Government between 1970 and 1974 cleared up. In addition, they are happy to feel that the Royal Commission set up by the Labour Party forms the basis of the reorganisation that is being introduced this year.
Although I am not against the reorganisation of the National Health Service, Lewisham opposes the reorganisation proposed for its health services. Therefore, I shall support my hon. Friends in the Lobby tonight. Lewisham wants a district health authority that is based on the boundries of the London borough of Lewisham. In that way the people of Lewisham can run their own health affairs without any more than minimal interference from outside bodies.
We want conterminous organisations for Lewisham's health services and for the London borough of Lewisham's social services department. We have been offered something entirely different. The order proposes that Guy's health district should be amalgamated with Lewisham health district to form a Lewisham and North Southwark district health authority. We do not like that. Almost all interested parties in Lewisham, with the exception of the consultants at the Lewisham district general hospital, are against the proposal.
Members of Parliament, the borough council, the voluntary organisations, and all sections of the Health Service are against the idea and have frequently said so. Even the consultants who supported the idea were unsure about their decision. At first they could not make up their minds. They then decided against the proposed merger. Finally, the regional medical officer came down to Lewisham and read them the riot act. As a result, they fell into line with the proposal.
We have not been given an exceptionally good hearing in the consultation process. The area health authority decided to support the proposed merger without having heard representations from anyone in Lewisham. To do the regional health authority credit, it listened to us. I echo the remarks made by the hon. and learned Member for Beaconsfield (Sir R. Bell), because I am sure that the fact that the deputy chairman of the regional health authority, who listened to our representations, is a Guy's consultant did not affect the outcome of the discussions. Similarly, the hon. and learned Gentleman's connection with Guy's did not affect the outcome.
The former Secretary of State for Social Services, the right hon. Member for Wanstead and Woodford (Mr. Jenkin) was kind enough to receive us. However, by the time we got to the right hon. Gentleman he had been advised by the London Advisory Group. That group had been given the task of making suggestions to the right hon. Gentleman about how the Health Service in London 441 should be reorganised. It was sufficiently arrogant to make up its mind without having heard any evidence from the people of Lewisham about the form that the health services should take.
We can now have our say in the House, but I am afraid that the clock stands at five minutes to midnight. The situation is serious. The London Advisory Group commented on the organisation of the health services for Lewisham and related parts of South-East London. It put on record some grossly ignorant and incompetent advice, and that was only natural, since it took no evidence from the local people. On page 6 of its advice to the right hon. Member for Wanstead and Woodford it said:Left on their own both halves of the proposed district health authority would be of doubtful viability.That takes the biscuit.
Lewisham has an adequately equipped district general hospital. It may not be perfectly equipped, but it has a reasonable range of medical equipment. The hospital is adequately staffed. It may not be 100 per cent. up to establishment, but it is probably as near that as are most district general hospitals. It has one of the best nursing schools run by a non-teaching hospital. It has a manageable budget of about £35 million. It has an appropriate population of 230,000. When I hear that there are district health authorities with 86,000 people in other parts of the country, I wonder how the London Advisory Group can ever say that an area with a population of 230,000 is non-viable.
Lewisham has good district services which take up 15 per cent. of the health district's budget as opposed to 71/2 per cent. of the Guy's district budget for its services. It has a social services department which, in my view, is second to none, and I have seen a number up and down the country. Lewisham district general hospital is sufficiently good for Guy's hospital to send students there for training in medicine as it is practised as opposed to as it is taught in the ivory tower of Guy's hospital.
If Lewisham borough is not viable as a district health authority, there is no such thing as a viable district health authority in the entire country of England, from Land's End to Berwick-upon-Tweed. There is no possibility of my retracting that statement.
The proposed reorganisation, if it takes place, will be a marriage of incompatibles. Guy's is a capital ship of the National Health Service. It is not only a capital ship, but a flag ship, with not just one admiral, but dozens of admirals. It is packed with powerful medical politicians. If there is a battle within the new district health authority for funds, there is little doubt that unless exceptional steps are taken—I shall come to some of them in a minute—Guy's will win every time.
This is the point that my hon. Friend the Member for Crewe made when talking about the role of teaching hospitals in a reorganised National Health Service. Guy's consultants will always want more money, so there will always be a battle for funds within the new district health authority on that basis alone.
Governments of all parties always want to make sure that the funds available to the National Health Service are more equitably spread among the various health authorities. If Guy's is included in the new district health authority, the North Southwark and Lewisham health authority will be considered to be a rich health authority and therefore will be under continual pressure from the county of Kent to give up funds to hospitals and health 442 services in Kent. From that point of view also there will be a considerable battle within the district health authority for funds between Guy's and Lewisham. Here again Lewisham, and not Guy's, will be the loser.
In the early years, if Lewisham hospital is subjected to these pressures, it will take money away from Lewisham district services of which we are proud. Eventually. money will go away from the Lewisham district general hospital. It will go to Guy's and there will be a general crumbling of the hospital and the district health services in Lewisham. I am not impressed with the constitutional arrangements which, by the allocation of places on the district health authority, are designed to counteract that. They do not take care of the well-enshrined principle of medical tactics known as shroud waving.
Guy's is some hundreds of yards from Fleet Street. As I said, it is packed with medical politicians, consultants dealing in the acute specialties. We all know that a prominent consultant can go to the press and say that unless he has money for this or that facility or machine, Mr. So-and-So, the next man on the waiting list, will die. He will get tremendous press coverage. No matter what the people on the district health authority try to do they will come under such severe publicity pressure that they will in the end give in to the consultant.
The experience is that where there is a large teaching hospital the smaller hospitals go. We already have the example of St. Olave's in Guy's health district, which has been temporarily closed for about two years. Then the district services go and finally the family practitioner services begin to wither.
The only criterion upon which the merger of Guy's health district and Lewisham health district has been pushed is a determination to ensure that the interests of Guy's hospital are looked after and that it is provided with an appropriate catchment area. Not the slightest concern has been expressed by the Minister for the viability of health services in Lewisham.
When the right hon. Member for Wanstead and Woodford took the decision that the merger should go ahead, he suffered pangs of guilt. He wrote me a letter in which as a sop for the unfortunate decision he offered two safeguards. First, he said:I certainly recognise that Lewisham representatives will feel the need for safeguards. I will bear this in mind when I appoint the chairman.That safeguard was not worth the paper on which it IA as written.
I have met Mr.Berriman, the new chairman. He strikes me as an admirable man personally and as an intelligent man. No doubt in a relatively short time he will learn a lot about the health service in Lewisham, but he will not understand Lewisham, because he is not part of it. He is a denizen of the City, which is a minority interest in Lewisham. Secondly, he lives in Sevenoaks and, as far as I know, he has always lived there, or has certainly lived there for a long time. In no way can he be regarded as a safeguard for the people of Lewisham in the unfortunate and unequal marriage which is being forced upon the Health Service there.
If the word of a Cabinet Minister can be circumvented as easily as that in seven months, it is clear that the Government cannot be relied upon. I make no criticism of the right hon. Member for Wanstead and Woodford. He was the man who gave the assurance, but by the time the organisation began to be implemented others were in 443 charge. If the Ministers who took over and the Minister who has been there all the time have any consciences left to twitch, they should feel that they have much explaining to do about the way in which the assurance was casually torn up.
§ Mr. David Crouch (Canterbury)
As a former Minister of Health, the right hon. Gentleman knows that it is not in the Minister's hands entirely what happens to the new districts. In between the Minister and the districts there are still the regions, as the right hon. Gentleman knows. I am a member of the region that advised the Minister. I was greatly involved in the decision about Guy's and Lewisham. The right hon. Gentleman says that Guy's will always overpower Lewisham and Lewisham will come off worst, but it will not be the Minister alone who will be concerned to see that that does not happen, or Mr. Berryman alone, because the region, representatives of the region and representatives from Lewisham will be there to ensure that Lewisham does not get an inadequate share of resources. I hope the right hon. Gentleman will be more fair about it.
§ Mr. Moyle
The hon. Gentleman's touching courage in trying to throw himself beneath the wheels of the juggernaut as it rolls forward appeals to my heart, but Ministers have come to the House this afternoon with an order that applies the reorganisation about which I have been talking. They have advocated it to the House, they have taken responsibility for it and they must take responsibility for the consequences.
A second safeguard was given by the hon. Member for Wanstead and Woodford in the letter of 22 July 1981. He said:The major safeguard, of course, is that any substantial changes in services which are opposed by the community health council would have to be referred to Ministers under the usual procedure.That solemn assurance has fared no better than the first. Our watchdog is to be decimated and amalgamated with a community health council that includes people from Southwark and Guy's district. Therefore, it will cease to be an effective watchdog from the point of view of the people of Lewisham. It will become a toothless watchdog.
In Lewisham we have a high regard for our community health council. In the quiet times that we have had from time to time in our health services in Lewisham, our community health council did a competent job in keeping in touch with people, representing their health interests on various bodies and putting forward a good case. In times of crisis it was outstanding. When the Minister was engaged in incompetently sacking the area health authority of Lambeth, Southwark and Lewisham, and when he was appointing health commissioners when he had no power to do so, the community health council was a great rallying point around which we could gather and fight our case. It was an excellent channel of communication and organisation. We won that case.
When the boundaries battle and reorganisation started, again we were able to use the community health council as a rallying point. Its dissolution is probably an act of petty vengeance wreaked upon it by the Department as a result of the trouble that it has caused.
We want two community health councils for North Southwark and Lewisham. We have the population to 444 justify that—326,000 in total. If we do not have them, where will the headquarters of the community health council go? If it is in Southwark, no one in Lewisham will use it. If it is in Catford, where the present Lewisham community health council offices are, no one in Southwark will use it. If it is Deptford, with all due respect to my right hon. Friend the Member for Deptford (Mr. Silkin), no one will use it, because no one from Southwark or Lewisham ever goes shopping in Deptford. The whole range of that large district health authority, which is 12 miles from end to end, will have no focal point.
At present we have 60 community health council members in North Southwark and Lewisham. That is a large group of people, who can keep in touch with the population, make representations and act as public relations officers, often for the National Health Service. After the reorganisation we are threatened with only 24 members, only eight of whom will have to represent the voluntary organisations of one and a half London boroughs. That is most inappropriate.
The whole object of "Patients First", which I supported and which the Minister spoke passionately in favour of, was that the National Health Service should be taken nearer to the people. That has been thrown overboard.
The South-East Thames regional health authority's consultative document on the reorganisation of the Health Service was called "A More Responsive Service". However, the National Health Service will become less responsive in Lewisham under every heading. The district management team that was situated in Lewisham hospital will go and perhaps disappear to Guy's hospital. The headquarters will be moved to the eye hospital at St. George's Circus. The community health council will cease to exist. From every point of view the National Health Service in Lewisham will be less responsive and further from the people than the unfortunate organisation that we inherited from the right hon. Member for Leeds, North-East (Sir K. Joseph).
Whatever the merits of the reorganisation nationally, locally it has failed on every count. There is also a shoddy tale of deliberately broken ministerial assurances to tell the people of Lewisham. We shall have to monitor what happens under the reorganisation. We shall have to keep an eye on things in Lewisham to make sure that a disproportionate flow of funds does not go to Guys teaching hospital. We may have to set up our own unofficial organisation to do so. We may have to set up our own mini community health council to keep an eye on that. We may have to service those organisations, in which case we could ask the London borough of Lewisham, strapped though it is for resources, to provide us with the odd office and secretary to do so.
We may have to raise on the Floor of the House, on a regular basis, matters relating to the Health Service in Lewisham. I assure the Minister that with two Privy Councillors and the well-known Back-Bench campaigning proclivities of my hon. Friend the Member for Lewisham, West (Mr. Price), there will be no difficulty in doing that on a regular basis.
Where we tread, many others may wish to follow. They may wish to follow our footsteps in respect of their health organisations. I rest my case there. If the Minister proceeds with the reorganisation planned for Lewisham or North Southwark, he has been warned.
§ Mr. Raymond Whitney (Wycombe)
In his opening remarks my hon. Friend the Minister enumerated some of the achievements that he and our right hon. Friend the previous Secretary of State had contributed to the National Health Service over the past two and a half years. I congratulate them on those achievements and urge them to take every opportunity to make sure that the people understand much more clearly than they do now the progress that has been made in the improvement of the National Health Service over the past two and a half—now nearly three—years. However, I sadly remain profoundly sceptical about the structure of the National Health Service. I am by no means convinced that it is the best method of using our national resources to give the maximum health coverage and prevention care to our people.
We must proceed with the improvements that we are debating tonight, but I hope that a more imaginative and far-reaching approach to the problems of health care will always be in the minds of my right hon. and hon. Friends. I hope that the search for examples overseas will go on and that we shall not be put off by the superficial impressions of what is achieved overseas. I do not claim anything like the experience of my hon. Friend, but my impression is that we have a lot to learn.
Tonight we are considering the reorganisation of district health authorities. I join my hon. and learned Friend the Member for Beaconsfield (Sir R. Bell) and my right hon. Friend the Member for Chesham and Amersham (Sir I. Gilmour) in supporting the argument put forward by most of my hon. Friends with such power and eloquence about the drawing of the boundaries, especially in what is known as the overlap area in South Buckinghamshire, south of the M40.
Some of the admirable principles in the drawing of the district health authority boundaries mentioned by my hon. Friend the Minister have been breached. My hon. Friend suggested that he had found widespread agreement and that he and his colleagues in the Department of Health and Social Security had worked on the principle that they would adapt to local requirements.
I reinforce the message of my hon. Friends from Buckinghamshire. In Wycombe there has been no manifest adaptation to local requirements or to local opinions. In Wycombe the view was not as clear-cut as in other constituencies, for which I cannot speak. One view was that the proposals in the new order were adequate. However, the majority view has always been in the other direction. That view is now even stronger.
It is difficult to find any informed opinion locally in medical or administrative areas of our National Health Service that is content with the proposed arrangements. Therefore, I greatly welcome the undertaking given by my hon. Friend to approach the problem in a spirit of flexibility. I urge him most strongly to adhere to that spirit. I look to him to follow up what I took to be his undertaking to have an early review. That is the gist of the message of my hon. and learned Friend the Member for Beaconsfield.
I hope that my hon. Friend the Minister will recognise that the operation has not been satisfactory. It is unrealistic to expect a change at this late hour, but I beseech him to give an undertaking to have an early and sincere review, so that he can respond to local requirements and informed 446 local opinion, and enable us to change the boundaries in a more effective way to meet the health coverage needs of the people of South Buckinghamshire.
§ Mr. Laurie Pavitt (Brent, South)
The hon. Member for Wycombe (Mr. Whitney) will not wish me to follow him and the other two members of the gang of three into the leafy areas of Stoke Poges to hear the curfew tolling and the bell ringing loudly on behalf of his constituents. However, I applaud them for what they are doing. It has, to some extent, been a measure of the debate so far. Although we are trying to look at the overall picture as a result of these three orders, it is inevitable that the starting point for most of our contributions must be the way in which they affect that area of the National Health Service of which we have most knowledge—our constituencies.
I should like to begin, therefore, by mentioning one or two of the problems which affect the Brent district health authority. First, I acquit the Minister of the charges of failing with his general idea of coterminosity in my area because my district health authority is coterminous with the social services department of the borough council. This is essential in view of the increasing numbers of senior citizens. Joint funding and liaison arrangements are totally inadequate when it comes to the way in which our constituents move from one department—social services—into hospital and then out of geriatric wards and back home with home helps. The opportunity has, therefore, been missed in many cases, but, fortunately for Brent, not in mine.
I wonder whether the Minister had in mind, as one of the priorities, that at least in inner cities, where liaison is so important, is was important to try to find a coterminous boundary between the health authority and the local authority. I did put a proposition to him as far as my area was concerned. It might have been a useful experiment if one of the persons appointed by the regional health authority had been not just a member of the local authority, but the director of social services of that authority. That person is dealing, day in, clay out, with the necessary liaison arrangements, whereas the councillor will be serving on a number of different committees, including social services. During the discussions on the appointments of chairmen and members of regional health authorities to district health authorities, it would hake been a useful experiment in one or two instances—perhaps for the next three years—to appoint the director of social services to ensure direct and purposeful liaison.
§ Dr. Vaughan
We have, in fact, recommended that one of the members of the district health authority, where possible, should be the chairman of the social services committee.
§ Mr. Pavitt
I am afraid that the Minister is missing my point. I am asking not for an elected representative—the chairman of the social services committee—but for the local government officer who is in charge, is doing the work and is the servant of the local authority, to be chosen. Such a person could make the liaison between the two bodies more effective, especially when we know that the most important problem is encountered in the estimates for the coming year when expenditure priorities have to be decided. If at that stage of economic and financial planning there could be co-ordination, it would be a great advantage.
447 Still on local problems, I find it difficult to know why a person whose only qualification was that she had previously been a Conservative mayoress should be appointed chairman of the Brent health authority. Many names were put forward—people with knowledge and practical experience of the Health Service from either the medical profession or the social services. I feel that they ought to have been considered. Instead of having to start from scratch, they could have brought to the post a certain amount of knowledge and experience. I have no criticism of the lady herself. I think that she will probably learn very quickly and may make a very good chairman. However, I cannot understand why, when there is a possibility of appointing someone with experience and a number of names are being considered, the Minister should decide to appoint someone without experience.
Turning to a number of general questions arising from the three orders, I should like to pick up immediately the comment made by the Minister about the famous £30 million being saved and his challenge to Professor Townsend. Like my right hon. Friend the Member for Lewisham, East (Mr. Moyle), I feel that I have been through this one before. The Minister made some stringent remarks about Professor Townsend's article. If he had consulted his right hon. Friend the Member for Leeds, North-East (Sir K. Joseph), he would have been told that in 1973 Professor Townsend made a similar analysis and critique of what was going on at that time, and that was totally rejected by the Conservative Party. It seems a little odd, therefore, when the same knowledgeable source makes a knowledgeable criticism, which has been seen to come out right once, that he is now quite certain that it will come out wrong.
I am a little concerned about overlapping on regions. I feel, like a number of my hon. Friends, that the decision that consultants be appointed by regions and not by districts is wrong. What will happen in some of these overlapping areas where a consultant has sessions in hospitals on both sides of the border? Will there be some arrangement whereby one region reimburses the other? How are the estimates worked out in that respect?
I am also concerned about the way in which the attempt to keep full-time consultants in the hospital service has been eroded. I do not know how this fresh arrangement for boundaries will affect this matter. As the Minister knows, at present a consultant may spend only 10 per cent. of his working time outside the National Health Service while still retaining his appointment. There has been a rumour that the Government are about to change that percentage as a kind of sop to the consultants in place perhaps of a rise in salary. I hope that the Minister will put my mind at rest on that.
I am also concerned about the monitoring of the amount of private work done by a consultant under this new arrangement. How does the regional health authority know that the consultant is within bounds? In view of the present dogmatic attempt by the Government to extend private practice—a move which can only erode, especially in acute hospital services, the National Health Service—how is monitoring to be carried out to ensure that consultants are not going over the limit of 10 per cent.?
Publicity for private practice has been accelerated recently. The Minister gave a figure for the administrative costs of the NHS that I found most interesting. I had the 448 figure as 6 per cent., but his figure is even better at 5.14 per cent. In trying to have a comprehensive consultancy service and a comprehensive general practitioner service, why does not the Department give more publicity to the success of the NHS in this regard? The average administrative expense of health services in the other countries of the European Community is 16 per cent.—more than 10 per cent. higher than here. In the Unted States it is 21 per cent.—four times as high. Are we blowing our trumpet, saying what a marvellous organisation we have with the lowest administrative costs in the world for a comprehensive health service? No, we are pretending that it is much better to build a sector of private medicine.
In private medicine in the United States, under Blue Shield and Blue Cross, the poor doctor has to fill up so many bureaucratic forms that our Health Service arrangements for the family practitioner look like heaven. I hope that the Minister will not allows the continual denigration of the NHS to continue. The reorganised pattern gives him the opportunity at all levels to praise what we do instead of constantly putting ourselves down.
I join my hon. Friend the Member for Crewe (Mrs. Dunwoody) in very much regretting the failure to do something about the family practitioner committee. It is nonsense in a comprehensive medical service to divide doctors into different classes—first-class, second-class, third-class, white jackets, no jackets and so on. Therefore, the Government's decision is entirely wrong.
Will the new system affect the present anomaly between those doctors paid by the family practitioner committee as practitioners and the consultants coming under the regional health authority? The anomaly is that one set of doctors have their trade union dues paid for them. The only trade union in the country for whose members the taxpayer pays the annual subscription is the trade union of the general practitioners, whose remuneration is fixed by the review body. The nurses and all other servants of the NHS have to pay their own trade union fees.
What is more, it does not matter whether the GP actually pays the fee to the British Medical Association, because that amount is still included in his remuneration whether he is a member of this trade union or not. I hope that the reorganisation will clear up that anomaly. The Under-Secretary told me this week in answer to a question:We do not reimburse subscriptions for professional and trade union bodies made by salaried National Health Service employees, nor do we think it appropriate to do so."—[Official Report, 16 February 1982; Vol. 18, c. 89.]But the Government do pay the trade union fees of general practitioners. Why is it appropriate to pay the general practitioners' trade union dues and not those of the nurses and other workers in the NHS?
The anomaly is comparatively recent, because it was only in recent years that the BMA became a trade union. It is now a responsible body and follows all trade union practices. It used to have a second body called the British Medical Guild which it pretended was its doppelganger. However, now the BMA itself is a fully recognised negotiating body.
I should like to ask something about the boundaries in the orders. What happens where there are a number of family practitioner committees which do not coincide with the DHA's and where there are joint arrangements? For example, in my area the family practitioner committees 449 combine in a number of different health authorities to have one headquarters in Wembley. Will that arrangement be affected by the orders? Will there be any change as a result of them?
Some changes in the NHS are made by stealth. Recently the forms for consultant obstetricians and gynaecologists were changed, but nothing was done at the same time about the two general practitioners who had to sign abortion forms. It was not until that was revealed that the House knew anything about it.
I am very concerned that since 1969 under my district health authority, previously the district management team, Willesden general hospital has been under threat of closure. I have been fighting that case on the Floor of the House with questions and Adjournment debates since 1969. The whole of the thick pile of correspondence that I have received from the regional health authority and the Department states that everything is temporary. "Temporary" in this case is like the Nissen huts which were put up in the First World War and still exist in my constituency.
Changes go on, and although no decision has officially been made, I see that the Willesden general hospital is now listed as a geriatric hospital. What was a general hospital has been changed by stealth. I am concerned about the way in which that happens. I hope that in the new organisation there will be more accountability, especially when Members of Parliament raise these matters and then find that they have been circumvented, not by any decision by anybody, but because the administrators have carried on as though a decision has been made.
My hon. Friend the Member for Crewe spoke of the niggardly and mean approach to "CHC News", production of which costs £74,000 a year. The NHS budget is now £11,000 million. The Minister and my right hon. Friend the Member for Lewisham, East will recall that when we fought the terrible scheme of the right hon. Member for Leeds, North-East for the previous reorganisation, we feared that the community health councils would be window dressing. To quote my right hon. Friend again, we believed that they might well be watchdogs without teeth. They were, but they acquired dentures and became very powerful. I am very pleased with the work of my local community health council. But the community health councils are under threat, and have been since the present Government came to power. They will suffer if their means of communication with one another is taken away, and it will not be practical under the new district health authorities for them to maintain that organ of communication. This is an attempt by stealth to erode their power. I hope that the Government will change their mind about "CHC News".
I should like a categorical statement from the Minister contradicting the advice recently given to my community health council by the regional health authority that whatever it does it must not talk about, or refer to, matters which are political. I cannot see how any community health council faced with an increase in the cost of prescriptions for the patients it seeks to serve from 20p in 1979 to £1.35 on 1 April 1982 cannot be concerned if it is supposed to be a watchdog for its people. But that issue is political. Is this another example of the authorities seeking by stealth to take away our watchdogs' power of criticism?
Other hon. Members have mentioned the relationship of the community health councils with the new boundaries 450 that have been drawn. I hope that the Government will set at rest the minds of those who give so much devoted service voluntarily in their own time to try to help in their localities.
I am worried about the Secretary of State's announcement this morning that he will now take greater control of health authorities' expenditure. According to a newspaper report this morning, under these orders the Secretary of State for Social Services is following the example of the Secretary of State for the Environment. The headline reads:New powers allow Ministers to intervene".What are these new powers? Can the Minister tell me what orders Parliament has made to give him the power to intervene? Does the responsibility for running the National Health Service that still rests with the Secretary of State under the original Act give him the power to intervene? Are we to have the same position with these new district health authorities and the redesignated regions as we had with local authorities and the rate support grant? If so, that will make nonsense of the Minister's claim that the whole purpose of reorganisation is to give local districts more power to do what they wish to meet the needs of their residents. I should welcome some information on that matter.
The cut in rate support grant is affecting elderly people living alone in my local authority. We do as much as possible to provide free telephones and so on, and in the International Year of Disabled People we spent a fantastic amount of money, despite the cuts. However, because of the public expenditure cuts, money has had to be shaved off projects such as holidays for senior citizens and relief for families by giving grandparents a holiday.
If the same arbitrary limits to expenditure are to be applied to the National Health Service as the Secretary of State for the Environment has applied to local rates it will be a disaster—a calamity. This is yet another reason why the community health councils should be given more, not fewer, teeth.
The debate has raised issues that we have debated many times. For example, I should like to see far more accountability. We occasionally have debates of this nature which enable us to air local problems, and the Select Committee can look at the wider sphere.
It is about time that forward planning and expenditure—the keynote of the proposals—were subject to parliamentary surveillance. However, consideration should be given to the priorities before and not after the expenditure has been made. In that way the House of Commons can give its advice through a Select Committee., or by other means. Only by having an effective distribution of resources, with the right priorities, will these orders be relevant to the people we try to serve.
§ Mr. Charles Irving (Cheltenham)
During my eight years' service in the House I have tried to be courteous and make friends on both sides. I do not think anyone could label me as a troublemaker, a nuisance, a ranter or raver. I have never sought to take on the mantle of "the beast of Cheltenham". That would not suit Cheltenham.
However, for the first time in eight years I am hopping mad. The saga that I am about to unfold—I do so in the area that I know best—illustrates the absolutely shameful way in which Gloucestershire has been treated under 451 reorganisation. I have sat through the whole debate, and, apparently, no hon. Member is satisfied with the proposals.
I am sorry to launch into an attack on the Minister, who is courteous, friendly and polite, although he may not feel that way after hearing what I have to say. Frankly, I am ashamed of the reorganisation of the Gloucestershire Health Service which yet again, for the third time in eight years, is to be reorganised and returned to two districts. The saga is not unlike that of the Mafioso that we see in films. I am disappointed that no pressure or persuasion can extract from the Minister the facts of the situation. Only time and shame will heal the breach. I speak as a former member of both the regional health authority and the area health authority. I value both those bodies greatly. Apparently, however, their service is not appreciated as much as it should be.
Let me give so me of the details. I am not in the habit of taking up much of the House's time, but I want to recount some of the sordid, miserable facts. Following the reorganisation of Gloucestershire into two district health authorities in 1974, it was decided, after full and frank discussions with more than 30 organisations in about 1977, to form Gloucestershire, a small county, into one area health authority. I had discussions at the time with the then Secretary of State, the right hon. Member for Norwich, North (Mr. Ennals), and also with my right hon. Friend the Member for Wanstead and Woodford (Mr. Jenkin). After all the consultations, it was decided at that time that that was the best thing for Gloucestershire. A substantial majority of the bodies that had been consulted was in favour of Gloucestershire becoming a one-district authority. It would save money, it recognised "Patients First", and it was right for the county.
Now, suddenly in 1982, at a time of great economic restraint, my hon. Friend the Minister for Health, aided by the former Secretary of State, my right hon. Friend the Member for Wanstead and Woodford, has decided otherwise. They were good enough to have brief discussions. They had discussions lasting 45 minutes on 15 June with the South Western regional chairman, Mr. Bailey, and the Gloucestershire area chairman, Sir Robert Hunt, to whom the hon. Member for Crewe (Mrs. Dunwoody) referred a few minutes ago, and who has resigned. The Minister for Health joined in the charade, and had 10 minutes with Sir Robert at a social event. It was good of him. He spent only three or four minutes with me outside the Members' "loo".
I was alarmed by the situation, and wrote immediately to the Secretary of State on 17 June. He did a little better than the Minister. He gave me 20 minutes, for which I was most grateful. Then he presented me with a complicated departmental brief that had taken the Civil Service six months to prepare, and asked me to give him my answer the following day, which of course I refused to do. It was really a lot of hocus-pocus. In the pursuit of fairness and justice for my constituents, I spent the weekend preparing a considered reply. I consulted professionals in the Health Service; I wanted to be positive about my facts.
I was told that the splitting of my authority would be bound to cost at least £300,000 and, with inflation, might reach £500,000. It seemed to me that the Ministers' minds 452 were made up. The bubble burst following correspondence, with the resignation by the chairman of the area health authority, following 24 years of dedicated work with the Health Service.
Then came the resignation of Mr. Douglas Grazier, former Labour councillor of distinction. Like Sir Robert, he had given a lifetime of service to the area health authority. These are not men of straw but men of stature and distinction in their careers. However, even worse facts came to light. When I addressed the joint staff consultative committee, which represents 32 different organisations, none had been consulted by the area health authority—which was taken into the confidence of Ministers only at the last moment—or by the regional health authority, or anybody else. The committee was as astonished as I was. It seemed a total negation of democracy, and I felt ashamed about it.
Not only had the area health authority received this scant and shabby treatment, but complaints were received from district and county councils. It was a programme of cavalier treatment unequalled in my 35 years of public service.
Sir Robert Hunt was assured, only in 1979, by my right hon. Friend the former Secretary of State that Gloucestershire would be left in peace at last to settle as a single district authority. So much for ministerial assurances. Not a bit of that happened; the squalid saga continued. Letters from staff unions tried to tempt the Minister to disclose his secret consultations. Letters were exchanged, but not one detail about anyone who had been consulted was revealed; not a word would the Minister utter, not even to me, his old pal.
Gloucestershire, one of the lowest cost value-formoney counties, will receive no extra money from central resources unless the Minister decides to diminish some of his so-called "savings" elsewhere.
The former area chairman—a great leader in industry—sees no economic sense in the decision. The evidence of secrecy is undeniable and, with sorrow, I rebuke the Minister for his action. I praise the Gloucestershire Echo? for its superb leading article clearly spelling out:This reorganisation lacks merit in every sense of the word".I feel distressed that my friends in the unions, hospital organisations and the 32 authorities should, sadly, be subjected to such treatment. I cannot find any words strong enough in the parliamentary vocabulary to portray my anger and disgust. I can only show that by leaving the Chamber, as I feel that that must be seen as the strongest protest I can make.
§ Mr. Frank Haynes (Ashfield)
Bearing in mind what has happened in Gloucestershire, it seems difficult to follow the speech made by the hon. Member for Cheltenham, (Mr. Irving). The Minister seems unable to give us the facts. The hon. Member for Cheltenham mentioned some things about Nottingham, and I shall add to those.
I, and I know many other hon. Members, believe that the Minister for Health is a smooth operator. There is no doubt about that. He could talk and laugh himself out of anything. It is easy to sit on the Government Front Bench and grin at some of the comments made. However, we are debating the serious issue of the health service provided to our constituents.
453 When Ministers stand at the Dispatch Box and have a real go at the trade unions, they frequently talk about "consultation". They constantly say that it is the trade union leaders who make the decisions and not the unions' membership. The Government cannot have it both ways. People holding high places in the medical world, such as administrators, doctors, and consultants have been consulted.
The hon. Member for Abingdon (Mr. Benyon) was in the Chamber not long ago, but has now left. Not very many Sundays ago he stood in Trafalgar Square when it was full of nurses and talked to them. I bet that 90 per cent. of those nurses, perhaps more, were not consulted by the Government or the Minister on what might happen on the reorganisation of the NHS. The biggest mistake of all is for a professional man—a doctor—to be the Minister for Health. The Minister well remembers the question I put to the Prime Minister some while ago on his appointment to that post.
The Minister and people who are supposed to be administering the NHS are wearing blinkers and have one-track minds. I remember attending an area health authority meeting in Nottinghamshire some time ago. I was told by a professor of pathology:We professionals know what should happen and that lay people do not know what is going on.That is what the problem is all about. The Minister wears blinkers and has a one-track mind. I had the same experience in Committee on what became the Health Services Act 1980. It seems to me that some of the promises made by the Government at that time are not being carried out.
More worrying than anything is the fact that representation on these bodies seems to be a case of jobs for the Conservative troops. If I were to attend the next district health authority meeting in central Nottinghamshire, I could be forgiven for thinking that I had arrived at a meeting of freemasons. They are all over the blinking place as members of the district health authority. I often wonder what is going on. Some of them have not a clue about what happens within the National Health Service. Something is happening in the background to ensure that such people serve on these bodies. One of them got the message and resigned. At least that is a start. People are required on these bodies who know what the job involves and who can perform the job correctly. We do not need people who have to be told what to do. They should be capable of getting on with the job in the interests of those whom they serve.
It is easy for the Minister to say that councillors cannot get to district health authority meetings because of their duties as local authority members. I accept some of that argument. If, however, the number of local authority representatives is reduced to four, this means that there will be no representation at all should those four be absent. Under the present arrangement, even if some local authority representatives are not present, there will be others who can attend. I cannot agree with the Minister's argument.
§ Mr. J. D. Concannon (Mansfield)
I agree with my hon. Friend, who has referred to Central Nottinghamshire, that a number of well-known and dedicated people will not in future be able to sit on these bodies. The constituents of my hon. Friend and myself will regard their omission as strange.
§ Mr. Haynes
My right hon. friend is correct. This shows the political flavour that enters into the issue. We should be looking for people who know what the job involves. There are those who have given years of first-class service and who have made first-class decisions in the interests of the people. Now we have another reorganisation. The last reorganisation was a disaster. The right hon. Member for Leeds, North-East (Sir K. Joseph) who was responsible for that reorganisation, has more recently reorganised industry. One need only consider what has happened in that sphere. The nation will be ruined if decisions of this sort are implemented. We are well on the way to ruination.
The decision on boundaries in Nottinghamshire is shocking. It is all very well for the Minister to say that consultation took place. That is rubbish. There are people in Nottinghamshire who were not consulted. The Minister looks surprised. The hon. Gentleman has that little smile on his face again. The consultation took place with professional people, such as the professor who remarked that lay people did not know what the issue was all about. His attitude was "We are the boys who know." The Minister shakes his head. If the hon. Gentleman wishes to accompany me back to Nottinghamshire, I shall prove that people who are interested in the National Health Service and who wish to know the Government's intentions over reorganisation would have expressed an opinion if they had been consulted.
Many people in Nottinghamshire, which has a population of 1 million, have not been consulted. The Minister preached to me during the progress on the Health Services Bill in 1980 that he wanted smaller units so that issues could be handled closer to people in the locality. Yet two district authorities in Nottinghamshire are to be converted into one. The new authority, with responsibilities towards 600,000 people, will be massive and a mile removed from those people. This change cannot be described as a move to give people their services locally. Elderly people especially will experience great difficulty. Some elderly people have been present at the House of Commons today. They have mentioned the travelling that will be involved under these National Health Service proposals. The Minister should heed the cry that comes from Nottinghamshire. Hon. Members representing Nottinghamshire constituencies, who agree with what I say, are present for this debate. If it is not too late, I hope that the Minister will take on board the views that I have expressed.
I am convinced that the previous Secretary of State for Social Services was dedicated to getting rid of community health councils. However, following pressure from outside, he changed his mind. The Minister for Health agreed with the previous Secretary of State, but people outside beat them. The community health councils are performing a first-class job. I spent a number of years as chairman of a community health council.
§ Mr. Haynes
I thank my right hon. Friend. Community health councils do a first-class job. It was a mean decision to take away their £74,000. With that amount removed from their budgets, the community health councils will go short of something. This may affect the necessary consultation that takes place with the people whom they represent.
455 I have been encouraged by hearing criticism from the Government Benches of the reorganisation of the Health Service. I hope that the Government will heed some of the ideas that have been proposed, with a view to implementing them. Hon. Members do not represent themselves here. We represent the people outside. It is the people outside who pay taxes and national insurance contributions. Their voice should be heeded to a greater extent than it has been over the last three years. If hon. Members listen to them and implement what they want, we cannot go far wrong.
§ 7.8 pm
§ Mrs. Jill Knight (Birmingham, Edgbaston)
No one can say that this is a dull debate. There was, however, a period when our wide, soaring discussion became bogged down in a Lewisham lay-by. Hon. Members were also conducted along a Buckingham byway and taken on a visit to Brent. It was the hon. Member for Brent, South (Mr. Pavia) who made the statutory attack on private health care. I would not wish to be drawn down that lane. My own feeling is that everyone should be thankful for the number of people prepared to pay for their own health care, despite the fact that they have already paid fully in taxes towards the National Health Service. I fear that the NHS would be in a difficult position if it had to cope with the patients who are presently in private health care.
I put it to the hon. Member for Ashfield (Mr. Haynes) that it is an unfortunate fact of life that when one political party takes one course, which it follows fervently, there is a reversal of policy when another party takes power. It was the Labour Party which made a clean sweep of all the representative appointees in the Health Service and the volunteers who worked for different parts of the NHS. It is a regrettable fact that one party takes one course and the party which follows it takes another. Nobody should be surprised about that.
§ Mr. Leslie Spriggs (St. Helens)
The hon. Lady appears to be saying that when a different party takes power it reverses the legislation of the party formerly in power. The Minister issued a leaflet to area health authorities drawing their attention to the need for care for patients first. No hon. Member should want anything other than the best possible care for patients in the NHS.
§ Mrs. Knight
I am sorry to tell the hon. Gentleman that that was not the line that his party took. Obviously I did not make my point clear. When in office the Labour Party made a clean sweep of people who had worked for many years in area health authorities. This Government have not made a clean sweep. However, there is an inevitable reaction when one knows that certain political appointees have been placed in certain positions. It has nothing to do with health care. I am sure that there is no difference between the Opposition and the Government in their genuine desire for good health care.
§ Mrs. Dunwoody
Is the Lady saying that Ministers have changed appointments to district health authorities on a political basis?
§ Mrs. Knight
I am not saying that. What I am saying is that it is inevitable that there should be some reaction when appointments are made on a political basis. There are many examples of that. When Labour Party candidates 456 first appeared in local government which had hitherto not been conducted politically it brought politics into local government. It is a fact of life.
I want to ask my hon. Friend the Minister about various costs in the NHS. I agree with my right hon. Friend the Secretary of State that every pound spent unwisely and wastefully on the NHS denies a pound for good service and good patient care. I was amazed to notice a certain amount of hilarity and mirth among Opposition Members when my hon. Friend the Minister mentioned saving £30 million. They rolled about on their Benches. Is £30 million a humorous figure? Do they think that it is not possible to make that saving? Is it too much or not enough? The reason for their humour escapes me.
Does not my hon. Friend think that £30 million is a rather small proportion of the overall costs of the NHS? I had some difficulty discovering the exact overall sum spent annually. The 1981 public expenditure White Paper states thatthe resources available to the National Health Service have risen in real terms from £8,850 million in 1978-79 to £9,156 million in 1981–82.Only yesterday someone made some terse remarks about the way in which the House expresses itself in various papers. No wonder! I do not understand the meaning ofthe resources available to the National Health Service.Have we spent the resources available? Some estimates show that spending on the NHS is higher than that. I was given a figure of £13,000 million a year. Perhaps my hon. Friend could clarify that figure. If it is correct, £30 million is a rather small amount to save from such a gigantic total.
A great deal is said about our free NHS. Another set of figures reveal some astonishing facts. For the so-called free service a married man with two children and on the average wage contributes through direct and indirect taxation no less than £1,000 per year for his "free" service. Therefore, we are discussing everybody's money. It is important that it should be used with the utmost care. The official mind should remember that patients and improving patient care matter more than anything else in the NHS.
My hon. Friend said that we should save on management costs and that there would be a search for maximum efficiency. Do those management costs include the tremendous burden of drugs? My research has led me to become more and more convinced that we spend far more on drugs than is sound or wise. Not too many weeks ago a woman walked into a chemist's shop with a large bag and a determined expression. She emptied bottle after bottle of pills and potions on to the counter. She was being public spirited. She said that they had been prescribed by her doctor but that she did not take them. The pharmacist worked out that the cost of the drugs was more than £1,200. Why was the woman prescribed those drugs?
I am not suggesting that most general practitioners are not excellent men. However, I am becoming convinced that many doctors get rid of patients who are a nuisance by prescribing drugs. That is not good patient care, and it is extremely expensive for the NHS.
I was told by a senior doctor who worked in health care prior to the NHS, throughout its existence and still works in it that the way in which medical care is structured and financed encourages bad doctors. I have no doubt that the overwhelming majority of doctors are excellent, but I am most anxious about that statement and all that he said to back it up. Perhaps I can disuss the matter with my hon. Friend the Minister later to avoid delaying the House.
457 There is little effective control of spending in the NHS. I am convinced that there is still great waste in hospitals on the drugs bill. Can the Minister assure me that no further economies can be made in this respect or that the scope for them has been exhausted? I am aware of the importance that the medical profession attaches to the freedom to prescribe, but I cannot help thinking that we have sometimes allowed that freedom to become a sacred cow. It is a highly expensive animal, and I am by no means certain that hospitals are not the greatest abusers of the money available to be spent on drugs.
Not long ago there was a scandal about the amount of stealing from hospitals. It is strange and sad that people who would never dream of stealing from ordinary citizens see nothing wrong in stealing from the State or from a nationalised industry. It has been said many times that an immense quantity of articles, such as sheets, disappear because people feel that they do not belong to anyone, and I fear that the cost of such losses may be substantial.
There is also the question whether we are spending money wisely in, for example, keeping elderly people in hospital beds. I have always felt that it is wrong to force elderly people who wish to remain in their own homes to leave them and go either into care in an old persons' home or to a geriatric hospital. We are sometimes arrogant in the way in which we impose our own standards of how we think that they should live. All that really matters is that elderly people should be happy, able to stay in their own homes for as long as possible and given every assistance to do so. That again is a matter of cost within the NHS, but if it could be achieved the rather unkindly termed "elderly bed-blocker syndrome" might be solved.
§ Mr. Deputy Speaker (Mr. Bernard Weatherill)
Order. These are important matters, but perhaps the hon. Lady will confine her remarks to the reorganisation of the health authorities.
§ Mrs. Knight
I ask for your forgiveness, Mr. Deputy Speaker, if I have strayed. I understood that one of the subjects under debate was costs. I was referring to management costs within the NHS and how matters could be improved.
Will my hon. Friend the Minister examine the possibility of departmental budgets in hospitals? I understand that University College hospital has adopted this system with remarkable savings and gains in efficiency. I realise that it is extremely difficult to apply that process everwhere, as some departmental heads are bound to disagree. Nevertheless, perhaps the Minister will examine the benefits accruing to costing in the NHS through departmental budgeting systems which have already been adopted.
Spending wisely in managerial and all other aspects of the NHS is vital to the interests of patients and to the care that they receive.
§ Mr. James Lamond (Oldham, East)
The Minister must be feeling a little bruised, having been subjected to some fairly severe mauling not only by the Opposition but by Conservative Members. I do not aspire to match the attack made by the hon. Member for Cheltenham (Mr. Irving), who showed his anger by leaving the Chamber as soon as he had finished speaking. Indeed, I do not wish to attack the Minister at all, but to be as constructive as I can.
458 The right hon. Member for Chesham and Arnersham (Sir I. Gilmour) said that the Minister had presented his arguments with an air of genial self-congratulation. That is not a bad phrase, and I do not entirely disagree. I would certainly say that he presented his arguments with unwarranted self-confidence. Indeed, some of us recall earlier Parliaments when other Ministers appeared at the Dispatch Box with every confidence in their proposals for the Health Service.
When we discussed the matter in 1973, I felt that I knew something about it as I had worked in the Health Service for 16 years. I was well aware of its shortcomings, because nothing is perfect, but I realised that there were many dangers inherent in the proposals put forward by the Conservative Government at that time. As we now see, after a comparatively short time, they have come to realise that a fairly fundamental reorganisation of the structure is necessary.
I shall not make constituency points about the changes in membership of the area authority that will result from the proposal for a district health authority in Oldham or about the district that it covers. Following the comments of the hon. Member for Birmingham, Edgbaston (Mrs. Knight) about the increased efficiency that the Minister expects to flow from the reorganisation, I trust that that must mean better value for money and an assurance that money will not be wasted or lost to the Health Service..
Will the Minister consider the following case and perhaps tell me later in a letter whether he believes that the proposed changes will lead to such increased efficiency that such cases will not occur in the future? About two years ago rumours began to circulate throughout Oldham that the 200-bed Strinesdale hospital was to be closed and that the area health authority was seeking the views of doctors and consultants in the area on whether they saw any future use for it or whether it should be closed.
There was, of course, considerable local resistance to the proposed closure, headed by the trade unions organising all levels of staff at the hospital. They saw myself and other Members for the area and asked us to carry out investigations. We did so. We asked the area health authority for explanations and it assured us that, after fully considering the matter, its view was that there was no further medical use for a hospital in the area and that it would be closed. That was despite having spent £31,000 on the hospital two years earlier to upgrade it.
The hospital was closed in October 1981 and the regional health authority began to look around to see whether anybody would like to buy it. The people of Oldham are considerably concerned, because it appears that a consortium of local doctors are interested in buying the hospital to provide a private service. Are they the doctors and consultants who were asked whether they could envisage any future medical use for the building? I am not saying that they are, because I do not know, but that is the question that is being asked in Oldham. If they were asked about it, why did they say that they could see no further use for it, when they seemed to take art interest in it as soon as it came on the market?
The Minister may think that this is all gossip, but an editorial in the Oldham Chronicle, which is a pretty responsible daily newspaper, stated:Finally, there is good reason to believe—indeed we could name names—that a consortium of local doctors are somewhere in the background, especially when the development company talks of turning Strinesdale into a private hospital.459 Is the building to become a private hospital? If so, and if it is used by consultants to treat patients and the patients at some stage require more sophisticated medical attention, can my constituents be assured that the consultants' patients will not be taken into National Health Service hospitals to receive that more sophisticated treatment and be placed at the head of the queue for treatment before many of those in Oldham who have been waiting for many years?
The Minister may ask "What has this to do with saving money in the Health Service?" A second and equally important matter is that it was decided to put the hospital on the market. As I have said, it is quite a large hospital with 200 beds. The building is not in first-class condition, but £31,000 was spent on it to try to bring it to a reasonable condition only two to three years ago. It stands in fairly extensive grounds. I understand that they amount to 28 acres.
Large headlines appeared on the front page of the Oldham Chronicle. One read:Strinesdale Hospital sale: calls for an inquiry. Oldham councillors have demanded an inquiry into the procedures surrounding the sale of Strinesdale hospital. Health union NUPE also made a similar call because they believe that a six-strong consortium of local doctors may eventually be involved if the building is used for private medicine.The article continues:The hospital buildings and grounds were sold privately for £17,500.That was the price for a 200-bed hospital standing in 28 acres. It was sold for that priceafter an auction in Manchester failed to attract any bids. And it was recently revealed that the North-Western Regional Health Authority turned down a better offer than the sale price in the hope that the property would fetch more at the auction.Councillor Jowett revealed at a meeting of the Oldham area health authority that the better offer was £25,000. It is believed that the better offer of £25,000 which was turned down, was made by the same consortium, which was able later privately to buy the hospital for £17,500.
The Minister has said that one of the reasons for reducing the number of local authority representatives on the new district health authorities was that elected members of local authorities had little time to devote to that extra task. I suppose that there is something in that, because I know how busy they are already. However, that did not seem to be the case on the evening of 2 February 1982. A number of councillors were present at a meeting of the area health authority and they seemed to be those who were most critical of the decision. It must have cost the NHS hundreds of thousands of pounds when the buildings and the grounds were disposed of for such a small sum.
Among those who were critical was Councillor Brierley, Labour, who said thatthe committee was also anxious to know who the buyer was.Councillor Charles Tucker commented:There is a considerable amount of local disquiet about the Strinesdale affair, and there are a number of questions which need to be answered. Who is the new owner? Was a better offer than the sale price received? Was there or was there not a reserve price?One of the most critical of the councillors, if the House should think that I am quoting only Labour councillors who were present in some number, and one of the most 460 vociferous critics was Councillor Albert Jowett, a prominent Conservative member of Oldham metropolitan council, who said:I watched 'Sale of the Century' on television—but this was the give away of the century.He was referring to all the property and land being sold for £17,500. What would one get for that on the property market today? In London it would not be possible to buy a one-bedroom flat, or anything like it, for that sum. However, National Health Service property was disposed of for that amount, and disposed of in a way which, at the end of the day, will be detrimental to the health provision for my constituents.
I wonder whether the Minister is confident that the new authorities that he is setting up under the orders will be sufficiently strong, efficient, knowledgeable and determined to ensure that that sort of thing does not happen again. Will the Minister set up an inquiry into this issue?
§ The Under-Secretary of State for Health and Social Security (Mr. Geoffrey Finsberg)
First, the hon. Gentleman asked about ownership. It was a sale to a company and, therefore, one would not know who the individuals were. Secondly—this is much more important, because councillors should know better than to make allegations without foundation—the sale price was arrived at by the district valuer. As the hon. Gentleman knows, Government Departments, nationalised industries and local government obtain a valuation from the district valuer when they are disposing of assets or purchasing. The district valuer's figure was nowhere near the hundreds of thousands of pounds that have been talked about. Those comments are rubbish, because much depends upon planning. The hon. Gentleman will know from a press release that was issued either yesterday or today by Mr. Sidney Hamburger, the chairman of the North-West regional hospital authority, that the reserve price put on by the district valuer of £25,000 was not reached at the auction. It was decided to take the best available offer after that.
§ Mr. Lamond
It is obvious that the Minister has knowledge of this, and I am not surprised, because it has aroused considerable interest beyond Oldham. For example, The Guardian carried some articles about it. I accept what the Minister says, and I have read Sir Sidney Hamburger's press release, but it is worth looking at how it came about that after not reaching the reserve price of £25,000—I am not sure what the reserve price was; some questions were asked about that—the building was sold for less. There was planning permission with the sale, although no planning permission is necessary if the building is still to be used as a hospital.
The Minister must surely concede that it is worth looking at the matter to see whether there were any shady practices, because, in any event, there are strong rumours in Oldham about what has happened. In the long run it can only be detrimental to the Health Service, to the consultants involved, to the doctors engaged in it, and to the Health Service staff, both at regional and area board level, if matters are not cleared up to the satisfaction of the people at Oldham. We want to strengthen and improve health services. That is what the debate is about. The Minister owes it to the Health Service to look into the matter and have an inquiry.
§ Mr. W. R. Rees-Davies (Thanet, West)
It is natural in this type of debate to have a number of constituency speeches about the orders as they affect certain parts of the country. We have certainly had one from the "Cheltenham Flier" on the Conservative Benches, although my hon. Friend the Member for Cheltenham (Mr. Irving) does not usually fly that way. We have also heard from the hon. Member for Oldham, East (Mr. Lamond) about parochial matters, and from a few others.
I shall be brief. First, shortly after I had broken my leg and managed to get back to the House, the Speaker at the time was good enough to call me immediately to speak. I advocated extremely strongly the abolition of the area health authorities, and I am delighted that that has, at long last, been achieved. That was three years ago and the following year it was adopted as Government policy to carry it into effect, which shows how long the consultations have been going on and the efforts that have been made to try to achieve agreement throughout the country.
Speaking for Kent, and for my own part of the world, I think that the Government have done extremely well. They have done so because we now have truly district health authorities which are infinitely more local. So local will they be that the 16 representatives, plus the chairman that we shall have, will represent a great many local interests.
My hon. Friend the Member for Canterbury (Mr. Crouch) is no longer here, but he was until a moment ago, and he is a member of a regional health authority. We recognise that there is complete agreement with all the district health authorities throughout Kent, which is a big county. They are the right size to maintain local autonomy, and at the same time they are large enough to be an effective area of the community from the point of view of hospital needs, which must come first. The medical question must be top priority.
By setting up these district health authorities we shall have a much greater opportunity to tackle the real problem in many parts of the country, and particularly in Canterbury, and Thanet district, that of hospital waiting lists. I know that the Secretary of State wants to tackle this problem. My case is that he cannot tackle them all at one and the same time. There are bound to be some areas that will progress more rapidly than others, but it is a priority for the Government.
There are large numbers of retired people in my area and we have long waiting lists, particularly because of the large amount of surgery that has to be done. There are many new types of surgery, such as hip replacement. In Canterbury, Thanet and East Kent a disproportionately large number of people are waiting for surgery, and have been waiting for between two and four years. We have a local problem, in that we want to ensure that we have immediate additional surgical opportunities by having additional surgeries in Thanet. Nowadays, that can be done by putting in one of these units, which can be done relatively cheaply. This is particularly important when there are elderly people who have been waiting a long time. It is essential for them.
By splitting what is proposed down to district health authorities, the Government are well within their objective of at least a 10 per cent. cut in administrative costs. When the area health authorities are abolished, we have to make 462 sure that we do not make the mistake that we made with the reorganisation of local government. Unfortunately, in most cases there were not the staffing and administrative savings that there should have been. I remember the leaders of the Thanet district council telling me that they had to make sure that they made the cuts early, otherwise other appointments would be made and nothing would be saved. In the end, little was saved.
The Government must monitor this change very carefully. If need be, they can call on the Select Committee on Social Services, which is ready at any time to consider the matter. I say that as the Conservative leader of that Committee. We have to see that we obtain the cuts that we expect from the abolition of the area health authorities so that money remains to benefit other aspects of the services, and in particular aspects that will ensure that the cuts are made.
We in the Select Committee went the whole hog and recommended that virtually all appointments should be by the district health authority. The Government carefully considered that and came to the conclusion that the consultants should be appointed at regional level. It is a finely balanced argument. I do not say that the Government are wrong. My view was to the contrary, but it is a finely cut argument. What is essential is that the regional health authorities have sufficient consultants and that the specialist consultants, such as neurologists, dermatologists and so on, can cross the boundaries of the district. That is probably why they will be proved right, because if the region looks at the consultant picture clearly it will be able to see whether there can be shared consultants across the board.
At the same time, it is essential that these new designate chairmen should take on their duties and make sure that no unnecessary appointments are made to their staff. At the moment such appointments are made in many instances and this is the last opportunity to make sure that they do not over-appoint. It would be better to under-appoint now and keep some reserve appointments, so that in a year or six months they can consider whether to make other appointments.
§ Mr. Pavitt
Is the hon. and learned Gentleman aware that because of the 1 April deadline a large number of consultant posts are being held vacant, especially for professors at the teaching hospitals? As a consequence there are growing waiting lists because of the lack of consultants, who have to wait for the 1 April deadline.
§ Mr. Rees-Davies
That is right. There are twin aspects of this. The appointments should be reserved so that the new powers will make them. They will make them quickly enough to cover what they see as the necessities. That will come about with the complete understanding of Local needs, which we shall have in each of the orders.
The other point to which the hon. Gentleman referred arises because all the hospitals, especially the universities, must consider the medical cuts. As a result of my interrogation of the chairman of the University Grants Committee this week and the chairman of the Hospital Doctors Association, I recognised that the medical cuts arise almost entirely from the delay in permitting any increase in the number of medical students. The intake has been frozen at the 1980 level, which will enable us to carry some of the cuts. We must he careful to ensure that those 463 cuts do not fall in the wrong spheres and, more especially, on the specialist departments, which would then be in difficulty.
The UGC, the Hospital Doctors Association and the Department, together with the regional and district health authorities, can ensure that we do not have cuts in the areas where services are needed and that we can maintain a service that has increased immeasurably, not only in the amount of money spent in the National Health Service, but in the numbers of doctors and nurses. With the recommendations that we hope will be accepted by the Government, we shall have more consultants and a better balance in the years ahead.
§ Mr. Andrew F. Bennett (Stockport, North)
The hon. and learned Member for Thanet, West (Mr. Rees-Davies) seemed to be complacent about the damage being done by the cuts in medical education. The message that came out of the Select Committee's inquiry this week was the lack of liaison between the Department of Education and Science, in imposing cuts on the universities, and the Department of Health and Social Security in the way in which those cuts are fed through to the service.
However, I congratulate the hon. and learned Gentleman on being the first—other than the Minister—to give wholehearted support to the measures. Almost everyone who has spoken tonight has been critical of the orders. The orders demonstrate the Minister's motto—that one should fit people to the bureaucracy rather than make the administration serve the people. The orders are irrelevant to the needs of the hospital service. When the Minister introduced them, he said that during his period in Opposition he had gone round Britain and that everywhere people had complained about the system. In the Labour Party in 1973, people were predicting that and telling the Government that the reorganisation of the Health Service would produce problems. The Minister should not have been surprised when he found those problems. The problems were found in those places that had a district, an area and a regional authority. However, there were also problems in those places where there was only an area and a regional authority. Nothing in the order helps the two-tier areas as opposed to the three-tier areas.
It is important that we consider the areas in which people resent the bureaucracy in the Health Service. The vast majority of nurses and ancillary workers feel that they are undervalued and underpaid compared with others in the community and some administrators and consultants in hospitals. They feel that they should have more recognition for their essential role. Nurses are very bitter that they cannot earn a decent wage unless they stop nursing and go into administration. The rates of pay for people who are qualified but who are not in charge of a ward are very poor. Even a ward sister is not paid well, but, if she moves away from nursing towards administration and becomes a nursing officer or a senior nursing officer, the salary scale is much more attractive. If the Government are talking about reorganising the Health Service, the first thing that they must do is to ensure that the people on whom the service depends—the nurses and ancillary staff—are paid a decent wage.
When I talk to patients about bureaucracy in the Health Service, the one matter about which they are all upset is 464 the time at which they are woken up in the morning. They find it amazingly bureaucratic that they must be woken up in the last hour of the night shift. The nurses have been there all night, but they are expected to work hardest in the last hour of the shift getting patients up at a time when most people wish to have another hour's sleep. The patients are awakened much too early because of the bureaucracy that has developed and the way in which hospitals seem to be run for the benefit of the consultants, not for anyone else who works there or for the patients. It is sad that nothing in the order suggests that the new authorities will do anything to ensure that patients are given some consideration.
I bitterly regret the fact that the orders have not increased the number of local council representatives. Unfortunately, nothing has been done to ensure that those who serve on a district health authority live in that district and experience the services that are provided. There has been mention of persons who live outside or who have never lived in areas being appointed as chairmen of those areas. For example, Stockport had an excellent chairman of the area health authority. Instead of appointing him to the new district health authority, the Minister—perhaps for political reasonsdecided to bring in a new man. I have no doubt that the new chairman will do a good job, but it is a sad fact that he lives in Salford rather than Stockport. I am sure that he would have been pleased if he had been appointed in Salford, although he is probably not complaining too much about being appointed to Stockport. However, it is crazy to bring a person from one area to become the chairman of another.
We must all be concerned about the participation in the democratic process of those who work in the Health Service. At every level, consultants play the key roles. Those who work in the Health Service are kept out and are given no opportunity to participate in the way in which matters are run. A nurse or an ancillary worker has as much knowledge of and as much to offer in the running of a hospital as a consultant. However, in far too many hospitals the consultant is still given preferential treatment, and often he does not really see the problems.
Unfortunately, the Health Service is not delivering the goods. It is simply patching up when things have gone wrong. The vast amount of money that is spent on the hospital service is an admission that we have failed. We are not keeping people in good health. We should give resources to the prevention services to try to stop people becoming ill, and to the primary care services of family practitioners and community health services. Yet we are not integrating those services. In the order we are still saying that the family practitioners' committee shall be autonomous. Yet many hospital doctors say that they must admit too many patients to hospitals because of bad treatment or lack of treatment from family practitioners.
I have talked to three constituents recently, all of whom told me that they have been prescribing drugs for themselves. They go to the surgery and say to the doctor's receptionist "Those are the drugs that I have been on. Please can I have the same again?" So they get the same drugs again. It may be that some of those people are observant and know what is happening to them because of the drugs that they are being given. In that case, if they saw the doctor themselves, they would simply assure him that they were receiving the right treatment. But, increasingly, the people I have come across are elderly and are a little reluctant to admit that their grip is not as firm 465 as before or that they cannot get about so well. Those people are also diagnosing themselves. Some of them end up in hospital because the doctors have got the drug dosages wrong. The hon. Member for Birmingham, Edgbaston (Mrs. Knight) said that some doctors give out too many drugs.
To improve the liaison between the family practitioner and the hospital, one authority should bring the two groups together to identify and iron out the problems. The independent family practitioner committee is not in the best interests of the service. I stress that in my constituency some family practitioners provide excellent services for the elderly. However, some of them do not.
There are problems up and down the country. I went to a Campaign for the Homeless and Rootless conference in Leeds on Saturday. It was clear that those who run hostels for the homeless and rootless often find it difficult to get a doctor to give regular medical treatment to many of the elderly who use them.
It is also sad that in all the talk about reorganisation the Government will not debate the recommendations in the Black report, which stresses the inequalities in health care throughout the country. Whenever the Government are asked for a debate on the Black report, they say that they are not interested. It would have done much more for the reorganisaton of the Health Service if the Minister had said that he would take notice of the Black report and do something positive to remove the inequalities in health care in Britain.
I think that it was my hon. Friend the Member for Brent, South (Mr. Pavitt) who pressed the Minister to tell the House what was in the statement that was reported in The Guardian and was given to the House about a fortnight ago about the Secretary of State having a greater role in imposing his policy on the regions. Will he announce the abolition of the regional health authority? Will the Secretary of State take over? I hope that the Minister will tell us a little more about that later.
My hon. Friend the Member for Oldham, East (Mr. Lamond) developed the argument about the Strinesdale hospital, which is causing a great deal of concern in the Greater Manchester area. A similar situation could develop in Stockport. It illustrates the problem that exists in the present organisaton of the Health Service, and we fear that it will not be remedied by the orders. In a brief intervention, the Minister seemed to suggest that everything was peffectly all right because there had been a press release by Sir Sidney Hamburger on behalf of the regional health authority and that had solved the problem.
I assure the Minister that the problem will not go away. Sooner or later we must have a statement in the House about the principles involved. Let us consider the Strinesdale hospital. The area health authority had discussions about the cost of running the hospital. That is odd, as £31,000 had just been spent on it. In addition, not all the beds were being filled. Discussions were then held with the doctors and consultants as to why—when there were long waiting lists in the Oldham area for the treatment of patients—they were not prepared to have their patients in beds at Strinesdale. Apparently, the consultants said that the hospital was inconvenient, that it was a long way from other hospitals and that they did not like travelling backwards and forwards. They said that there were beds, but few other facilities, and that the chronically sick could not be treated there because they may need the sophisticated support services in the main hospital. We 466 understand that that is what the consultants said. We should like to know those consultants who told the area health authority that the hospital was unsuitable.
What was the area health authority told about the amount of money that would be saved? The day-to-day running costs would obviously be saved. I believe that one of the arguments was that there would be nurses available for other wards. I understand that the area health authority was also told that the closure of the hospital would release a valuable asset which could be sold, and that the money could be used to improve the Health Service facilities in the Oldham area.
All those points were put to the area health authority. Despite trade union opposition, particularly from some of the groups representing the nurses and ancillaries in the hospital, the closure was agreed. The amazing thing is that, although the area health authority took the decision, the disposal of the land is not its responsibility. It cannot try to realise as much as it can or decide, if sufficient money cannot be realised, to continue hospital services. It must hand the asset over to the region, which will then dispose of it.
When the hospital was put up for sale, a reserve was put on it. Presumably the reserve was the district valuer's price. However, it was then sold for £7,500 less than that. Given that £31,000 was spent only a year before, it is odd that it should be sold for only £17,500. When people asked who had bought it, they discovered that a consortium of consultants had done so. The Minister should tell us whether that consortium consists of the same consultants who were asked by the area authority during the previous two years whether they could use it for their National Health Service patients. The consultants refused because the hospital was too distant and had insufficient facilities. If they are to start using it for private patients, we must ask whether they will put in the sophisticated facilities that they claimed the NHS could not afford. If not, what provision has been made for the safety of patients? If A is practical to transport private patients from the hospital to the area health authority's establishment in the centre of Oldham, why was it impossible to do that for NHS patients? The Minister should consider those serious and disturbing points.
I understand that the area health authority was told that the matter was no concern of the consultants and that they know nothing about it. However, I am told that letters from some of the consultants to the area health authority asked about the arrangements that could be made for transporting emergency patients if a private hospital could be set up. Therefore, the matter is serious and rightly causes us considerable concern.
The problem affects others in the Greater Manchester area. Stockport has a similar hospital at Marple Dale. It is an old tuberculosis sanatorium, just like Strinesdale, and it is not convenient for or close to the main hospitals. As a result of the reduction in the number of patients in hospital for tuberculosis, the number of beds occupied has fallen. Stockport area health authority has asked local consultants why they cannot use the beds at the Marple Dale hospital. They have replied that it is inconvenient and has not got the facilities necessary for the sophisticated treatment of patients. They have said that it would be better to close the hospital.
Stockport area health authority has brought forward proposals for closing the hospital. My constituents point out that the consultants had the biggest say and claim that 467 they cannot use it. They want to know whether the region will put the hospital up for sale within the next few months and whether a local group of consultants will wish to buy it and to open it as a private hospital. If that happens, the Minister will have a major scandal on his hands. It is ridiculous to ask consultants, in their capacity as employees of the National Health Service, whether they can use the facilities. The consultants can say "No", but at the back of their minds they may be thinking that they will be able to buy the hospital in a few months—perhaps cheaply—and use it for private medicine. That causes great concern.
There is great concern in Stockport because another private hospital, the Alexandra, has just opened in another part of the town. The nurses tell me that some patients are being transferred from the private hospital to the Health Service hospital when the Alexandra has not the facilities for the full treatment of the patients. This happens when the complaint that the person is being treated for is more serious than was expected or when the doctor who did the operation made a mistake and the patient's condition has deteriorated.
A further disturbing point is that when I have put down questions about the Alexandra, the Minister has refused to answer the allegations that are being made. Also, he will not give clear guidelines as to whether it is ethical for a consultant who is treating a patient in a private hospital to transfer that patient into an NHS hospital and to go on treating him not as a private patient but as an NHS patient. Such a consultant is working in a dual capacity, most of the time in the Health Service and part-time as a private consultant.
If a patient has to be transferred because of neglect or lack of facilities in a private hospital, it is essential that that patient should be treated by a different consultant. The Minister must answer to the House how far private medicine is being allowed to feed off the back of the National Health Service. A few individuals who can pay for operations in private hospitals are in a privileged position because they know that if anything goes wrong they can use the back-up of the NHS hospital.
I do not believe in private medicine, but, if we are to have it, it must stand on its own feet and not feed off the back of the National Health Service. I hope that the Minister will tell us what he proposes to do about the scandal in Oldham, where private consultants have been allowed to rip off the Health Service by buying a valuable asset at a giveaway price, and how he will ensure that the same thing does not happen in regard to Marple Dale in Stockport. Most important, I hope that he will tell us how the orders will improve services for the patient, improve the health of people so that they do not need hospital services, and eliminate the grave discrepancies in standards of health and life expectancy up and down the country which were highlighted in the Black report.
§ Mrs. Sheila Faith (Belper)
I am pleased to speak after the hon. Member for Stockport, North (Mr. Bennett), a colleague on the Select Committee on Social Services, and to have the opportunity of speaking in the debate. As has been said in the debate, resources have risen in real terms in the National Health Service. More has been spent on capital building projects and on the National Health 468 Service generally. Also, waiting lists have been reduced and there are many more doctors, dentists and nurses operating in the service. Nevertheless resources are becoming more and more strained because during the last decade there has been increased technical innovation in medicine. Surgical treatment is possible for heart diseases, arthritis and many other common disorders which were formerly treated by rest and medication.
The 1970s also saw the growth of organ transplants which are now routine treatment. New ways have been found of saving the lives of new-born babies. On the other hand, people are living longer. All this has put extra strains on the National Health Service budget. Therefore, it is important that the finance available should be spent on patient care and as little as possible on administration.
After reorganisation in 1974 many complaints were made both by the medical profession and by the public about red tape and cumbersome administration. Every new action required extensive form filling and numerous meetings. The Royal Commission in 1980 found that there had been a decline in the quality of hospital administration and thought that the process of consultation had proliferated unduly, particularly in the medical profession.
The Royal Commission concluded that there were too many tiers of administration in most places. Acting on that the Government produced a document on administrative reform called "Patients First" which said that area health authorities would be removed and new district authorities have the functions of both previous area and district authorities. Once this is enforced not only will it mean the removal of duplication and a reduction in the number of bureaucrats but decisions will be brought closer to the community and should be more responsive to local feelings and needs.
I was delighted to be a member of the Standing Committee which looked at the enabling Bill and I welcome the provisions. After provision has been made for redundancy payments and early retirements there should be substantial savings of about £30 million or 10 per cent. of administration costs. When a highly esteemed hospital in my constituency was threatened with closure—a threat now removed, the hospital having reopened—it was felt that the cost of administration in Derbyshire was excessive at the time the hospital was being closed, yet it was not easy to extricate administrative costs from other costs nor to compare the costs of one authority with another.
I welcome particularly the fact that each authority will have completely separate budgets for management and for patient service. I am delighted that for the first time we shall know locally how much is being spent on administration. In future costs should be easier to control and reduce. For the most part, therefore, the new organisation will be a great improvement, although we can understand that in an organisation of this dimension there must be difficulties in some localities.
Concern is being felt in the dental profession about the effects the changes will have on the organisation of community medicine. At a time when the profession is worried about increased charges and also that possibly a smaller proportion of the National Health Service budget may be being spent on dentistry, this is an extra matter of concern.
Community dentistry still has an important part to play, particularly in working with the handicapped and long-stay hospital patients. In certain deprived regions, such as 469 Trent, there is a shortage of dentists and some parents still do not understand the need for regular examinations. Therefore, there is still a need for a high proportion of children to receive examination at school. Many children do not receive regular dental care. Therefore, in areas such as these the school dentist is still important. A community dentist can see where this provision is most required.
It is worrying that in many regions under the new arrangements district dental administrators may have to go cap in hand to district community medical officers for funds before making decisions about services. This is seen by the whole profession as removal of the opportunity being given to it to organise its own services, particularly the services to the handicapped and the socially disadvantaged. Some of these services may be lost for ever.
The position in Wales is set out clearly in annex B of circular WHC(82)1:Whatever decisions are reached by authorities in relation to the management of these professional services the senior members of the dental, pharmaceutical and works professions employed by the authority will have the right of access to the authority and will receive the agenda and minutes of the district team and have the right to attend these meetings when matters affecting their particular services are considered in order that the health authority and the district team may have the benefit of their professional expertise.No such guidelines have been made for England.
It should be obvious that the dental officer should be called on to advise the district health authority on subjects relating to dentistry. We should bear in mind that doctors are not always well briefed on dental matters. For example, only a dentist sees and is aware of suffering caused to children by toothache and will understand the need for fluoridation of water supplies. The dental profession is asking that the district dental officer should have as of right the opportunity to put his case personally to the chairman and to the authority.
I know that the Under-Secretary has met representatives of the dental profession and that he has shown sympathy and understanding of the problem. However, I hope that he will publicly give an assurance that clear guidance will be given to the new authorities on the matter.
§ Mr. David Crouch (Canterbury)
I am glad to have the opportunity of making a speech. I have been discussing health almost all day because, as the House knows, I am a member of a regional health authority, and I attended one of its monthly meetings this morning. We were concerned about the problem of the new district health authorities which we are discussing today.
I listened with great interest to the argument put forward with skill, clarity and force, as always, by the right hon. Member for Lewisham, East (Mr. Moyle), a former Minister for Health. He was speaking responsibly not as a former Minister for Health but as the right hon. Member for Lewisham, East. I would not deny him the force of his argument in speaking up for what he believes to be a disadvantage to his constituents brought about by the amalgamation of Lewisham with North Southwark, the Guy's district, to form a new district health authority.
The right hon. Gentleman has made representations to me. He was honest and fair enough to say that in the South-East Thames regional health authority there had been consultations and that members of the authority and 470 officials had listened to the views of those in Lewisham. We took on board the fact that Lewisham was worried about being bracketed with Guy's hospital.
So much for the argument of a Member speaking for his constituency interests. However, I think that the right hon. Gentleman should have reflected on his total knowledge of the health problem in Great Britain, for which he had responsibility as a Minister. I would be the first to say that he was a good Minister. However, he should have been more responsible and should not have exaggerated the danger to Lewisham of being swamped by the great Guy's hospital. What did he mean by that? will tell the House what I understand by it. No district hospital likes being too close to a great teaching hospital because it fears the power, contacts, skill and weight that the consultants serving that teaching hospital will have in various corridors of power. Those corridors of power are in the Royal colleges, and the British Medical Association, and they lead to Alexander Fleming House.
The right hon. Gentleman is perhaps right to say that any district is worried when it is bracketed with a great teaching hospital such as Guy's. There is something in that argument because Guy's as a teaching hospital is one of the great centres of excellence in our country. It is a centre of research and of great tradition; it has a great history of success in medicine and in the care of patients. Why should anyone be afraid of being bracketed with such a great centre of excellence as Guy's hospital? The reason is the one that I have given. [t is feared that that centre will grab the greatest amount of resources to be allocated to the district and will dominate and tower above arty other hospital or section of health provision in the new district. Therefore, the right hon. Gentleman is right to say "I am afraid of it." However, he is not right to say "I shall not have anything to do with it "
The Minister, the Government, the Department and the regions will always put patients first. So will the members of the new district health authorities. It is not for them to put consultants, nurses or ancillary workers first. They must always consider whether the decisions that they make about the allocation of money, resources, nurses, ambulance services and blood transfusion services are right for the patients in the district.
Perhaps the right hon. Gentleman is still concerned that too much money would go to the big hospital—Guy's. I do not think that that is a fair assumption. Too many people would stand in the way of that. I know because I have had to fight the case for Guy's in the region for 12 years. You would be surprised, Mr. Deputy Speaker, if you knew how many people say that we must do nothing for that great hospital because it can do it for itself. One has to cut across that view sometimes to ensure that even a great hospital gets its fair share.
Another question raised by the right hon. Gentleman—he did not dare to sketch it out exactly—concerned the remoteness of Southwark from Lewisham. He said that Guy's was so far from Lewisham that it was impossible for it to be bracketed with Lewisham in one district. Anyone would think that Guy's was on the other side of the Thames, in the north of London. It is only four miles from Lewisham station. I would be willing to walk there. It is quite a good walk. I know London backwards. It is connected by bus and tube. If one goes to districts in remote areas in other parts of the country, one is separated by a distance involving 45 minutes travel from the hospital, even under the new set-ups. People 471 accept that. If one wishes to use a regional specialty such as cardiac or thoracic surgery, one has an hour's journey to reach a centre of excellence that specialises in that discipline.
To say that it is wrong for the region that I work in to have recommended to the Minister that Guy's should be put together in a district with Lewisham is not a responsible comment. The recommendation was not influenced in any way by my hon. Friend the Minister, who was at one time a consultant at Guy's. I cannot believe that it would have anything to do with him. The recommendation went from the region to him.
I remember the discussions that we had in the high street complex in Lewisham. I shall not call it the town hall because it is nicer. I have forgotten its name, but the right hon. Gentleman will remember it. He was there with other Members of Parliament and we received them. We received also the chairman and secretary of the CHC and they made a very good case. Nor were they all members of the party in opposition. They were a good mixture. People in health are not always of one party. It does not matter what party we belong to because we are concerned about health, patients and the right decisions.
Of course, this might have been a wrong decision, but I believe that, on balance, it was the correct one. The right hon. Gentleman may have made a mountain out of it. It is not a molehill, but he made a big constituency point when I maintain that it is more than a constituency point; it is a question of making the right decision for this area of London.
This debate is not about an individual district; it is about all the districts which have been decided upon and recommended to the House. Had it not been for the prayers put down by the Leader of the Opposition and his supporters, the order would have gone through. I must confess that I nearly put down a prayer myself. Of course, this would have stopped the proposal dead and we should have had a debate. However, I was prevented in the nick of time, having written it and sent it up to the Journal Office. When I saw the company I might be keeping, I thought my intention might be misunderstood if my name were bracketed with those of the Leader of the Opposition and the distinguished hon. Lady the Member for Crewe (Mrs. Dunwoody).
Nevertheless, I am very happy to take part in the debate for I think it is very important that we should debate the decision to reorganise the Health Service and to determine the boundaries of the districts and the membership of the district authorities. I have listened to almost every speech in this debate and have heard the concern which Members have expressed about how those decisions were made.
The principle of bringing health care closer to the people and closer to the patient is absolutely correct. We must not forget that because, whatever we decide to endorse tonight in the Government's determination to carry this through, we must ensure that we not only bring the districts and appointments into being but that in doing so and in gaining the blessing of Parliament we bring the administration of health care closer to the patient. We must never allow ourselves to forget the importance of this.
Before coming to a decision on district boundaries, in my own region—South-East Thames, which covers South-East London, East Sussex and Kent—we went in for a great deal of consultation. Not only did we send a great 472 many letters to everyone we thought might wish to put forward a view; we held, at my suggestion, a series of public meetings. At first, the idea of holding public meetings was not received enthusiastically. A regional health authority or an area health authority—perhaps in the future a district health authority—is not as accustomed to the idea of public meetings as are Members of Parliament. We are in the front line of democracy. We know that we must meet our constituents and face their criticism; we have to keep a brave face and produce answers. Other people in public service sometimes view this with misgiving.
The public meetings were a great success. They were attended by hundreds of people. Many Members of Parliament turned up in both the rural areas and London. I learnt a great deal from the kind of people who came, not only chairmen, secretaries and members of CHCs but individual members of the public, hospital consultants, GPs, nurses, ancillary workers, trade unionists and ordinary people. Everyone at some time will be a patient of the Health Service and everyone feels concern when decisions are to be made. This was their opportunity to criticise or ask for changes, and we felt that the consultation was a worthwhile exercise.
As regards the members appointed to the DHAs, I have some reservations about what we do. They are not elected; they are nominated by various persons, although all have to be approved by the Secretary of State. Four or five local authority members are required in each district authority. This is what nearly caused me to pray against one of the orders tonight, because I saw the force of the argument put forward by the county councils for equal numbers in representation with the district councils. They argued that, although this was to be a district health authority, it was at county level in local government that education and social services are handled, and therefore they should have a strong membership of the district health authorities.
But, as it is, there will be only two representatives from the county council on each district health authority, and I think that on balance that is about right. If we are to return to my original premise of producing a Health Service closer to the people, we must make it closer to the district council. That is why it is important to have two or three—often it is more—district council members on the authority.
In addition, there are about five general members recommended to the Minister by the regional health authority for consideration. They are carefully screened. We did not have to scrape the barrel. Many people from all walks of life were put in for the appointments. I have been very impressed by the high calibre of people who have come forward to work in the public service in the district health authorities. There is no lack of will to make the Health Service better than it is.
People are coming forward for no payment. When a district councillor or county councillor comes to work for a day or for half a day in a district health authority he will not be able to claim any attendance allowance. He can claim his travel expenses, but that is all. That might be a deterrent to the busy county councillor or district councillor who can claim for attendance when he is working on local government business. Therefore, it is impressive that so many are willing to come forward.
The 11 general members must include a consultant, a general practitioner, a nurse or midwife, a nominee from one of the universities, where there is a medical school in 473 the area, and a trade unionist. The rules clearly lay down what sort of trade unionist he must be. We have been looking for a trade unionist of wide trade union experience, not limited to the Health Service, a man who can bring experience of negotiations, of trade union problems, of dealing with trade unionists and representing them. In our region I have known for many years the great value of such a voice. I am the first to admit that one often obtains a great deal of sound sense and experience from such members.
The members will have a busy time. The job is no sinecure. We, my hon. Friend the Minister and the Government are wasting our time if we appoint people and they do not turn up. They have the responsibility for doing the job. They will have officers to work for them, but they must be there to direct the officers, to bless the officers' plans if they agree with them, and to chase the officers and get things done at the point of sale, where the consumer is. The members are the people who will meet the consumer, the customer, the patient. They will have to say "I shall try to get something done for you. I realise that you cannot get orthopaedics done quickly in our district and that there is a long waiting list for hip operations."
It is not the officer but the district health authority member whom we appoint today who will have to take that matter on board, just like a Member of Parliament or a councillor. He or she will be completely involved with delivering a service. We must make the members close to people so that people can get at them, talk to them, chivvy them, chase them, ask "Why isn't this hospital built? Why isn't the hospital redecorated? Why isn't it extended?" and so on.
According to the paper issued by the Department, the members will have to put in two to four days a month, which is a lot of time. They will have to attend a monthly meeting, as I have done today, and read papers. They will receive a wad of papers and they will not want to go into meetings ill informed, because the officers will be well informed and they will find that their colleagues have read the papers. They will have to visit hospitals and health centres, hospital laundries and ambulance men. They will be involved in many problems and will listen to many industrial dispute questions. They will have to meet and listen to patients, their consumers.
Only today I again found in the region—and it will be no different in a district health authority—a hestitation over listening to complaints. I am the only Member of Parliament on the authority. I am not afraid of listening to complaints. People complain about the NHS, and it is not enough to reply "Write to us. Submit a paper, and we shall study it and take it into account." We cannot deal with people in that way. I said today that we must make ourselves ready to listen. We may be busy and it may be difficult.
When we speak in this Chamber the public can listen. They can read reports of our proceedings in the paper. They can hear them on the radio. Standing Committee proceedings are open to the public and to the press. Meetings of the district health authorities will be open to the public, and to the press, apart from the occasions when they have confidential discussions about medical matters or complaints against consultants, and so on. But that will be the only time. When a community health council wants to put forward a point of view about a hospital closure it is entitled to go right to the Minister, but on the way it may 474 want to see the DHA and the RHA. Those of us who serve on authorities must not be like shrinking violets. We must be prepared to stand up and take it, even if that takes time.
The Government have moved in the right direction by producing a new shape for the National Health Service. Let us pray that the shape is right, because we must not get it wrong again. We must hope that the new arrangements have a good run, and a good spirit. Politics will always be involved in the NHS, but we must keep that involvement to a minimum, and to this Chamber. Outside the House we must do the best we can.
My wife has recently been a patient with the NHS. I have learnt more about the NHS by accompanying my wife than by sitting in a regional headquarters considering budgets involving hundreds of millions of pounds for nearly 200 hospitals. To go into a hospital with a patient and queue up for two hours is to learn about health and health care. It is worth waiting two hours to see a good consultant, a friendly nurse, a friendly chap who puts on the plaster, and a friendly friend of the hospital who produces a cup of coffee at half the price we pay in the House. The hospital league of friends provides that service at no profit to itself. Much is needed to make the NHS tick. It helps to see for oneself as a patient, and I pray that I do not often have to do that.
I conclude by referring to a point which has not yet been mentioned. Health authorities at all levels administer the Health Service. A vast amount of money is involved—£12,000 million a year. The authorities are the biggest employer in Britain, employing over 1 million people. A whole range of services are provided for the public, the principal service being the hospital service. But we must not forget that before a patient goes to hospital he must see his general practitioner. That is what is known as primary health care. That first contact may be through a health visitor or a district nurse. It is important to remember that, because we do little about primary health administration.
When the NHS was established, the GPs separated themselves from the administration of hospitals. This area of primary health care is the work of the GPs. It is the one remaining gap where reform is required, although the DHAs will not have much power to effect such reforms or even to have their offers of help considered. The GPs have managed to keep themselves apart, at arm's length, dealing through the family practitioner committees.
I ask my hon. Friend the Minister to allow us to have a debate soon on a matter that is even more important than district health authorities. Let us have a debate on the Acheson report and the Harding report, both of which relate to primary health care, and one of them concerns London. Today in London 50 per cent. of general practitioners work single-handed. Thirty per cent. of the telephone calls to GPs in inner London are answered by telephone answering machines. That is the problem in primary health care that we must consider next.
§ Mr. Leslie Spriggs (St. Helens)
I shall follow the example of the hon. Member for Canterbury (Mr. Crouch), who described his experience as a member of ore of the regional health authorities. All right hon. and hon. Members are obliged to him for what he has said ltus evening. Some of us speak, not as members of regional or area authorities, but as people who have been in-patients in National Health Service hospitals.
475 I was invited to sit in at one of our area health committee meetings, and it was interesting to note that many of its members were non-medical people. They have no real understanding of the health care that is required by the many thousands of patients who attend our hospitals for treatment each year. Instead of putting people on committees because of their political persuasions, it would be better for political parties of all persuasions to make sure that members of area or regional health authorities have a real interest in health care.
Our thanks are due to the Minister for the circular that he sent to health authorities some months ago about patient care. I heard that circular read out to members of the committee that I attended, and that is why I raise the matter this evening.
Members of Parliament who have been unlucky enough to be struck down and have to stay in hospital, sometimes for many months, gain first-hand experience of nursing and medical staff. My doctor sent me to see a consultant in a London hospital. When I saw the consultant, I regret to say that within a few minutes he asked me whether he could treat me privately. He was employed on a salary as a consultant in the National Health Service, yet he used his position to help himself and his bank balance.
I wish that members of area health authorities would take a closer interest in the many people—men, women and children—who have to spend time in hospital waiting rooms, waiting for appointments. I was given an appointment at the Westminster hospital for 2 o'clock on a Friday. My train home left Euston station at five minutes past five that evening. I had to leave the hospital at half past four without being dealt with. I had to go to the desk and say "I am sorry, I can no longer wait". In the meantime, I discovered that about 30 to 40 patients had all been given the 2 o'clock appointment that day. That is not good enough, and I should like the people appointed to serve on committees to take an interest in that aspect of the matter.
I assure hon. Members that I do not go to hospital to waste my own, a medical officer's or a nurse's time. There is nothing nice about hospitals. I have learnt to appreciate good nursing, medical treatment and the generally good medical care given in our hospitals.
The Minister has been badly advised about the community health councils. The chairman of my CHC in St. Helens sends me its newsletter regularly. It is a means of communication between my constituents who serve on the council and their members of Parliament. If that letter is reduced in size or content or even ended, it will be a disservice to the public. Community health councils serve the public and patients' interests. Those who advised the Minister to withdraw financial support from the community health councils did a great disservice not only to those councils but to Members of Parliament and many members of the public, who were kept informed of what the NHS had to offer those requiring treatment.
The chairman of my community health council in St. Helens is particularly interested in health care and public relations. We should call on the Minister to reconsider the withdrawal of financial support from the CHCs. He should think about it very carefully. I strongly advise him not to make the cuts that he has in mind.
§ Mr. Den Dover (Chorley)
It is a pleasure to welcome these orders and to thank my right hon. Friend the present Secretary of State, his predecessor and the Minister of Health for taking action and making health control and management more local. We said that in Opposition, and the crying need has existed for several years.
That need is well instanced in the Chorley and South Ribble health authority, which is to be splintered off—the only area in such a position—from the existing district and become a district on its own. Therefore, nearly 200,000 out of 330,000 people will get their own local control.
It is only by having local control that local people can exercise management efficiency and make savings. I am confident that the target of a 10 per cent. management saving can be achieved. The new chairman of the Chorley and South Ribble health authority, Mr. Sellers, said that we would have no problems. He added that we would have to manage it carefully and control our costs, and that we might, thereby, make a saving and put that money into patient care and services.
Local district health authorities are vital. Their members know what people want. They know the shortcomings of the present service. Chorley lacks a full casualty service. A new district hospital is to be built in the next few years. Under the previous organisation, the casualty service, our main need, was placed at the end of the last phase. Under the new district health body, the casualty service, all being well, will feature at the start of the first phase. This will make a major difference.
Today is a famous day in the history of Chorley and South Ribble. Ten thousand workers at British Leyland have voted to go back to work. This shows a local community spirit, and it will be helped enormously by the introduction of our own district health authority. There is a feeling that the Government want to see investment in the area and jobs for the local work force. I am glad to have this chance to welcome the orders. I look forward to 1 April and the setting up of our new health authority.
§ Mr. Nicholas Winterton (Macclesfield)
I shall endeavour to be brief. I recognise that my hon. Friend the Minister for Health wishes to have his full allocation of time to deal with the many points that have been raised.
This debate has been interesting. I found especially interesting the opening speech of my hon. Friend the Minister for Health and that of the hon. Member for Crewe (Mrs. Dunwoody) who represents a constituency close to mine. In some respects, the hon. Lady and I have shared common problems over the reorganisation as it relates to the Cranage and Mary Dendy hospitals.
I am always delighted to follow my hon. Friend the Member for Chorley (Mr. Dover) who shows a deep concern for patient care in his area. My hon. Friend has clearly taken the trouble to visit the hospitals in his constituency to see the problems at first hand and to talk with those in the Health Service who are providing the patient care with which Government policy is concerned.
In recent weeks I have also taken a great interest in the hospitals in my constituency. I met representatives of the Royal College of Nursing in my constituency at the request of Miss Ann Woodbine, their senior representative. The nursing officer at the Macclesfield infirmary, Miss Elliott, informed me that I had not visited the infirmary formally 477 for 18 months. I asked when she would like me to visit. She asked me to choose a time and I replied that I was prepared to go immediately. I saw at first hand what is happening in that hospital. As my hon. Friend the Member for Canterbury (Mr. Crouch), a member of a regional health authority, has indicated, this will be one of the duties of the members of district health authorities. They—like hon. Members—will be at the sharp end in dealing with matters related to patient care.
I hope that those appointed politically, those appointed by the Minister and those nominated by local authorities—in my area, the Macclesfield borough council, the Congleton borough council and the Cheshire county council—and even the consultants, together with others possessing special qualifications, will visit every hospital and clinic within the district health authority. They should see for themselves the service that the patients receive to assess the quality of the service, to decide whether it needs to be improved and to ensure that when the meetings to which my hon. Friend the Member for Canterbury referred are held, they are as well briefed as the officers. I am sure that the hon. Member for Crewe will agree with that. Often in the past both regional and area health authorities have been run by the officers rather than the appointed members.
I hope that the Minister will respond to the deep concern felt by the members of the Select Committee on Social Services about the Government's decision to place consultants' contracts at regional rather than district level. The districts know what consultants they require. Junior doctors will continue to he abused and the public will not obtain the quality of service that they require if the Government insist on placing consultant contract decisions at regional rather than district level.
The Select Committee on Social Services, of which I am pleased to be a member, under the chairmanship of the hon. Member for Wolverhampton, North-East (Mrs. Short), having received a great deal of evidence on this, decided, after much consideration, that consultants' contracts should be placed at district level. We felt that junior doctors were being abused and, in many instances, forced to do work, for which they were neither experienced nor qualified, which should be done by consultants.
I am delighted to see the hon. Member for Brent, South (Mr. Pavitt) nodding assent. We believe that in the long term the hospital service will save money if all patients receive the qualified service and treatment which every NHS patient deserves. I hope that the Government will deal with that aspect.
I know that there has been controversy in some areas, but that has not occurred in Cheshire. I am delighted with the Macclesfield district health authority and with the appointment of its officers and members. The balance of membership is absolutely right. We do not want too many members—too many cooks spoil the broth—but we want the professional input and the commitment of those who are appointed for their particular skills and qualifications and of those who are appointed by the local authority.
I hope that my hon. Friend will bear in mind the points that have been made. I pay tribute to the chairman of the Cheshire area health authority, Mr. Charles Stevens, who is not seeking reappointment as chairman of the district authority. He has made a magnificent contribution to the Health Service over many decades. He was well known in the pharmaceutical industry and the hospital service before 478 reorganisation in 1973–74. He has done a brilliant job as chairman of the Cheshire area health authority, and my constituents have benefited immensely from his efforts. It is fortunate that his vice-chairman, Councillor Joe Millett, has been appointed as the new chairman of the Macclesfield district health authority. I am sure that, with his knowledge of the area, he will give the same encouragement and attention to the needs of the Macclesfield area as Mr. Charles Stevens did for the whole of Cheshire.
I hope that my hon. Friend appreciates that these are important orders. I think that he might ignore some of the political rhetoric. Indeed, he might be wise to ignore some of the rhetoric of the hon. Member for Crew and other Opposition Members who criticised the orders because: of what might result from them. Nevertheless, I hope that he will take the valid criticisms to heart and give them serious consideration.
§ 9.4 pm
§ Mr. Terry Davis (Birmingham, Stechford)
We have had a wide-ranging debate about these three orders.
It is natural that hon. Members on both sides have tended to concentrate on the proposals for determination of districts, for several reasons. First, there is bound to be great local interest in the boundaries of the new districts. Secondly, we all recognise the importance of getting the boundaries right because nobody wants to go through another massive reorganisation in the near future. Certainly no incoming Labour Government will wish to spend time considering the boundaries of every health district authority in the country.
Nevertheless, several other issues have been covered. I shall not comment on many of them, but I urge the Minister to reply to the questions put to him by both sides and especially by my hon. Friend the Member For Stockport, North (Mr. Bennett) about hospitals in Oldham and Stockport.
Also I myself wish to put one important question to the Minister of State about the constitution of the district health authorities and the appointments already made. E am especially interested in the chairmen. The chairmen are appointed by the Secretary of State, but press releases from the Department have been issued in the name of the Minister of State. It appears that the task of choosing the chairmen has been delegated to him, so it is fair to ask him the question. I shall not comment on the individuals appointed or on their qualifications or lack of them. My hon. Friend the Member for Brent, South (Mr. Pavitt) referred to the lack of experience of the chairman of the new Brent district health authority. I have read in the press of another chairman who said that he only got the job through a friend—he has a friend who is a Conservative Member of Parliament, so he obviously chooses his friends wisely—and that he was surprised to be appointed. I say no more, as I find it distasteful to comment on individuals in the House. Indeed I found the Minister's comments on Mr. David Townsend to be cheap and unworthy of a Minister of the Crown.
A different aspect of the matter interests me. Looking at the list of chairmen of district health authorities, it is clear that one common factor applies to more than 80 per cent. of the appointments. It is not their politics or their occupations; it is the fact that they are men. This is especially interesting because women account for a large proportion of those employed in the Health Servce, but 479 apart from nursing officers there are very few women in senior posts—in my view, too few. I do not hold the Minister of State responsible for that, but he can be held responsible for his failure to appoint more women to chair the new district health authorities. This reorganisation gave the Government a rare, perhaps unique, opportunity to ensure a better balance between men and women in these appointments. Instead, fewer than one in five is a woman. Why? Was it deliberate? Or was it an oversight—just something that never even crossed his mind? I await the Minister's answer with interest.
If the Minister has had little to say about appointments, he had a great deal to say about the savings which he expects to flow from reorganisation. He still insists that the changes will save 10 per cent. of management costs. As he introduced the point, I shall ask some questions about it. How did the Government calculate that the saving would be 10 per cent.? The Minister said that there would be 58 fewer chief officer teams, but how does that equate with a saving of 10 per cent. rather than 15 per cent., 20 per cent. or 5 per cent.? I am always suspicious of round figures. Why should management costs be reduced from 5.1 per cent. of turnover to 4.6 per cent.?
I make it quite clear that the Opposition favour smaller authorities to run the Health Service, and we are in favour of district health authorities. Smaller authorities may be better for the Health Service, but they are not necessarily cheaper.
One of the smallest authorities in the West Midlands is the Solihull area health authority, which is to become a new district health authority. In terms of management costs, it is one of the most expensive area health authorities. It will be a single district health authority and there will be no change in its organisation or structure as a result, of the orders, so why should that very expensive authority's management costs be reduced? I understand that at present its management costs exceed 6 per cent. of turnover.
On the other hand, the Birmingham area health authority is a much bigger authority and is one of the authorities in the West Midlands region with the lowest management costs. I understand that they are slightly over half those of Solihull. Why should a change from one area health authority to five district health authorities reduce the management costs of Birmingham, which are already very low?
I am not surprised that Solihull's management costs are high because the overheads of smaller organisations are often greater than those of larger organisations as a percentage of turnover. I am not criticising the Solihull AHA. It may be that its management costs are tightly controlled. However, the fact is that they are higher than those of other authorities.
As I have already said, smaller organisations may do it better, but they do not necessarily do it cheaper. In the Health Service fewer teams of chief officers do not necessarily mean fewer officers. We may have fewer teams but more officers.
District health authorities will have more responsibilities than the district management teams have had in the past. We may see more duplication of functions. There may have been duplication in the past between the chief officer teams and district management teams of area health 480 authorities. However, we shall now get duplication of functions between district health authorities, the functions that previously were performed by area health authorities.
My hon. Friend the Member for Crewe (Mrs. Dunwoody) referred to the chairman of the Gloucester area health authority who resigned as a result of the Government's proposals for that area. He estimated that the decision to have two district health authorities instead of one district health authority in Gloucestershire would increase management costs by £500,000. I understand that the vice-chairman, who obviously has the confidence of the Minister because he was appointed the new chairman of the authority, confirmed his predecessor's estimate that the new organisation would increase costs by £500,000.
If the Minister's aim is to reduce management costs and if he really believes that costs are a function of the number of chief officer teams—the only explanation he has advanced today for saying that costs will be reduced is that there will be 58 fewer teams of chief officers—why not abolish the district management teams? If that were done, we would have far fewer teams as there would be only area health authorities and their teams.
In short, the Minister has no ground for saying that there will be savings of 10 per cent. He plucked that figure out of the air. It is a management task that has been arbitrarily imposed and he has blind faith that it will be achieved.
In dealing with the boundaries of district health authorities, it is necessary to begin by referring to the circular that was issued by the Department 18 months ago. It was stated in the circular that the new authoritiesshould as far as possible comprise natural communities, and the boundaries of one or more DHAs should normally be coterminous with the boundary of a social services or education authority.Coterminosity is an ugly word, but it is important. It means that the Health Service should be organised on a basis that is similar to the organisation of a local authority's services.
In opening the debate the Minister said that the purpose of the reorganisation was to have a balance between health care needs and administrative needs; but that is not a reason for coterminosity. The reason for having similar boundaries is to improve patient care, which the Minister also said is important. That was explained clearly by my hon. Friend the Member for Brent, South. The issue was also explained vividly by the illustration that has been given by Conservative Members who represent Buckinghamshire, who are complaining about the removal of part of that county in order to be joined with Berkshire in the new organisation. It applies also to Lewisham and North Southwark, on the one hand, and to the West Lambeth district health authority, on the other.
I thought that the hon. Member for Canterbury (Mr. Crouch) was rather unfair to my right hon. Friend the Member for Lewisham, East (Mr. Moyle). The hon. Gentleman referred to the recommendation from the regional health authority. When the Minister replies I suspect that he will shelter behind that authority's recommendation.
The recommendations of the regional health authorities are extremely important and are to be taken into account by the Minister when deciding what boundaries to put before the House tonight. However, the Minister was not so ready to accept the recommendation of the regional health authority on the boundaries of Gloucestershire 481 district health authority. We heard about that in great detail from the hon. Member for Cheltenham (Mr. Irving). The Minister is willing to over-rule a regional health authority in one area but not, apparently, in South-East Thames.
The point that my right hon. Friend the Member for Lewisham, East (Mr. Moyle) made about the distortion of the budget is valid. It is not just a question of competition between Guy's hospital and Lewisham hospital; it is also a question of balance between the proportion of the health budget to be spent on hospitals and the proportion that is spent on community care. I refer to the Minister's written answer on 23 July 1981 on the arrangements for London, when he said that these arrangements would reflect the need to give higher priority to community care. I do not see how the boundaries for the Lewisham and North Southwark district health authority reflect that priority. There is an effect from these boundaries on the liaison with local authorities. The case is just as strong for Lambeth as it is for Buckinghamshire. Hospitals are not the Health Service and what the Minister has done in South-East London is to set up not district health authorities but district hospital authorities.
The problem in Liverpool is different. I am sorry that my hon. Friends the Members for Liverpool, Scotland Exchange (Mr. Parry) and Liverpool, Walton (Mr. Heffer) could not be here. My hon. Friend the Member for Scotland Exchange particularly asked me to speak on his behalf about Liverpool.
Liverpool is the special creation of the Minister of State. It is necessary to go into the history of the Liverpool problem, which is somewhat similar to that of Gloucestershire. It was originally set up as two districts under an area health authority. Then it merged into one single district health authority four years ago. When the regional health authority came to consider the boundaries for the new district health authorities and how many should be created, the regional authority was split evenly. There was a tied vote on whether there should be one or two district health authorities, and this was resolved by the casting vote of the chairman, who had already voted once. I make no complaint about that, but the truth is that members of RHA were equally divided.
The proposal to have two district health authorities was opposed by everybody in Liverpool—and I mean everybody in Liverpool. All the political parties and the city council as a whole were opposed to the scheme. The Minister's answer was a typically silly compromise. He suggested, and has now put through in the order, something which is neither one thing nor the other. There is not one district health authority, nor are there two district health authorities; there is a single district with two sectors—one district health authority with two teams of chief officers.
This is similar to what used to appertain in area health authorities. During the Committee proceedings on the Bill which became the Health Services Act which led to these orders, the Under-Secretary of State gave frequent assurances that it was the Government's intention not to keep an area health authority anywhere. But that is what has happened in Liverpool. It has been opposed by everybody in Liverpool—the existing Liverpool area health authority, Liverpool city council, Liverpool university, the family practitioner committee, the local medical committee, the area medical committee, both the community health councils as well as trade unions.
482 When the Minister went to Liverpool he asked whether there was anybody who was in favour of the proposal
§ Mr. Davis
As my right hon. Friend says, so much for consultation. The answer was that there was little evidence of significant opinion in favour of the proposal. In this case not even the consultants wanted this arrangement in Liverpool. Everybody agrees that it is unworkable. The decision has been taken personally by the Minister, who told us today that his aim is to simplify organisation. The Minister went on to tell us that he believes that two chief officer teams are necessary to solve the tremendous administrative and financial difficulties of Liverpool. Why, and how? Is it a matter of size? Is Liverpool too big to be managed by one team of chief officers? I see that the Minister is nodding, so we shall put that into the record. If Liverpool is too big with a population of 537,000., perhaps the Minister will tell us why Sheffield is not too big with a population of 544,000, Nottingham is not too big with a population of 600.000 and Leicestershire is not too big with a population of 836,000. Will the Minister explain why Liverpool is too big when it is only two-thirds of the size of Leicestershire?
The Minister must also explain why he flouts local opinion in such a way. In his opening speech he referred to local responsibilities. He said that the Government will not tell district health authorities how to run their own shows—his words, not mine. He decided the structure of the Health Service in Liverpool, before the district health authority was appointed. He did not leave it to the district authority to run its own show. He did not even consult it about the structure. He decided it, announced it and then appointed people to tackle the problem. When discussing the names of district health authorities, the Minister says that the Government want district health authorities to have what they wish. However, he does not want the people of Liverpool to have 'what they wish.
If he is so concerned about savings in management costs, how can he justify two chief officer teams in Liverpool instead of one? The Minister has told us that there will be a saving of 10 per cent. in management costs as a result of a reduction of 58 in the number of chief officer teams. Many of us are very sceptical of both the scale and the rationale of those savings. However, let us take the Minister's figures. If we have one district health authority for Liverpool, with one instead of two teams of officers, and one district health authority for Gloucestershire, also with one instead of two teams of officers, there would be another reduction of two teams of officers in the Health Service. There would be 60 instead of 58 fewer teams of chief officers. That means that we could save, according to the Minister's figures, £1 million for the Health Service. Therefore, I ask Conservative Members to vote with myself and my right hon. and hon. Friends against the orders tonight.
§ Dr. Vaughan
We have had a very useful debate. It ranged over many subjects, and some parts of it were quite heated. At least one speech was somewhat overheated, but hon. Members have strong feelings about these matters. I shall try to answer all the points raised by hon. Members, but if I do not succeed entirely I shall gladly answer Fetters from them.
483 There have been some comments about one or two of the chairmen who have been appointed. The hon. Member for Brent, South (Mr. Pavitt), the hon. Member for Birmingham, Stechford (Mr. Davis) and the right hon. Member for Lewisham, East (Mr. Moyle) all referred to that. It is unfortunate that a few chairmen have been picked out because individual appointments have not pleased some hon. Members on both sides of the House. We tried to appoint people who would do their job on a non-party political basis—there is no question of party politics in the matter—people who would use as their yardstick a genuine concern for the health services in their districts.
From the meetings that we have had with the new district chairmen, I believe that we have been fortunate. Many people who do not support my party or my philosophy have told me that they are surprised by and interested in how fortunate we have been in many of the people who are willing to take on such a task.
For example, we have just been hearing about Liverpool. I hear nothing but praise for the quiet skilful way in which the shadow chairman of the new authority has set about his task. Praise has come from people who did not agree with the appointment, but who are now having second thoughts on their original opinion. They now think that he will make a very good chairman indeed.
§ Mr. Moyle
The hon. Gentleman outlined a series of propositions on the basis of which he appointed chairmen of district health authorities. However, I have a statement from the present Secretary of State for Industry, the right hon. Member for Wanstead and Woodford (Mr. Jenkin)—in a letter dated 22 July 1981—saying that the chairman of the north Southwark and Lewisham district health authority was to be appointed to safeguard the interests of the people of Lewisham. Why has that criterion not been adopted?
§ Dr. Vaughan
The right hon. Gentleman knows that extensive discussions took place and great efforts were made to find a chairman who would be acceptable to all parts of the health authority and who would safeguard the interests of Lewisham. I believe that we have found such a chairman. From the conversations that we had, I believed that the right hon. Gentleman felt that the chairman would be a good appointment. I should, however, be very glad to discuss that appointment with him.
The hon. Member for Stechford raised the question of female chairmen. We have appointed 32 female chairmen out of a total of 192. That is slightly more than were appointed by the Labour Government. We have gone further in appointing women than our predecessors did. We have chosen chairmen on the basis of merit and the experience and enthusiasm that they will bring to looking after the health services. The hon. Member for Brent, South mentioned the chairman of Brent. He was criticising a woman.
§ Mr. Pavitt
Will the Minister accept that I do not have a chauvinist male pig attitude to the good lady? I paid tribute to her, but why appoint someone without experience when there are plenty of nominees with experience?
§ Dr. Vaughan
I shall leave the hon. Gentleman to sort out his attitudes to and relationships with women.
484 I spent this morning visiting Chailey Heritage with the shadow chairman for the Brighton district. She is a highly intelligent, capable woman. I have no doubt that we have chosen an extremely efficient and able woman to chair that new district health authority. I resent the suggestion that we have not given women a full share of the appointments.
A number of hon. Members—including the hon. Member for Stechford—have questioned the 10 per cent. saving of management costs. If management costs increase—I gave a figure of about £300 million—the savings in costs will increase proportionately. Our target of a 10 per cent. proportion of management costs will remain constant. We have every expectation of achieving that. It was suggested that we plucked that figure out of the sky. Not at all. We think that it is a reasonable figure. I have had discussions with many regional treasurers. When I inquired whether they had any doubts that we would achieve that figure, they told me that they did not. The message from the health authorities is that the figure will undoubtedly be achieved. In some districts the cost may increase a little, but in others within the region the cost will fall. We have a clear expectation for each region and are confident that we shall achieve the 10 per cent. proportion.
§ Mr. Terry Davis
The Minister has missed the most important point, which is not whether he had discussions with the treasurers of regional health authorities after establishing the figure of 10 per cent., but how he established it in the first place.
§ Dr. Vaughan
I suggest that the hon. Member for Stechford should wait. Time will show whether Opposition Members are right or whether we are right. I think that Opposition Members will find that we are right.
§ Mr. Pavitt
Does the Minister recall that in an earlier reorganisation the present Secretary of State for Education and Science thought that by taking away 9,000 members of hospital management committees we could save some money, but that that did not happen after the 1973 Act?
§ Dr. Vaughan
I, too, have a good memory. If I had any doubts I should not be prepared to rise to my feet and say with the confidence that I have that we should achieve such savings. Opposition Members are troubled because they tried, but failed, to achieve such savings. They cannot believe that we can not only say that we shall do so, but will achieve them.
§ Mr. Nicholas Winterton
Perhaps I can get my hon. Friend off the hook. As I believe in my hon. Friend's sincerity, will he give an assurance that if savings are achieved a contribution will be made to nurses in the wards in the form of a wage increase, and that a contribution will be made towards the necessary improvement of the Health Service to reduce perinatal and neonatal mortality?
§ Dr. Vaughan
My hon. Friend is very ingenious. Although he has rescued me from one hook, he has sought to impale me on two others. He knows perfectly well that such discussion would be out of order.
The hon. Member for Brent, South referred to a press report about regional reviews and accountability. My hon. Friend the Member for Birmingham, Edgbaston (Mrs. 485 Knight) also raised that issue, which is very important. The press report is not entirely accurate. The day-to-day running of the Health Service is, of course, a job for the health authorities. The orders before us aim to continue that. However, as hon. Members know, Ministers are responsible to Parliament. The system of annual reviews that was recently announced by my right hon. Friend the Secretary of State is designed to consider the outcome of the planning system and to ensure that the health authorities deal with national and local priorities efficiently and effectively. That is all.
My right hon. Friend is not about to try to run the National Health Service from the Elephant and Castle. That would be absurd. He recognises that we owe it to the House and to the taxpayer to ensure that local health authorities are accountable for their actions. I should have thought that that would please, not concern, the hon. Member for Brent, South. After all, he asked that the House and the Select Committees should be given more satisfactory and relevant information about how money is spent. That is exactly what we are doing.
§ Mr. Pavitt
The heading to the report states that the Secretary of State is to take control. It then states that the right hon. Gentleman is to take powers to intervene. That implies that he is taking new powers. If that is true, what are they? Is the Minister saying that there are no new powers and that nothing is different?
§ Dr. Vaughan
The hon. Gentleman should not get carried away by everything that he reads in the press. We have the powers. My right hon. Friend the Secretary of State is instituting a series of discussions with the regions, looking ahead at how they and their districts are planning to spend their resources in the coming months. We can discuss it with them again later to see how they actually spent the resources. In that way we shall introduce an important and fundamental aspect of accountability into the system. This will be of benefit to the Health Service.
§ Mr. Andrew F. Bennett
Will the Minister confirm that up to now he has been leaving it to the officials in the Department of Health and Social Security? What is the Minister adding by going along with the discussions that officials have in the past had with the regions?
§ Dr. Vaughan
We are having discussions of a kind that have not taken place before. We are getting the health authorities to commit themselves on how they will spend their resources. As I say, we can discuss with them where changes have been made. We are introducing a level of accountability that we did not have under the previous Administration.
The hon. Member for Crewe (Mrs. Dunwoody) was remarkably restrained in her speech. That seemed to me to suggest substantial agreement with what we are doing. The hon. Lady accused me of indecision. She seemed to be advocating greater rigidity. She seemed upset that we were prepared to have health authorities which are largish, if that is appropriate to the part of the country they are serving, or small. In my opening remarks I gave examples of the difference between Rugby and Leicestershire.
§ Mr. Michael English (Nottingham, West)
I am grateful to the hon. Gentleman in two respects. He has been very helpful to all the people of Nottingham. He knows that the guidelines originally had a certain limitation. He knows equally that he went beyond those, 486 as a sensible Minister should. In that area and in a few other areas he acceptd the fact that not every immediate limitation should be obeyed. Would he do one simple extra thing? Now that he has granted that the order should include something slightly more than for the rest of the United Kingdom, will he say also that if four district councils are included, they should have more than three places on the local district health authority?
§ Dr. Vaughan
I was about to refer to the excellent virtues of Nottingham and the problems that it has over representation by authorities. I have discussed this with the hon. Gentleman. We would be pleased to have a further look to see whether a slightly different representation would be of benefit to Nottingham.
In regard to the variation in sizes of population, it surprised me that the hon. Member for Crewe should have brought this up in the way that she did. I should have thought that it was of benefit to the various parts of the country to have small or large district health authorities. If the hon. Lady looks at "Patients First" she will see that the criterion we set out on population was not rigid, although we made some suggestions on population size.
We suggested as the main criterion that the boundaries of the district health authority should include the majority of the patients being served by the main hospital in the district. That is what we have tried to do. On every side we have been looking at the Health Service's needs rather than rigid boundaries.
§ Mr. John Major (Huntingdonshire)
Is my hon. Friend aware that the variation in size is welcomed by those of us who are now in the midst of small and new district health authorities? Will he bear in mind that new district health authorities, such as Huntingdon, which are among the smallest in the country, are establishing an homogeneous unit that was in danger of disappearing when the old county of Huntingdon departed to Cambridgeshire? Will he bear in mind that that has caused great pleasure locally and that we are extremely grateful to him for his decisions?
§ Dr. Vaughan
I shall give way to any other hon. Member if he or she will also make such points.
The hon. Members for Crewe and for Brent, South referred to teaching hospitals.
§ Mrs. Dunwoody
I am grateful to the Minister for giving way. We all seem to he playing this Box and Cox game. What is the Minister's attitude towards the generation of resources by small units? If a unit is too small, how is it expected to generate resources? It suited the Minister not to stick to his own criteria.
§ Dr. Vaughan
The hon. Lady has taken a gloomy view about some of the smaller authorities. The hon. Member for Birmingham, Stechford gave us one example. I could give other examples where we believe that smaller authorities will lead to quicker and better decisions, less waste of money and less faulty planning. We believe that more direct and locally orientated authorities will make considerable savings, which I hope will be greater than we forecast.
The hon. Lady referred to teaching hospitals. She must know that there is an allocation of extra funds to health 487 authorities which have a teaching hospital in their area. Of course there is an extra allocation. She must also know that we arranged extra university membership in places where there are teaching commitments. We have also recommended one university liaison committee for a medical school. We have recommended that the dean should be able to attend meetings of a district health authority when necessary.
It will be sweet to the hon. Lady's ears to hear that the salaries of chief officers will be enhanced in the teaching areas. Therefore, I should have thought that we have given ample attention to the problems of the teaching hospital areas.
The hon. Lady referred to "CHC News". The estimated cost of central funding for "CHC News" and the associated information service this year is £74,000. In our view, such a service and expense is more properly paid for by the community health councils.
I understand that there is considerable support for "CHC News" among many community health councils. There is no reason why they should not be prepared to pay for it themselves. If the hon. Lady believes, as we do, that the community health council is a local body, local action is required. If community health councils want to have a national paper, we feel that they should fund it from their own resources.
The hon. Lady also mentioned the family practitioner committees. Free-standing family practitioner committees will be better able to promote community health care. We believe that it will give them a more powerful new voice in community health developments, but we cannot achieve this until we have legislation before the House.
§ Mr. Spriggs
It seems to me and to the chairman of my community health council that there is something of which to be afraid. The £74,000 is being withdrawn from the community health councils because it has been a means of communicating with Members of Parliament and the public. Will the Minister tell us what he is afraid of?
§ Dr. Vaughan
I listened with sympathy to what the hon. Gentleman said, but I really think he is talking absolute nonsense. To suggest some sort of fear as a motivation for this is rubbish. We believe that if it is so valuable to the community health councils they should be able to pay for it themselves.
The hon. Member for Crewe and other hon. Members talked about the value of coterminosity. We made it clear during all the discussions that, where possible, we would like to see a coterminosity between the Health Service and local authority boundaries. This makes great sense when it comes to co-ordination with, for example, the social services. However, we do not believe that that should be the overriding consideration. Where the Health Service needs demand a different boundary, we said, as the hon. Lady knows, that we would expect the Health Service needs to be the yardstick in determining the new boundaries.
My right hon. Friend the Member for Chesham and Amersham (Sir I. Gilmour), my hon. and learned Friend the Member for Beaconsfield (Sir R. Bell) and my hon. Friend the Member for Wycombe (Mr. Whitney) questioned the Berkshire-Buckinghamshire overlap. They put forward a very strong case from the Buckinghamshire point of view. Indeed, it was all one way. They made no 488 reference to the people who have expressed opposing views, although my hon. Friend the Member for Wycombe admitted that the view in his constituency was not wholly in favour of the Buckinghamshire side.
§ Sir Ronald Bell
My hon. Friend the Member for Wycombe said that in his constituency there was a minority view to the opposite effect. I said that in Berkshire there are no doubt opposing views, but that in my constituency—and the whole of the area concerned is in my constituency—there is virtual unanimity.
§ Dr. Vaughan
I have a list here of those in favour of the transfer of the overlap to the Wycombe district health authority. There are actually 11 bodies, but I am not playing the numbers game. I also have a list of 22 bodies whose views are very strongly in the opposite direction. While the hon. Members to whom I have referred feel strongly one way, my hon. Friend the Member for Windsor and Maidenhead (Dr. Glyn) feels differently. So does my hon. Friend the Member for Wokingham (Sir W. van Straubenzee). When I look at the people who are in favour of the status quo, what do I find? The answer is the Berkshire FPC and also the area dental advisory committee—it should know a little—and the Thames Valley branch of the Health Visitors Association.
§ Dr. Vaughan
Not quite as easy. I also find the chairman of the hospital medical committee of the High Wycombe district.
§ Dr. Vaughan
Therefore, I suggest that things are not quite as solidly in one direction as was suggested. However, I understand the strength of feeling and the anxieties of my right hon. and hon. Friends on this matter and I suggest that I call the new East Berkshire chairman to see me and discuss with him procedures to ensure a proper cover for health services in the overlap. Then, if my right hon. and hon. Friends are still unhappy and can show that, as it turns out, we are wrong, we shall of course reexamine the situation in about 12 months' time and take steps to put matters right.
§ Mrs. Dunwoody
Is the Minister prepared to give that kind of undertaking for other areas where people are desperately concerned about the changes?
§ Dr. Vaughan
The hon. Lady has misunderstood the degree of support in other parts of the country. My right hon. Friend the Member for Chesham and Amersham made one incorrect statement. Under the agency temporary arrangements with the family practitioner committees, there will not be an expense of £80,000 to transfer records as he suggested.
I understand how my hon. Friend the Member for Cheltenham (Mr. Irving) feels, but he used some powerful words, some of which I much regret. I cannot accept the way in which he expressed his feelings and I hope that he, too, will regret the way in which he spoke tonight.
I understand how my hon. Friend feels and I understand also how his good friend Sir Robert Hunt feels. My hon. Friend knows that not only did I examine the matter, but that it was exhaustively examined personally by my right hon. Friend the Member for Wanstead and Woodford (Mr. Jenkin).
My hon. Friend was correct in telling us that it had been thought that a single authority for Gloucester and 489 Cheltenham would be best, and it was tried for three years. But that is as far as my hon. Friend was correct, because in the view of many people it did not work. Cheltenham and Gloucester did not work together. They were described to me as merely working back to back, facing in different directions.
§ Dr. Vaughan
My hon. Friend did not refer to the strongly held views of my right hon. Friend the Member for Gloucester (Mrs. Oppenheim), which are contrary to those that he put to us tonight.
I know that the right hon. Member for Lewisham, East feels very strongly about the Lewisham-Guy's connection. I shall not disappoint the hon. Member for Stechford when I say that what was done was recommended by the region. In this matter we must look at the whole Health Service. We cannot look at one part of a district and leave another out of consideration. We must look at the problems of Lewisham and at the problems of the Guy's district to the north of Lewisham.
I believe that what has been proposed in the amalgamated district will, over a period of time, be to the satisfaction of the residents of those areas. I ask the right hon. Gentleman to look at Guy's not as an intruder but as an additional jewel in the Lewisham district crown.
The hon. Member for Brent, South made the valuable suggestion that a director of social services might be a member of the matching health authority. Why not? There is no reason, so far as I know, to stop a local authority appointing a director of social services as a member if it wishes. I suggest that the hon. Gentleman should take the matter up with his local authority.
§ Mr. Pavitt
What the Minister has said means that the four representatives do not necessarily have to be elected representatives, and that the council can appoint anyone it likes to take its four places on a district health authority—council officers or even members of the general public.
§ Dr. Vaughan
I shall be pleased to discuss this matter further with the hon. Gentleman later.
The hon. Member for Brent, South asked about teaching hospital trust funds because of the commitment to teaching hospitals in regard to medical education and NHS patients. Since 1974 those trust funds have been kept separate from the rest of the NHS trust funds. These arrangements will continue and special trustees will still be appointed.
The hon. Member for Ashfield (Mr. Haynes) is always lively and original in his remarks. I was pleased to hear him say that he wanted on these authorities people who know what they are doing and who will look to the health care needs of the future.
The hon. Member for Easington (Mr. Dormand) said that I was wrong in pointing out that there was an Easington member on the Sunderland health authority. I hope that I am not wrong. I am assured by the Northern regional health authority that a member from Easington was nominated by the Easington council voluntary services. That gentleman lives in Seaham, as far as the regional health authority knows. Therefore, I hope that the hon. Gentleman will accept that Easington is properly represented.
§ Mr. Dormand
The Minister wrote to me to say that someone who lived in Seaham was on the new authority and that therefore that met the point. I told him that that was incorrect. The person to whom he referred does not live in Seaham. He lives in Houghton-le-Spring, which is an entirely different area. I can give the Minister his address. I was making the point that with a remote body such as the Government, or the Minister, such mistakes can be made. Therefore, he should put it right.
§ Dr. Vaughan
I shall be glad to look into that matter again.
My hon. Friend the Member for Edgbaston made a number of telling points. She asked about the money going to the NHS. We are proud of the resources that we have channelled into the NHS. In my opening speech I referred to some of the press comments, which have pointed out that more resources have gone into the NHS under this Government in the past two and a half years than at any time since 1948. In 1978–79 the gross outturn of capital and revenue costs in England only were £6,500 million. Those are cash prices. In 1982–83 the figure will be £12,100 million. That is an increase of £5,600 million—87 per cent. That is a 5 per cent. increase in real ten-ns, and a further 1.7 per cent. increase this year in real terms. Channelling resources into a needy part of our services is something of which we should be proud.
I was particularly interested in the points raised by my hon. Friend the Member for Canterbury (Mr. Crouch). I agree with him about the value of having as a Member of this House someone who has experience on a regional health authority.
I ask the House to contrast what we have done, for patient care, the urgency with which we have taken action, our decision to respond to the almost universal wish that changes should be made because the service was too remote and bureaucratic, with the lethargy and fog of the Labour Administration. When I took up my present appointment I was appalled by the drift and indecision that we found in the National Health Service, the lengthening waiting lists, which we have had to bring down, and the decaying buildings. The House should contrast that with the £1,000 million of building development that is now under way.
These orders will profoundly change the way in which the National Health Service will operate, but more important than any of the technicalities of these orders is the change in the style of national health care management that we hope for. These orders will provide a truly local framework in which the district health authorities can exercise their functions for health care in the way that local communities need them.
I therefore ask the House to accept these orders arid to reject the prayers which have been moved against them by the Opposition.
§ Question put and negatived.
§ It being after Ten o'clock, MR. DEPUTY SPEAKER proceeded, pursuant to Order this day, to put forthwith the Question necessary to dispose of the remaining motion.
§ Motion made, and Question put,
That an humble Address be presented to Her Majesty praying that the National Health Service (Determination of Districts) Order 1981 (S.I., 1981, No. 1837), dated 21st December 1981, a copy of which was laid before this House on 15th January, be annulled.—[Mr. Terry Davis.]
§ The House divided: Ayes 54, Noes 125.492
|Archer, Rt Hon Peter||Home Robertson, John|
|Atkinson, N.(H'gey,)||Homewood, William|
|Barnett, Guy (Greenwich)||Hooley, Frank|
|Bennett, Andrew(St'kp't N)||Kerr, Russell|
|Booth, Rt Hon Albert||Lamborn, Harry|
|Brown, R. C. (N'castle W)||Lamond, James|
|Callaghan, Jim (Midd't'n&P)||McDonald, Dr Oonagh|
|Carter-Jones, Lewis||McWilliam, John|
|Clark, Dr David (S Shields)||Moyle, Rt Hon Roland|
|Cocks, Rt Hon M. (B'stol S)||Newens, Stanley|
|Concannon, Rt Hon J. D.||Palmer, Arthur|
|Cryer, Bob||Powell, Raymond (Ogmore)|
|Davis, Terry (B'ham, Stechf'd)||Prescott, John|
|Dean, Joseph (Leeds West)||Skinner, Dennis|
|Dormand, Jack||Snape, Peter|
|Dubs, Alfred||Soley, Clive|
|Dunwoody, Hon Mrs G.||Spearing, Nigel|
|Eastham, Ken||Spriggs, Leslie|
|English, Michael||Stoddart, David|
|Evans, loan (Aberdare)||Walker, Rt Hon H. (D'caster)|
|Fraser, J. (Lamb'th, N'w'd)||Welsh, Michael|
|Freeson, Rt Hon Reginald||Whitehead, Phillip|
|George, Bruce||Whitlock, William|
|Graham, Ted||Winnick, David|
|G rant, George (Morpeth)||Woolmer, Kenneth|
|Hamilton, W. W. (C'tral Fife)|
|Hardy, Peter||Tellers for the Ayes|
|Harrison, Rt Hon Walter||Mr. James Tinn and|
|Haynes, Frank||Mr. George Morton.|
|Alexander, Richard||Glyn, Dr Alan|
|Alton, David||Goodhart, Sir Philip|
|Aspinwall, Jack||Goodlad, Alastair|
|Beaumont-Dark, Anthony||Gow, Ian|
|Benyon, W. (Buckingham)||Greenway, Harry|
|Berry, Hon Anthony||Griffiths, Peter (Portsm'th N)|
|Bevan, David Gilroy||Haselhurst, Alan|
|Biffen, Rt Hon John||Hawksley, Warren|
|Biggs-Davison, Sir John||Heath, Rt Hon Edward|
|Blackburn, John||Heddle, John|
|Braine Sir Bernard||Hogg, Hon Douglas (Gr'th'm)|
|Bright, Graham||Holland, Philip (Carlton)|
|Brinton, Tim||Hunt, David (Wirral)|
|Brooke, Hon Peter||Hunt, John (Ravensbourne)|
|Brown, Michael (Brigg&Sc'n)||Hurd, Rt Hon Douglas|
|Brown, Ronald W. (H'ckn'y S)||Jopling,Rt Hon Michael|
|Budgen, Nick||Kaberry, Sir Donald|
|Cadbury, Jocelyn||Kershaw, Sir Anthony|
|Carlisle, John (Luton West)||Knight, Mrs Jill|
|Carlisle, Kenneth (Lincoln)||Knox, David|
|Clarke, Kenneth (Rushcliffe)||Lamont, Norman|
|Cope, John||Lang, Ian|
|Costain, Sir Albert||Lawrence, Ivan|
|Cranborne, Viscount||Le Marchant, Spencer|
|Crouch, David||Lennox-Boyd, Hon Mark|
|Dorrell, Stephen||Lester, Jim (Beeston)|
|Dover, Denshore||Lloyd, Peter (Fareham)|
|Dunn, Robert (Dartford)||Loveridge, John|
|Dykes, Hugh||Macfarlane, Neil|
|Eggar, Tim||MacGregor, John|
|Faith, Mrs Sheila||Major, John|
|Fenner, Mrs Peggy||Marland, Paul|
|Finsberg, Geoffrey||Marlow, Antony|
|Fletcher-Cooke, Sir Charles||Marshall, Michael (Arunde)|
|Fowler, Rt Hon Norman||Mates, Michael|
|Garel-Jones, Tristan||Maude, Rt Hon Sir Angus|
|Maxwell-Hyslop, Robin||Speller, Tony|
|Mayhew, Patrick||Spicer, Michael (SWorcs)|
|Mellor, David||Stanbrook, lvor|
|Mills, Peter (West Devon)||Stanley, John|
|Moate, Roger||Stevens, Martin|
|Morris, M. (N'hampton S)||Stewart, A. (ERenfrewshire)|
|Morrison, Hon C. (Devizes)||Stradling Thomas, J.|
|Murphy, Christopher||Taylor, Teddy (S'end E)|
|Needham, Richard||Tebbit, Rt Hon Norman|
|Nelson, Anthony||Temple-Morris, Peter|
|Neubert, Michael||Thompson, Donald|
|Newton, Tony||Thorne, Neil (Ilfordsouth)|
|Osborn, John||Townend, John (Bridlington)|
|Page, Richard (SW Herts)||Vaughan, Dr Gerard|
|Penhaligon, David||Waddington, David|
|Percival, Sir Ian||Wainwright, R. (Colnev)|
|Pink, R. Bonner||Waller, Gary|
|Proctor, K. Harvey||Watson, John|
|Pym, Rt Hon Francis||Wells, Bowen|
|Rathbone, Tim||Wheeler, John|
|Rhodes James, Robert||Wickenden, Keith|
|Rhys Williams, Sir Brandon||Wilkinson, John|
|Roberts, Wyn (Conway)||Williams, D. (Montgomery)|
|Ross, Stephen (Isle of Wight)||Winterton, Nicholas|
|Sainsbury, Hon Timothy||Tellers for the Noes:|
|Shaw, Giles (Pudsey)||Mr. Robert Boscawen and|
|Shelton, William (Streatham)||Mr. Selwyn Gummer.|
§ Question accordingly negatived.