HEALTH SERVICES BILL

Lord WELLS-PESTELL

My Lords, I shall not pretend that the measure to 1480 which I am asking your Lordships to give a Second Reading is not a controversial one. It deals with an issue on which sincerely held opinions have been deeply divided for a long time, and we on this side of the House recognise that there is a very deep divide between the Government and the Opposition and that it may well be that there is little, if any, meeting point between us.

But the issue is whether today it is socially acceptable to set aside in National Health Service hospitals accommodation and facilities to enable consultants to treat their private patients. When the National Health Service was established in 1948, the late Aneurin Bevan accepted as a means of securing the wholehearted co-operation of consultants in the new service that the practice of the former voluntary hospitals of setting aside a few beds for patients who wished to receive and pay for private treatment should, for the time being, continue in the National Health Service; that was the new National Health Service. Although he made it clear in his book In Place of Fear that he had not contemplated that it would continue indefinitely, the arrangement has in fact continued for the best part of 30 years. In that time demand for private treatment has diminished with the development of a comprehensive National Health Service. Increasingly, however, in recent years the co-existence in the same hospital of a small private sector and public provision of essential medical services has come to be regarded by many patients, and by a large number of people who work in our hospitals, as socially divisive, a source of serious grievance, dissension and, I regret to say, in some places, as your Lordships know, confrontation.

The root of the dissension and confrontation is the widely held belief that it is morally indefensible that those who can afford the high cost of private treatment or the cost of insuring against it, say with BUPA or one of the other provident associations, should be able to arrange for non-urgent hospital treatment sooner in the National Health Service than if, like the majority of patients, they had to rely solely on the National Health Service. In short, it is a widely held belief that the continued existence of pay beds has conferred, at the expense of the majority, an unacceptable 1481 degree of privilege on those who can afford to pay a premium for jumping the queue.

In the Government's judgment, access to a service that is financed by the community as a whole should not be influenced by any consideration other than the relative urgency of the individual patient's need for treatment. No one, my Lords, would dream of denying immediate access to the Health Service if life was endangered. Society as a whole recognises that where it is a question of life and death immediate access should be afforded regardless of a patient's means or financial circumstances, and all our arrangements for emergency services are directed to that end. In fact, 42 per cent. of all admissions to National Health Service hospitals are classed as emergencies.

Difficulty begins only where one is considering essential but non-urgent admissions. It is, I am afraid, a fact of life that demand for health care is infinite, and that ascertained need for treatment exceeds the capacity of available resources to meet that need immediately. In a perfect world no doubt, where resources would be unlimited, there would be no need for waiting lists, no need for queues. In the real world in which we live we have got to face the fact, whether we like it or not, that some rationing of health care is unavoidable.

One issue which this Bill seeks to resolve is how such rationing should be effected; whether a priority should be assessed in terms of clinical and social needs, or in terms of the individual's ability to buy a higher priority than his clinical condition really warrants. In the Government's view there can be only one answer in National Health Service hospitals: priority must he assessed on clinical and social need alone. The Government are satisfied that so long as it is possible for a patient to receive treatment privately in a National Health Service hospital, it will be difficult to ensure that that will happen, or to satisfy the public at large that ability to pay a private fee does not in some way influence the speed of admission.

The National Health Service exists to provide a comprehensive health service for all citizens, irrespective of their means. It is not, therefore, in business to meet the special needs of private patients. The 1482 fact that it has continued to set aside some of its resources for the benefit of private patients is regarded by many of the most ardent supporters of the Health Service as morally objectionable, socially unjust, and a potential source of abuse.

That view is shared by the Government, and that is why my Party laid the policy of separation before the electorate in the successive General Elections in 1974; a policy which the electorate endorsed twice. I need not remind your Lordships that the policy was strongly opposed by the medical and dental professions, and equally strongly supported by the representatives of Health Service staffs. No one, however, could accuse the Government of acting precipitately in this matter. For nine months after my Party was returned to power we tried in the Owen Working Party to discuss future arrangements for private practice with representatives of consultants. And what happened? We were told that they had no mandate to discuss private practice, but we continued to try.

I will not weary your Lordships by recounting the events which led up to the publication in August last year of a Consultative Document or of the discussions between the then Secretary of State and representatives of the professions—discussions in which the noble Lord, Lord Goodman, acted as an intermediary. I do not see the noble Lord in your Lordships' House and perhaps it might well be considered a piece of impertinence on my part to say how indebted the Government, and I think probably everybody in your Lordships' House, are to him for the part he played in what we have come to call the "Goodman proposals".

I do not think that it is going too far to say that the Goodman proposals marked a dividing line between a period of increasing dissension and confrontation in the National Health Service and a period of calmer counsels. I would not pretend that the Goodman proposals offer the perfect solution. I am sure that the noble Lord would be the first to admit that. They are essentially a compromise formula that recognises the deep division of view between, at one extreme, those who see advantage in the continued existence of private medical practice in the National Health Service and, at the other, those 1483 Who—quite frankly, like myself—see it as morally objectionable. They offer a formula for giving effect to the Government's commitment to separate private practice from the National Health Service, while at the same time providing for those who believe in private practice reasonable opportunity for making suitable alternative provision outside the National Health Service. They allow for the immediate phasing out of 1,000 pay beds, which I ask your Lordships to bear in mind are very little used, and thereafter for the pace of the phasing out of the remainder to be determined by a Health Services Board who will be quite independent of the Secretary of State. They lay down four basic principles for the guidance of the Board and provide for private patients to have access to National Health Service facilities for highly specialised treatment on an occasional basis and, a point to which the professions attached great importance, they provide for private practice to be guaranteed by legislation.

As I said earlier, the Government undertook, if these proposals were acceptable to the professions, to give effect to them in early legislation. The British Medical Association thereupon held a ballot of its consultant members and approximately 12,200 consultants in England, Wales and Scotland received the ballot papers. The ballot put to the consultants a rather severe dichotomy: Would you rather accept the proposals of 15th December 1975 as a basis for legislation or resign from the National Health Service? Out of 12,200 consultants, the British Medical Association received 7,039 replies; 63 per cent. of the 7,039 consultants were prepared to accept that the Goodman proposals should be incorporated in legislation. That means that of the 12,200 consultants, only 21 per cent., 2,604, were opposed to the Goodman proposals but, as I say, as a result of the ballot based on the Goodman proposals industrial action was halted and this Bill was prepared.

The Health Service Bill was introduced in another place on 12th April of this year. Since that date there have been almost continuous discussions of its provisions both within and outside Parliament. My right honourable friend, the Secretary of State for Social Services has had several meetings with representatives of the medical 1484 and dental professions. The Chief Medical Officer has had discussions with representatives of the Joint Consultants' Committee, the Department has consulted the Independent Hospitals Group on numerous occasions. There was continuous consultation up to 30th September with the National Health Service health authorities about the best distribution between individual Area Health Authorities and preserved Boards of Governors of the 1,000 pay beds whose authorisations are to be withdrawn within six months of the Royal Assent.

Simultaneously, from 18th May to 3rd August, through 29 sittings the Standing Committee in another place was scrutinising this Bill, not just clause by clause. I think the noble Baroness would agree with me if I said, word by word, line by line. There were something like 500 Amendments considered. They spent upwards of 70 hours discussing this matter. I only say this because I believe, my Lords, there can be few Bills so meticulously, so thoroughly and, let me be quite frank about it, so constructively considered. A number of highly important changes were made, with the Government's agreement, both during the Committee's consideration and also, as a result of it, at Report stage. So careful and intent was the examination of the Bill by the Committee that the Government yielded to the strong persuasion of honourable Members of the Opposition to grant two days for Report.

My Lords, there can be no doubt that this Bill has derived immense benefit from both the customary Parliamentary scrutiny and from the enormous amount of consultation with interested bodies outside. The Government wholeheartedly acknowledge that errors and weaknesses have been identified and have been eradicated. One of the major improvements, I would suggest, was the addition at Report of the provisions which will include the Health Services Board and its Committees among the bodies in respect of which the Health Service Commissioners are empowered to conduct investigations. So the Health Services Board will be subject to the authority of the Health Services Commission should the need arise.

The Board will, I think, gain in stature. Not only will it be fully independent, as 1485 the proposals brought forward under the aegis of the noble Lord, Lord Goodman, envisaged; it will also be openly required to maintain the high standard of administration required of bodies subject to the Health Services Commissioners. Moreover, the Board will, when acting in its quasi-judicial capacity under Part III of the Bill, also be under the supervision of the Council on Tribunals. Noble Lords, may therefore, be assured that both the administrative and the judicial integrity of the Board will at all times be subject to supervision.

Your Lordships may wish me to recapitulate the main provisions of the Bill. I do not propose, because of the time, to go into them in great detail. I know sufficient about your Lordships to know that many of you will have studied them in very great detail. The Bill as it now stands consists of four Parts (containing 24 clauses) with five Schedules. Part I and Schedule 1 deal with the constitution, status and method of appointment of the Health Services Board and its Scottish and Welsh Committees: they contain the important provisions which delineate the Board's relationship with Parliament, with the Crown (in particular with the Secretary of State), with the Health Service Commissioners and with the Council on Tribunals.

Part II begins with the declaration that consultants cannot be compelled by regulation to hold wholetime contracts, which would imply the loss of the right to practise privately. It goes on, in Clause 3, taken with Schedule 2, to require the Secretary of State to remove within six months of Royal Assent, the authorisation of 1,000 pay beds, distributed between the Area Health Authorities of England, Wales and Scotland in the manner set out in Schedule 2. Clauses 4 and 5 describe the way in which the Board must carry out its function to make proposals (which the Secretary of State must implement) for the revocation of authorisations previously given for pay beds and private out-patient facilities. Clause 6 lays an additional duty on the Board, to make recommendations to the Secretary of State for the best method of achieving Common waiting lists for NHS and pay bed patients requiring admission to NHS hospitals. The provisions of Clauses 7 and 8 are concerned with the new system under which patients who require highly 1486 specialised treatment which is not available at all, or accessible to them, in the private sector can be admitted, as private patients, to NHS hospitals on an occasional basis, and in carefully specified circumstances. The rights of general practitioners and others to preserve and make new arrangements with the Secretary of State to treat their private patients in health centres is also dealt with in Clause 9.

Part III contains the provisions for the setting up of a new system of control of some forms of hospital building in the private sector. The Board will have to operate that system. Developers of large acute private hospitals—that is hospitals providing over 100 beds if in London or with over 75 beds if outside London—will need to apply for authorisations from the Board before local planning authorities will consider an application from them for planning permission. These authorisations will be granted unless the Board is satisfied that the development in question would cause detriment to the National Health Service. Other acute private hospital developments will have to be notified to the Board (your Lordships will find that in Clause 14) but the Board will have no powers of control over these. The reason for the inclusion in the Bill of the notification procedure is that the Board must at all times—and it seems to me to be perfectly reasonably and will be acceptable to many of your Lordships—have adequate accurate information about all private sector developments of a kind likely to be relevant to the consideration of whether pay beds in a given area could be phased out. The four principles on which the Board must base its recommendations about phasing out pay beds include the existence or not of adequate alternative facilities in the private sector. I think most noble Lords will consider this to be of supreme importance.

Clause 19 makes a link between the Bill and existing nursing homes legislation under which at present private nursing homes and hospitals are registered by health authorities and are supervised for the quality and standards of the facilities, accommodation and staffing. The clause amends the nursing homes legislation, so that an additional ground for refusing orcancelling registration would be, in the case of a new development of the kind requiring an authorisation from the Board, the contravention by a 1487 developer of the requirement in Clause 12 to obtain an authorisation before building a private hospital. These Amendments also raise the penalty for carrying on a private nursing home or hospital without being registered from a maximum fine of £50 (which has been in existence at that level since 1936) to a maximum of £400 on summary conviction or an unlimited fine on indictment.

My Lords, I think it must be clear now, I hope beyond doubt, what are the aims of the Government in bringing forward the Health Services Bill. The care with which the independence, the rectitude and the balance of the Health Services Board have been attended to, cannot but lead to the evolution of a rational, just and methodical approach to the task of phasing out pay beds from National Health Service hospitals. There will be nothing hasty and nothing arbitrary in the way in which this is done. Similarly, in the testing and delicate field of considering applications for authorisation for the building of large acute hospitals in the private sector, the obvious standing and integrity of the Board must have its effect on the way in which these decisions are made.

In other places, there have been misrepresentations of the Government's intentions. I believe that some of these have been quite deliberate because the Bill itself is explicit, and the Government have explained time and again the reasons for the provisions of Part III. The Bill cannot and does not empower Ministers to squash, squeeze or hustle private practice out of existence; that is, out of the private sector itself—out of the National Health Service, yes.

Since the first announcements of the Government's policy, during the spring and summer of 1975, and increasingly since the publication of the Bill, the Department has kept itself as informed as possible about actual and planned increases in the amount of hospital provision in the private sector. I want to say something about that because I think it will surprise a good many of your Lordships. We know, for example, that between the spring of 1975, when the Government's policy was first announced, and the expected end of the "initial period", that is May 1977, about 300 new 1488 beds for acute treatment in the private sector will have become available in London alone. This will bring the total number of private sector beds for acute treatment in London to approximately 2,000, almost half of the total number of such beds in the whole of Great Britain. In addition, we are aware of a number of well-advanced plans for further expansion of the number of acute facilities in the country. All we say is that for obvious reasons if it is a hospital of over 75 beds outside London or over 100 in London the Secretary of State must know what these developments are for.

I trust that the Government's assurances of good faith are not going to be viewed with suspicion by your Lordships. We do not desire or intend to do anything further in the matter of private practice than carry out the provisions of this Bill; we do not therefore have plans to abolish private practice. Our aim is to foster harmony between the people who work in the National Health Service and who work in the field of health for the people of Great Britain.

We sincerely hope by this Bill to remove a long-standing source of bitterness, anger, frustration and disruption, and to get back to the most important thing; namely, the care of patients. It is because we are concerned with the care of patients, particularly those who have to use the National Health Service, that we have brought in this Bill. My Lords, I commend the Bill to you and hope that you will give it a Second Reading.

Baroness YOUNG

My Lords, I should like to begin by thanking the noble Lord, Lord Wells-Pestell, for introducing this Bill to us today and for explaining so clearly its purpose and its background. It is always a pleasure to work with the noble Lord, Lord Wells-Pestell, and on many occasions in the past we have found ourselves in complete agreement over a great many things, but as he himself has indicated it will not be the case on this Bill which is a highly contentious measure. I regret to say that the only congratulations I can offer him are offered because he has made the best of a very bad case. At the start I should like to offer my good 1489 wishes to the maiden speaker this afternoon the noble Lord, Lord Stone, and to say from this side of the House that we wish him well.

The Bill before us is important. It comes to us at a very late time in the day. As I understand it, it has only just managed, with one day to spare, to avoid being caught by the Parliament Act. I believe a month is required from the First Reading to the end of the Session, and in fact the Government have allowed one day over that time. However, I find it astonishing that the House of Lords, whose prime function is as an amending Chamber, should have so little time to consider a Bill which must inevitably affect all patients in the National Health Service in hospital now, a Bill which has been subject to a great many tied votes in Committee in another place and one on which finally the guillotine fell.

It comes to us at a time when the House seems to have been in almost continuous session since September, and many Members of your Lordships' House must feel that enough is enough. It seems to me that all the more deplorable such an important Bill should arrive here so late and with so little time for debate; for, despite the fact that the Bill has been looked at very thoroughly by another place, there area great many detailed points to which we shall want to return on Committee; and quite properly we should return to them on Committee. I cannot accept the reason given by the noble Lord that at two Elections the population voted for this measure. He will be as well aware as I am that only 28 per cent. of the population supported the Labour Government in October, 1974, and to claim by any stretch of the imagination that most people want this Bill is simply wishful thinking.

The fact is that although the Bill is entitled "Health Services Bill", it does absolutely nothing to help the National Health Service patient or to improve his care. I listened with great care to what the noble Lord said in making out his case and I cannot see that he advanced one single practical way in which the ordinary National Health patient will be better off when this piece of legislation reaches the Statute Book. I have looked very hard for evidence to find out how this Bill would make the care of a patient 1490 better. It is because I have been unable to find any at all—because I do not believe any exists—that we on this side of the House are opposed in principle to it.

The noble Lord, Lord Wells-Pestell, has explained the Bill, which does, broadly speaking, two things. First, it phases out 1,000 pay beds from the National Health Hospital Service; secondly, it introduces new controls over private hospitals, their building and maintenance. By the separation of the Health Service and private practice it created a kind of medical apartheid.

I am sure that no one wants the care of the National Health Service patients to decline. The doctors do not want it and I am sure the trade union leaders and their members do not want it; nor do the Government or the Opposition. At first sight it may be contradictory to say that we believe that National Health Service patients will be worse off because of this Bill; but so often is it the case that the full effects of a piece of legislation are not appreciated at the time that that legislation is going through the House. It seems to me therefore worth while to consider what will be the practical effects of this piece of legislation on the Health Service.

The first effect must he on the doctors, and because of that, its effect on the patients. I do not come from a family of doctors; but all my family have been engaged in the professions, particularly in education. The fact is that in the education world, if you get a good head of a school he or she will attract and will appoint good staff. The pupils, as a consequence, will be well taught. So it is in medicine: the quality of the service is measured by the quality of the staff. We in this country have, rightly, been proud of the National Health Service, which has been in many respects the envy of the world. It is the present generation of consultants and others in the Hospital Service who have to a very large extent given the National Health Service the reputation that it has. One consultant who came to see me put it to me that he was glad in 1948 to join the National Health Service. Before the National Health Service, medicine was not always an easy profession to enter, especially for a young man or young woman starting out. 1491 The introduction of the National Health Service meant that it was no longer necessary for a doctor to see enormous numbers of private patients in order to make a living, and that the staffing of the hospital was geared to the needs of the population and not dependent upon a generation of need by private patients. There were therefore great advantages to the doctor in joining the National Health Service; and beause there were great advantages to the doctor, there were great advantages to the patient, and a bargain was struck.

It is no exaggeration to say that many consultants have worked far more than the hours they are obliged to work by contract, and many will work as much as 30 hours a week over and above what they are obliged to do, because they believe in the Service. Part of the bargain was that they should be allowed private practice and that they should be allowed private practice in hospitals. The consequence has been, whatever the noble Lord, Lord Wells-Pestell, may say—and I do not doubt for one minute his sincerity—that they feel that this trust has been broken. The argument for taking the private beds out of the National Health Service hospitals is that somehow the doctors are doing something that is morally wrong.

What is being said—and all that the doctors are asking for—is the right to sell their skill in the market place after they have fulfilled their contracts, and frequently more than fulfilled their contracts, to the National Health Service. This, after all, is not a surprising request. If a plumber or an electrician works in the evening or at weekends in his own time, taking private clients after he has fulfilled his contract to his employer, what has he done that is wrong? If the teacher in his spare time coaches a backward child with reading difficulties and gets paid for it, is this a crime? Indeed, if the university lecturer lectures to the Workers' Educational Association two evenings a week, what is this but a form of private practice? Nobody is suggesting that any of these people who do things quite properly in their own spare time are doing anything but something which is a help to the community at large; and if it helps themselves in the process, there is nothing morally wrong with that at all.

1492 The fact is that many doctors see this Bill as a step in the direction of a full-time salaried Service, of a Service in which there will not be the freedom to practise medicine privately after fulfilling their work in the National Health Service. Everybody must realise that if this came to pass the care of the patient would inevitably deteriorate. What such a full-time salaried Service would mean is that minimum standards of care would be set, and not maximum standards, and so the patient would suffer. I cannot believe that this is the intention of the Government.

The noble Lord, Lord Wells-Pestell, has explained at length those parts of this Bill which have been written in to guarantee the right of private practice to doctors. But what are people to think? All sorts of guarantees were given in 1948. Legisation cannot guarantee because we cannot bind our successors; and what, above all, is needed is trust. That seems to be one of the most important things that is missing at this time.

The centre of my argument is that, as a result of this legislation, it is the patient who will suffer, and I should like to consider in detail a number of other points. The first is the question of finance. We are all agreed that we are in a time of economic crisis when money is scarce. I am not sure what the final sum is that it is accepted that private patients contribute to the National Health Service, but in the last figures I saw it was generally thought to be about £23 million a year. This money will of course be lost, and it seems to me very difficult to argue that when £23 million is going to be taken away from the National Health Service, National Health Service patients will be better looked after.

Secondly, what will happen to the pay beds when they are phased out? We must have an assurance from the Government that they will in fact be used for National Health Service patients. It is disturbing to learn, for instance, that at University College Hospital 24 pay beds have been phased out and the accommodation is now used for administration. As the Bill stands there is no guarantee at all that these beds will be used by patients in the National Health Service, and if this guarantee is not given, there can be no shortening of the National Health Service queue—if that is the aim 1493 of this Bill—and the position will remain precisely as it is now. As I see it, the Government's difficulty about giving such a guarantee at present is that it would undoubtedly cost the Service more money, because the money which paid for the beds and paid for the staff will not be there. The Government will have to find the money to pay for the beds and to pay for the staff, and it will find it difficult to do that with a background of the July cuts, when the National Health Service and the personal social services were asked to lop £70 million off their expenditure.

I find it exceedingly difficult, therefore, to see how having less money for the Health Service is going to help the National Health patient. By phasing out the pay beds from the hospital system and by replacing them with private nursing homes or private hospitals, it will be necessary in many instances for consultants to have to travel some distance to a private hospital or a nursing home to visit their private patients. That means inevitably that the consultants will have less time altogether to care for all of their patients. It is perfectly true that Clause 8 of the Bill sets out the terms under which the private hospitals are to be set up and indicates that they must be readily available for the patient. But it is equally important that they should be readily available for the consultant. There arc, after all, only 24 hours in a day, and if much of that is taken up by travelling then clearly there will be less time for all the patients—less time for the consultant to discuss his National Health Service patients with junior doctors. This will become inevitable, sooner or later.

The fact is that at present the overwhelming majority of consultants who work part time for the National Health Service—by which is meant nine-elevenths of their time—are able to do a great deal of extra work for their National Health Service patients because they are in the same building and can go from one to the other, seeing their National Health Service patients in the evenings. I cannot see that the National Health Service patients will benefit if consultants have altogether less time.

My Lords, modern British medicine is much respected all over the world. British standards of medical education are high 1494 and there is an international market for the skills of British doctors. In December, EEC regulations will come into force allowing a much freer movement of doctors within the European Economic Community. If doctors and consultants feel dissatisfied with conditions in this country they will emigrate, and it is distressing how many have already done so. For the reality of the situation is that emigration today does not mean going to the other side of the world and leaving one's family and relatives here for very long periods of time; it means working in Paris, or Holland, or Germany—in some cases no further than moving to a different part of Great Britain. In so going the doctors would find themselves going to societies that want them, respect them and appreciate them. Emigration is not simply an empty phrase but a reality in front of us all, and I cannot see how the National Health Service patient will benefit when large numbers of doctors emigrate if they feel that they are under threat in this country.

There are many other points that I should like to make but there are a number of other speakers and we shall have an opportunity to go into these points on Committee. Among the many matters that we need to discuss is the right of an individual to spend his own money as he chooses. If, after he has paid his taxes, he wants to spend it on a doctor of his own choice, why not? If a woman wishes to see a woman consultant of her own choice, why not? It may well be that if the doctors feel deeply disturbed, these rights of individuals will gradually disappear, not just through this legislation but because of what is implied behind it. We shall want to look carefully at the terms of reference of the Health Board and its composition and whether its freedom is guaranteed. It must be possible to see that it is impartial. We shall need to consider the problem of private facilities for anyone living in a new town, which at the moment seem to be almost an impossibility.

I am sure that we shall all listen with great interest to the speech from the noble Lord, Lord Goodman. We appreciate the work that he has done to bring about a compromise in a very difficult situation, and I am sure that he will know as well as anyone that what is needed now is trust and that we have somehow to 1495 establish trust, because if we do not, all patients will suffer. I believe, however, that we need more than to establish trust. Nothing could better illustrate the ills of our country today than the situation that now exists in the Hospital Service and, if I may say so, the reasons that the noble Lord gave for having this Bill. We, as a country, have got to learn to live together; otherwise we shall die by a series of self-inflicted wounds. The internal fights going on in the Health Service are damaging the doctors, damaging the patients, are damaging the country. Sooner or later all of us are going to require medical services, and it is a terrible thing that we cannot find a way out of these difficulties. For our part, we shall do what we can to be constructive, to try, in what is a very difficult situation, to make matters better than they are now. It is not our intention to vote against the Second Reading of this Bill or in any way to be obstructive.

I should like to conclude in much the same vein as the noble Lord, Lord Wells-Pestell, for it seems to me that what we should be talking about today are the real problems of the National Health Service: the need for extra money; the problems of health care in an economic crisis; the problems of an ageing population, when even now 40 per cent. of all National Health Service beds are occupied by the elderly and when the largest growth in our population is of those over 75 years of age; the problems of staffing in mental hospitals, and the relationship between the National Health Service and the personal social services. These are very big issues calling for the undivided attention of Parliament, of Ministers and of civil servants alike. It is to these problems that we should be turning our attention and not to this unnecessary and unwanted Bill.

Lord AMULREE

My Lords, I should like to join the noble Baroness who has just spoken in thanking the noble Lord, Lord Wells-Pestell, for the very good and clear way in which he explained this not entirely uncomplicated Bill to us. But as that is the kind of thing we have come to expect from the noble Lord, I am not really surprised at how well he did it. Before I came into this Chamber to speak 1496 this afternoon I looked up the preamble of the National Health Service Act which was introduced to help the sick, and it says: It shall be the duty of the Minister … to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people in England and Wales and for the prevention, diagnosis and treatment of illness… My Lords, that purpose was carried out very well in the Health Service when it first came in, and it went along very satisfactorily for a long time. Then we had the Bill which was introduced by the Party on my left for the reorganisation of the Health Service, and so far as I can make out that did nothing, or nothing appreciable, to help the care of the patient. It was a great managerial revolution, but that is about as far as it went. Now we have the present Bill coming along and, in spite of what the noble Lord has said so kindly and persuasively, I cannot see that it is going to be any help at all to the patients in the National Health Service. Therefore we have not got much "for-rarder".

I will begin by saying that I have no particular feeling myself either for pay beds or against pay beds. I have used them extremely rarely and that was for geographical and topographical rather than for ideological reasons. I think I admitted only two patients into the private beds of University College Hospital where I was on the staff; and one of those, I must say, was admitted at the urgent request of Transport House for a senior member of the Party opposite who was in need of medical care. That was in the happy days before there were bodies called by curious names, like NUPE, COHSE, and NALGO, with whom I have been associated for a very long time. Therefore I am not really a person who uses the pay beds; but there they are.

I remember once dining out privately in the company of Aneurin Bevan—that was shortly after the Health Service had come into being and we were talking about it in a general kind of way. He and I were both agreed that one of the really good things, among many others, that it had done was to have got rid of quite a lot of expensive and not very well run nursing homes, because the patients who would have been in them got into the private wards in the National Health Service 1497 hospitals. That must have been about five or six years after the Service had started; I am sorry that I cannot remember the exact date.

Therefore, I can see no real reason now for trying to phase out permanently the pay beds and I would agree entirely with the approach that if they are not wanted for paying patients they should at once be used for National Health Service patients. The noble Baroness referred to the sad fact that one of the floors of the private patients' wing at University College Hospital now has become the offices of the Area Health Authority. It is therefore lost to patients. I assume that that was the result of the National Health Service Reorganisation Act. I do not think that it has anything to do with the Bill in front of us now. I would very much hope that that kind of action will not be taken again and that if beds are not required for private patients they will be used for Health Service patients and not for administrative offices.

My Lords, one is not quite sure of what is the gain in money to the Health Service from the private sector. Perhaps the noble Lord when he comes to reply will be able to give me some idea. I have seen figures of between £20 million and £40 million, although I should have thought it was probably more likely to be the lower figure. Supposing that money were to continue to be available—and because it is going to be taken away I am going to regard it as money that could be used for something different and new—one wonders whether the sensible thing to do with it would not be to increase the number of people working in the National Health Service hospitals—particularly the mental hospitals and, particularly, those mental hospitals that take care of elderly patients. One has seen in the Press several accounts of troubles and disturbances and of things that go wrong in these hospitals. I am quite sure that the main reason for this is lack of staff and not lack of good will. That it can be the latter, I would not believe for a second. You do not need to have your hospitals fully staffed with trained nurses. Provided that you have a few good trained nurses in charge of the wards or departments they can make use of partly-trained people of good will to do quite a lot of the care and work that needs to be done in these hospitals.

1498 My Lords, that is where I should like to come back to the pay bed question and to refer to the strange tale of the amenity beds. These were mentioned in Section 4 of the National Health Service Act, the provisions of which would allow hospitals to use single rooms or small wards to provide accommodation for people who wanted them—provided they were not needed urgently for general medical purposes—on the payment of a relatively small weekly charge. These never get mentioned, so far as I know, in all the discussions that go on—and I am pleased to see that the noble Baroness, Lady Lee of Asheridge, agrees with what I say. It has always seemed to me that that was one of the weaknesses in the pay bed argument; that there were these amenity beds available which could be used on practically every occasion if they were required. One wonders whether their number is going to be increased or whether they are gradually going to fade away. I am not quite sure what is to become of them.

I am pleased that there is no intention to abolish private practice because, speaking purely as a consultant, I have found that to have a little private practice, one which was not big enough to make any appreciable financial return to myself, was extremely good for me from a training point of view. It made one think. For example, if I had been a full-time employee of University College Hospital and an elderly patient had come in, he or she would have been seen by my registrar or houseman or someone like that. It would mean that I came in at the end to give the final diagnosis, if I possibly could, or say something; whereas, in private practice one can get called out by a GP (and I can quote several cases like this) to a flat on the top floor of a converted house to find an elderly couple living by themselves, aged, say, 75 and 73, one of whom has had a stroke and the GP wants to know what to do. Unlike the hospital situation, you have nobody to call upon. You have to make up your mind; you have to think about it. I am sure that my friends in this House who are consultants will agree that it is a good thing for consultants to be made to think from time to time—it is very easy not to.

I now come to the question of waiting lists. I have always been rather sceptical about them. I agree that they are 1499 probably longer than they should be, but I wonder whether anyone has made a genuine inquiry into waiting lists and found out the number of patients kept waiting because it was more convenient to them as they wanted to settle their business affairs, and so on, before going into hospital; or, in the case of children, whether it was more convenient for them to go into hospital during the school holidays. So waiting lists pile up in a very odd way.

Then one finds that quite a number of people tend to be on the waiting lists of more than one hospital. I remember that when I first began to work in the geriatric department of University College Hospital we had a long waiting list which, luckily, was from a comparatively circumscribed area. The only way to find out what to do was to visit them all. One found that a certain number had died, a certain number were on the waiting lists of more than one hospital, and a certain number were not at all suitable for hospital and ought to go into a welfare home. So it did not take very long before that rather formidable waiting list vanished away to normal, workable size, and I wonder whether there could be a similar inquiry on a big scale. It would be an expensive operation, but it might save a great deal of trouble.

Finally, I should like to refer to what the noble Baroness, Lady Young, said about the waste of consultants' time if pay beds are moved from Health Service hospitals into private hospitals. It will mean that a consultant, whether male or female—I do not mind what sex a consultant is—has to travel a long way to see patients, which in London takes a very great deal of time. Whereas, if they are working in the same building, the private patients and the National Health Service patients will see their consultants for a longer time than if they are merely working regular hours—although I agree that most of them work considerably more than their official hours—and they will not be able to give so much time. Therefore, I am lukewarm about this Bill, which seems to me unnecessary, and the advantages of getting rid of unwanted private beds could have been achieved in a far less traumatic way than is proposed.

Lord GOODMAN

My Lords, I regard it as a considerable privilege to be enabled to address your Lordships this afternoon, and to say a word about a matter in which I was very much involved in time and effort some months ago. May I first say this? Perhaps I may be permitted, in relation to explaining my personal position, to incorporate in my speech two brief extracts from a letter that I wrote to The Times in April this year. I said—and here I am wholly in agreement with the remarks of the noble Baroness, Lady Young—that: I have already expressed my own view that the restoration of real confidence will only be achieved if the Government indicate a proper sense of values as to which voices are to have the Greatest influence. A medical service must be guided by informed medical views and it is imperative that doctors should feel that this is the spirit in which the present proposals emerged and will be operated. That does not mean that other views enjoy no relevance. The other extract which I should like to quote is this: The new Secretary of State has a grave and ever terrifying responsibility to restore tranquility to a profession which traditionally wishes to get on with its job. But he also has an historic opportunity. What he says and how he says it will to a considerable extent determine the matter. He must convey to the doctors that he understands their feeling that the profession cannot be restricted to State employment and retain the independence of action and judgment towards their patients about which the struggle s largely concerned. I believe he does recognize this and I hope indeed that he will succeed in conveying this recognition in sufficiently generous and reassuring terms to end this dangerous conflict. The tone and atmosphere in which the debate has been conducted this afternoon have been, in my view, exemplary. I think they create a situation and background in which, with a little luck, the whole of this unnecessary dispute can be resolved. Perhaps I ought to say this. I have not come here to urge these proposals on your Lordships. There is an honourable arrangement. If the medical profession contrive to defeat this Bill, they are regarded as entitled to do so. This assurance was given to them by the former Prime Minister, in my own hearing, in the clearest possible terms. I have come here to say—and to that extent I am prepared to take a partisan view—that I think it would be a mistake if they defeated this Bill. I say that for this reason. I wholly agree with the 1501 noble Baroness, Lady Young, and the noble Lord speaking from the Liberal Benches, that this Bill will not do anything to assist the patient. But I would ask the House to take into perspective, and into proportion, the nature of the problem.

We have, I believe, something like 400,000 hospital beds in the United Kingdom, and we are dealing with 4,000 beds—1 per cent. That is the extent and nature of the problem in terms of beds. But one also has to take very much into account the consideration that those beds are at the moment extremely expensive. They are not available to the great majority of patients, because of their cost. A much more urgent necessity today is to make provision for solitude, to make provision for privacy, to make provision for the things that a lot of people need and require on a mass scale, and these cannot be provided by dint of 4,000 beds out of 400,000.

What I would venture to say to noble Lords on the Opposition Benches is this. The importance of this Bill is not to provide additional facilities for National Health Service patients; it is to reassure doctors that private medicine will remain in this country, and remain indefinitely; and the importance of that cannot be exaggerated. It is to make the doctor, whether he is employed full-time in the State service, whether he is employed part-time in the paid service, feel that he has a liberty of choice if he wishes to take it. It may be a very limited field of choice, in terms of the availability of offices and appointments. But the fact remains that preservation of that liberty of choice makes him continue to feel that he is a free man operating in a free country; and that is very largely what the trouble is about.

The doctors suspected, and with justification—not with cause; I do not think their suspicions were well founded, but they were rational because of what was said and because of an unfortunate Consultative Document—that they were going to be squeezed at both ends. They suspected that the phasing out of hospital beds, accompanied by additional restrictions on the licensing of private beds, would mean the end of private practice. That was the suspicion entertained by all of them which it was impossible to dispel. I think it would be unreasonable if the doctors today, in the light of these 1502 recommendations, continued to maintain their suspicion. One of the most unfortunate parts of the whole matter is that suspicions are not easily dispelled. They remember the Consultative Document.

The noble Baroness herself said—and I think she might reflect, having regard to the generally conciliatory and helpful tone of her remarks—that it is not much use legislating at all, if one is going to take the position that that legislation can be repealed, revoked or amended by a subsequent Government. We must take legislation at its face value. It is no use saying that we have suspicions, doubts and misgivings about what people will do in the future. If we do that, then no action taken by anyone can ever be reassuring in a troubled situation of this kind. Also, I think it is important to remember that these proposals were not very acceptable to or very well loved by the Government. They have been accepted as a compromise proposal.

The Government's problem was a very real one. I do not know how well they handled it, or how ill they handled it. But their problem was that they had a number of people, who I do not think had any right to behave as they did, in key and crucial positions in hospitals, who were making what I consider to be unjustified and unreasonable demands. However, it is not much use saying that the demand is unjustifiable or unreasonable if some threat to the personal comfort of the patient and to the continuity of the health scheme can be maintained, and the Government have to deal with the situation.

I have no comment to make on how well or how ill they will deal with it, nor do I wish to say that if I had been asked to recommend what to do in the situation before the trouble started I should have said that any such legislation as this was necessary. In the light of the minute nature of the problem—the 4,000 out of the 400,000 beds—and in the light of the fact that in most parts of the country there was relative tranquillity, there was no reason why things should not have been left alone, but for some reason, and the history is well known to many of you, the situation arose where, things not having been left alone, an increasingly corroded atmosphere arose to a point where great numbers of consultants went on strike.

1503 In this country the medical profession is very largely a splendid and a great profession. We are doing remarkable things here which ought to redound more loudly than they do. To take an instance, the EMI scanner was invented by a young man who refused to take any personal reward for the royalties that came from the scanner; he insisted that the money should be put back into a fund for research. That is the kind of spirit which should till us with great pride and pleasure when we hear that it is happening in this country. There have been other discoveries. We were prominent in the development of the kidney machine and we now have an experiment with a new liver machine whose aid and assistance is sought all over the world. I could multiply considerably these details.

Our profession is one of which we can be proud and it should be a source of shame to all of us that the profession was nearly brought to a standstill by a relative trifle of this kind. I say "a relative trifle" in relation the the number of beds, their utility to the population at large and to the fact that the most was made of the difficulties, not because of the real issues but because the medical profession suspected, and suspected with justification if not with cause, that an attempt was being made to phase out private medicine. It would be the highest degree of folly in relation to the medical profession that the suspicion should be allowed to be maintained by doctors that private medicine is in peril.

As I have said before, and I do not apologise for repeating it, I believe that private medicine is indispensable for a healthy medical profession in this country. That does not mean that all our efforts and attention should not be concentrated on the real question of how to give an adequate medical service to the great number of people who are now without it at all. Some of them are rich people. I am inclined to believe that the rich are the worst doctored section of the community. They listen to every kind of nonsense that is talked, they consult every kind of doctor who has the most dubious qualifications and they end up in the cemetery long before anybody else. I strongly recommend rich people to take advantage of the specially established medical advisory service that will give 1504 them, free of charge, a list of addresses of honest, decent, simple doctors who can look after them.

However, that is not the issue before the House this afternoon. The issue today is for this House to consider whether, having regard to all the circumstances, it would be sensible to seek to defeat this legislation, remembering that it is legislation—I make no bones about it—that we could well have done without in different circumstances. It is legislation whose only utility is that it has resolved the problem that caused a great number of doctors, men to whom such behaviour was totally alien and contrary to the tradition of generations and centuries, to go on strike.

I know from my conversations that the great majority of consultants who went on strike were profoundly uneasy and unhappy; they did not think that it was right that they should go on strike, because it went against a tradition and they did not like the notion. However, they said to themselves, and it was difficult to answer, "What are we to do? How are we to achieve what we want if we do not take the same industrial measures as are available to the rest of the population?" It was no use putting to them what I regard as the total answer: "It is not available to you to take such measures. You have entered a profession which is akin to Holy Orders, a profession where you do not have the choice of undertaking industrial action in order to support material claims for your livelihood. You must leave it to the rest of the community to rate you properly." A society where the efforts of doctors are not rated properly and a society which sees that doctors do not get their proper return is one which deserves the kind of confusion that has operated here.

I have not come here to reproach doctors for considering industrial action. I have come here to say one thing only: that in my view the medical profession, in all the circumstances, is much more likely to be withdrawn from the political arena, and that there is much more likely to be peace and tranquillity if this Bill is passed into law than if, once again, the whole question is thrown back into controversy. That is the real merit of the Bill.

There are all kinds of points that I could raise, and I could carry on for hours 1505 but I will not. For instance, 1,000 beds are to be phased out immediately. I do not think that it is a matter of dispute that the experts, with whom I have had long discussions, have all agreed that something approaching 1,000 beds were redundant and unnecessary. The basis upon which the agreement was reached was that they had said, "We do not need these 1,000 beds; we can do without them." There has been argument and discussion, as the noble Lord speaking for the Government said, in immense detail about where the 1,000 beds should come from. Happily, I have not been involved in those discussions. I believe that a substantial measure of agreement may have been reached already, but that there was a considerable number of surplus beds was a matter of general agreement.

Nor is it quite true to say that the Bill is resolutely opposed by the entire medical profession. In private conversations with doctors one finds that there are great numbers—I would not presume to say a majority or a minority—who see the end of this dispute as the happiest thing which could happen to them in many years. They can historically maintain their grievances. At medical dinners over the years they can explain how it came about, how wronged they were and what misfortunes they have suffered; and that I think they are entitled to do. It is a very small return for the discomforts and irritations that they have suffered during the course of the negotiations. However, I do not believe that there is universal hostility to the measures, and I believe that a great number of people would willingly support them on the basis that it is the end of the battle, and that it will enable doctors to get on with the valuable and important work with which they are concerned.

One of the real problems has been that doctors are sturdy individualists. To get doctors around a table is one of the most interesting, frustrating and irritating operations that any human being can conceive. To find two doctors in agreement on anything is a near impossibility; to find three doctors in agreement is a total impossibility. To find a doctor who does not wish to express a view on a highly political matter is also a near impossibility. They will agree about the things that they know about: about remedies, prescriptions, operations and so on. But when it 1506 becomes a matter of medical politics, fortunately they have had no experience of the matter. They continue to do their work alone in their surgeries over the years.

May I make a few more specific observations about the Bill. I believe that the Bill represents pretty fairly the proposals that were put to the Government. I think that the Government have quite honourably discharged their obligation to produce proposals which were in conformity with the arrangements made to end the consultants' strike. Equally I say, as I did at the outset, that the Government and the doctors are absolutely entitled to urge your Lordships' House to reject the proposals in total.

I should like to see another ballot because I believe that that ballot said more than that the doctors were merely approving those proposals as a basis for ending the strike. I think they were expressing very general agreement that the proposals, for good or for ill, were better than they had been offered and that they might be wise to accept them and call it a day. In that respect, may I quote from the British Medical Association's own letter when they sent the proposals to their members. They said: Clearly it is difficult to assess the validity on the one hand of the assurances given by the Goodman proposals and on the other the anxieties expressed in debate that so much remains a matter of individual interpretation and, so far as implementation is concerned, a matter of good faith". I could not emphasise that too strongly. The letter continues: If the proposals were to be implemented as intended by Lord Goodman, then a significant measure of protection for the future of the independent practice of medicine would be achieved. If, however, the proposals were to be distorted by Government and Lord Goodman's aims were not to be preserved, then there is no doubt that both private practice and the independence of the profession would suffer. That is an objective and fair statement of the position.

If the Government continue as they have begun by enacting the proposals in a decent and honourable form, subject to some Amendments which seem to me might reasonably be called for, if they maintain that spirit and if, again and again, they will assure the profession, as the former Prime Minister did, that they have no intention whatever of attacking the continued existence of private medicine but 1507 intend to allow it to continue to exist side by side with the National Health Service, I think that we might in the end find that something rather good comes out of the whole of this unfortunate matter. That is my belief. I think that might well happen.

If the Government distort the proposals, if they allow people who are not doctors to have an undue sway in medical matters, if they allow situations to arise where patients can regard themselves as being at risk because they are private patients, I think there will again be trouble because the consultants have discovered that they have a muscle they did not previously think they had. If I may say so, it is a sorry discovery and it would be better if they had never discovered it, but I do not think they can be blamed for it. The fact remains that the day when the first doctor went on the first strike was the day when we ought all to have been alerted to the very real danger to this great profession which is so crucial to all our needs.

I should like to conclude by making just a few observations on matters in the Bill on which I think possibly there is need for reassurance. The first is, as I think was introduced by the noble Baroness, Lady Young, that there is a provision in the Bill that private medicine should have accessible and available to it facilities in National Health Service hospitals for specialised operations, so that if a specialised operation is required by a consultant he can use the National Health hospital if it is available, use the equipment and use his team, and in a sense that is a much greater assurance than has existed in the past in relation to these matters. But the wording is a little ambiguous and as there is a considerable degree of mistrust and lack of confidence I think it behoves the Government to see that in any case where there is ambiguity they should not seek to rely on the preferable interpretation which they think removes the ambiguity. I think they should accept an Amendment which enables one to point out to the most controversial and political of doctors and say, "Nothing on earth can make this mean anything except this and that". I think this is most important when dealing with the medical profession.

In the particular matter with which I am concerned there is a provision that these facilities should be available—I think the 1508 wording is "at a hospital accessible to the patient". It has been pointed out, validly pointed out, that this would be not only unreasonable but rather foolish. If there is a busy consultant in London and he has a patient in Bradford or in Newcastle it is an absurdity to suggest that he should travel to Bradford or Newcastle to carry out an operation with a brand new team of people, with equipment with which he is not familiar and in unfamiliar surroundings. I think this will be a very small concession to make, and I have a feeling from a conversation that I had with the Secretary of State—and I should like to pay a tribute to him, if I may, because I think from the outset he has approached this matter with a desire to restore confidence—that this was an arrangement he would like to accept.

There is another matter which concerns the profession and I think it is one where they are straining interpretation. It is on the nature of the alternative accommodation that the hospital board can accept as justifying the phasing out of a bed or two—or three or four. The Bill contains a provision that that accommodation shall be reasonably suitable. The doctors say that it does not necessarily mean "reasonable" in terms of quality: it means reasonable, perhaps, in terms of geographical position or in terms of size but it may not mean reasonable in terms of being good enough, clean enough, light enough, in the right position. My own interpretation of "reasonable", which I think would be supported by better lawyers than I am, is that the word must mean "reasonable in every sense". In my view it is not necessary to underline it but at the same time it would cost nothing to underline it. If the restoration of a little confidence can be achieved by adding a couple of words at the expense of the common printer, I would say let us add those words and make quite sure that everything the doctors want that is reasonably required by them should be provided and this Bill should be set off under the very best possible auspices.

There are other changes which are much of the same sort and they are changes which the doctors seek because they want a clarification of the position and a reassurance that what they are told the Bill means is in fact what the Bill 1509 means. I would urge the Government to give it to them in every single case. I think they deserve it. I think they have had a very rough time. As I say, how far it is their own fault will be a matter for historical examination, but I do not think that this situation need have arisen if it had been treated in a different way and with perhaps a greater recognition of the extraordinarily sensitive and suspicious nature of men who are engaged in a specialised activity all day long and who do not have time to come here to notice what an exceptionally reasonable and trustworthy people we all are.

I am very pleased to note that the debate is being conducted in a spirit where we are not spending our time describing how individual members of the Government have pay beds in Wellington Clinic—or wherever it is. I may say, perhaps unkindly, that on some occasions when I have been in this House—very rarely—I have had the feeling that it would not be a bad thing if the whole of the Government were occupying pay beds. That is an unkind comment and it relates to some of the activities of last week.

I should like to conclude simply by saying that this is not a highly political measure and it ought not to be made a highly political measure. In so far as in Committee we can improve it, let us do so, but I believe that when it is passed and when it is clear that the Government intend to accept it in the spirit in which it has been offered it will go a long way towards solving the problem that we observed at the beginning of the year and also at the end of last year—a problem that ought never to have happened and which can cause great rifts between the Government and a profession which should be held in high repute—and that this Bill will enable the sort of young man I was talking about who made that important discovery, and other young men, to continue their work and to make a real contribution to medical science, instead of endless argumentation on arid political themes.

Lord STONE

My Lords, after that great speech by my noble friend Lord Goodman I crave your Lordships' indulgence—a double indulgence. First, may I declare a vested interest in this Bill in 1510 that I am a practising medical practitioner. In my long experience I have often heard from patients such remarks as, "I've got butterflies and flutterings in my tummy". I have looked for them, felt for them and listened for them, but never found them. I now know, feeling as I do at this moment, here and now, that they can and do exist. In my maiden speech it is not for me to comment deeply on the Health Services Bill which is being presented to your Lordships today. Sufficient that it will allow me, at a later stage, to make comments in further debates.

I was in medical practice before 1948 when the National Health Service was inaugurated, and have been ever since. I find myself in a strong position to assess it right up to the present day and I wish to say at the outset that in my opinion it is the best Health Service in the world, despite what one reads and hears to the contrary and that—and I quote—"It is on its last legs". Not a bit of it! I know it all because I have been in it for such a long time. Given time, the present difficulties will settle themselves and those who are young in the profession will realise that in any field of medicine a good doctor will always make a good living (never a fortune) and he will learn that his reward will be the warmth of the satisfaction he gets by just helping along and being involved with the daily problems of people, old and young.

In the light of my experience I am in favour of the phasing out of pay beds—with emphasis on the "phasing". Let it he gradual and not dramatic and all will be well. I hope, too, that the present Bill will not overload the already top-heavy—indeed far too top-heavy—bureaucracy that now exists and that it will be realised that the backbone of the medical profession is the general practitioners, who are hardly brought into the status in the profession that they rightly deserve, despite the fact that day by day, and every day, it is the GPs who are dealing with a majority of patients who are in need of daily medical attention without having to be referred to hospitals or clinics for the purpose. One must remember that the GP as a family doctor finds himself involved, as well as with illness, in all manner of human domestic problems—in the young and the old, the diligent and the lazy, the scholar and the slow learner; with drug problems, the question of 1511 alcoholism and all kinds of social and marital and even legal problems.

In my long experience as a doctor I have seen tremendous progress and advances in medicine and surgery. Thanks to the enormous developments in anaesthesia surgeons have been able to perform what, at one time, could only he considered "miracles": the removal of lungs, the transplant of hearts, kidneys and even of the liver; replacement of joints, corneal grafting—I could go on. On the medical side we have seen the eradication of diphtheria and whooping cough and poliomyelitis, all brought about by mass inoculation. Tuberculosis has become a rare disease as a result of mass radiography and therapy of the highest order. One could go on and on. Smallpox has been eradicated all over the world. Recently, I learnt that the last pocket of smallpox in Eritrea has been eliminated. It has all been so exciting and stimulating—researching and developing all the time. Let there be no restriction on them. ft is all for the benefit of the human race, Catholic and Protestant, black or white, Jew or Moslem. Even so, let us be wary of recent advances; let us be cautious of the noxious gases and chemicals we hear so much about and, not least, the applications, ramifications and dangers of the advances in nuclear energy, and their trial experiments.

My Lords, when I was elevated to this House a friend sent me a message saying, "How do you feel now you are a Peer of the Realm?" I answered, "Highly honoured—but terrified". I still feel highly honoured but, as this speech is now over, I no longer feel terrified. I thank your Lordships for your kindness and indulgence in listening to me.

Lord FERRIER

My Lords, it falls to me to congratulate the noble Lord, Lord Stone, on his excellent maiden speech. His speech contributed very considerably to the general tone of the debate which was commended by the noble Lord, Lord Goodman. Now that the noble Lord, Lord Stone, is no longer terrified I think your Lordships will agree that we can look forward to hearing from him again.

1512 My Lords, on the subject of being terrified, I am a little terrified myself at the moment. I should have liked to hear more speeches from medical men before I brought my own contribution to the notice of your Lordships. But I must say that I was greatly fortified by the speech of the noble Lord, Lord Goodman, which held out a real hope—and I hope he is right—that this Bill, which he admits will require some amendment, may lead to a thorough improvement in the general atmosphere as between the public, medicine and the hospitals.

I followed the speech of the noble Baroness, Lady Young, with great interest. She covered nearly all the ground that I proposed to cover in my own speech and, therefore, I will spare myself and your Lordships from going on too long, except that there are one or two comments I have to make with regard to my own feelings. First of all, queue-jumping is the big headache so far as the public is concerned. Obviously, we do not like it and, obviously, it is to be avoided. I rather doubt whether the contents of this measure will do practically anything to reduce it. The way to avoid queue-jumping is to avoid a queue.

Reading the Explanatory Memorandum, I feel that the complications in terms of bureaucracy and expenditure are somewhat underestimated. As the noble Lord, Lord Stone, said, he hoped that this was not going to lead to more and more civil servants. I am thinking of Scotland, which is to have an individual Board of its own. The noble Lord, Lord Amulree, touched on the question of the money that will be spent. An eminent medical man with whom I was talking only last night, said he felt that to some extent the Bill was a mistake because there were so many more priorities. But here we are. We have all been heartened by what was said by the noble Lord, Lord Goodman, that this represents something which, when somewhat amended, will work. Let us hope he proves to be right.

My Lords, speaking of queue-jumping and waiting lists and the provisions of the Bill, I believe that in the North of Scotland the waiting list, for example for an operation on the hip, is very long. I have heard mentioned a figure of two years on the waiting list for an ordinary bed. I reinforce what was said by the 1513 noble Lord, Lord Amulree. Are these waiting lists really as long as that? Or are the figures for those such as children who can be dealt with only during the school holidays, and old people who cannot in winter travel long distances such as are necessary in the North of Scotland? When there are long distances to cover, there is also the difficulty that visitors cannot come to visit old people. Hospitalisation can be a lonely business.

I do not propose to take up the time of the House in repeating the catalogues of objections. I feel that the Bill might increase the overall burden of Government expenditure out of all proportion to the amount with which it will improve the overall—and I emphasise the word "overall"—treatment of patients, whether in pay beds or otherwise. At one time, I had thought that, with all the pressure on the shoulders of your Lordships as a result of the log jam of Bills, this was one which really could be dropped in order to give your Lordships' House and Parliament more time to give proper attention to going over legislation which comes up from below.

My Lords, I only hope that the tone of this debate will continue as it has begun and that it will not tend to make the matter a divisive one. I was greatly heartened by the speech of the noble Lord, Lord Goodman, as I have already said. One of the reasons why I am speaking is that I feel it proper to protest at what was said in the Commons the other day, when the right honourable gentleman the Prime Minister said: I have no doubt that the other place will continue with its self-appointed task of mutilating Bills…"—[Official Report, Commons; 19/10/76, col. 1111.] I hope your Lordships will agree with me in objecting to the phrase "self-appointed". No noble Peer is self-appointed. It is really a very odd idea.

The present form of the House of Lords is that laid down by Parliament by enactments of successive measures of reform by both Parties in Parliament assembled, introduced from time to time. To play, "Let's pretend" in the way in which the Prime Minister did does not do any good. This is the case, and I feel that the Prime Minister has just got to "lump it". I, for one, as a Life Peer feel offended that there should be the faintest 1514 suggestion that we came here of our own volition and that we choose to be beastly, which we do not. We are doing a duty laid down by Parliament here assembled, and if people go on knocking the Second Chamber then, as sure as night follows day, the spring from which comes the supply of individuals willing to serve your Lordships' House will dry up, but that is another matter and I will leave the subject there.

I got an angle on the relationship between the private and public ward some time ago that was new to me. A patient was to undergo an orthopaedic operation and the surgeon was warned that she was occasionally subject to severe attacks of asthma and that she might get one at any time. The surgeon and his team decided that she should be in a public ward, because they felt that if she suddenly had a seizure, that was the best place for her to receive immediate attention. In fact she had such an attack, but the skilful measures taken in time avoided further trouble. I had another curious experience in that orthopaedic hospital. I was visiting a patient and noticed that there were eight empty beds. "We hear about enormous queues for hospital beds, but here are eight empty ones. Why is that"? I asked, and I was told that the hospital, which was built between the wars, had accommodation designed to meet the surgical and medical post-operative experience of those days.

The noble Lord, Lord Stone, mentioned the enormous advances that have been made in anaesthesia in surgery and post-operative treatment. The theatre accommodation in that hospital was insufficient to keep the beds full because patients were being released so much earlier than used to be the case. In fact, the surgeon told me, "Those two old ladies over there could have been released last week but we happen to know that they live in not very commodious accommodation with lots of stairs. They are far better off here because we have the accommodation, nurses, heating, food and so on."

I give these illustrations to show that the money, every penny of it, which will be spent in perhaps bureaucratic ways to support this Bill could be spent on improving conditions in hospitals and elsewhere or in improving, as the noble Lord, Lord Amulree, said, the amount of 1515 staff available in geriatric, mental and other hospitals. Money spent in that way would be money well spent. Perhaps I should add that for all I know an additional theatre has been built at the hospital about which I have been speaking; my experience there occurred four or five years ago. Nevertheless, it illustrates how money should be spent on hospital developments. I would go so far as to say that we should save and scrape until we get the money we need for that purpose.

The medical man with whom I was speaking last night is desperately anxious, as I am, to see waiting lists reduced and no need for queue jumping, if it takes place. The noble Baroness, Lady Young, pointed out that one could not get away from the fact that the number of private patients, particularly in private hospitals, means shorter queues elsewhere. I feel that what should go out from this House when we have done with the Bill is a sense of compassion for all those involved, a feeling of confidence in our medical staff and a belief that the existing hospital arrangements under the National Health Service can and should be made to work as well as possible.

Lord WINSTANLEY

My Lords, I join in the congratulations that have been expressed to the noble Lord, Lord Stone, on his excellent maiden speech. It was delivered with the kind of clarity and directness that I have come to expect rather more from general practitioners than perhaps from consultants, and I agreed with much of what he said. I am not sure that I will always agree with him, because, as the noble Lord, Lord Goodman, said, one need get two doctors together for only a couple of minutes for them to arrive at a state of total and utter disagreement. Nevertheless, it was a pleasure to hear from a fellow general practitioner speaking in that way, and I am sure that we all look forward to hearing him on many future occasions.

I wish to make it absolutely clear at the outset that I have no interest to declare in this matter. Although I worked all my professional life in the National Health Service, inside and outside hospitals, I have no private patients and I have no present intention of acpuiring any. I 1516 might add that I not only worked in the NHS but perhaps I could be forgiven for saying that I worked very hard for it for many years, not only working in it but trying—through television, the Press and journalism—to help it to function; to help to overcome in this co-operative venture some of the misunderstandings between the two sides which have sometimes caused difficulties; and trying to help on official bodies. Going further back than that, I remember perambulating about the country making speeches, trying to persuade my fellow medical men not only to join the Service but fully to support it. That was in the days before 5th July, 1948. I hope, therefore, that it will be accepted that I speak from that standpoint.

My purpose in criticising the Bill, as I shall, is not to defend private practice but to try to defend and preserve the Health Service and the principles that underlie it. I would not shed many tears if private practice disappeared altogether, provided it disappeared for the right reasons and in the right way. Reference has been made, and rightly, to Nye Bevan, as it was made frequently in debates in another place and to his book In Place of Fear. Nye Bevan looked forward to the disappearance of private practice and I had the privilege of discussing this matter with him on two separate occasions way back just before 1950. It was my impression then that his view was the the same as mine; he looked forward to a day when the NHS would be so constructed and so working that private practice would disappear because of lack of need. In other words, there would no longer be a supply because the demand would have disappeared, and I think he was right.

He was certainly right to say that that would happen, and the proof of the pudding is in the eating. If we look at areas of this country where the Health Service is flourishing, where there are new and modern hospitals, fully staffed, where the doctor/patient ratio is adequate, where waiting lists are short if not non-existent and where there are enough nurses, physiotherapists and the other ancillary workers who go to make the whole business of medicine, we shall look in vain for evidence of private practice.

On the other hand, the worrying thing is that if we look at other areas—and I regret that there are too many of them— 1517 where the Health Service is beginning to fail, where the waiting lists are long, in my view disastrously long in certain respects, despite what the noble Lord, Lord Ferrier, and the noble Lord, Lord Amulree, said, we find in those areas that once the Health Service begins to run down and there is a suspicion that it is no longer giving an adequate service, there is a re-emergence of private practice. That is the area in which it flourishes. So my aim is to see what I can do and what we all can do in your Lordships' House to see that the National Health Service ultimately reaches the required standard for everybody, so that this argument about private practice can disappear. But I am afraid that at first sight I can see nothing in the Bill that can do anything to improve the standards of the National Health Service or to bring that Service everywhere up to the ideal standard that exists in certain areas.

First, I believe that the Bill will precipitate a conflict or at least arouse resentment and antagonism. The noble Lord, Lord Goodman, has talked about this and I believe that we are all indebted to him for what he has done to try to arrive at some kind of compromise which could perhaps minimise the degree of resentment and antagonism. However, I believe that he would agree that while what he has done may have cooled the atmosphere, it has certainly not extinguished the flames altogether. Whether we like it or not—and I do not like it—one of the results of the Bill will he trouble, antagonism and resentment. I am not saying that that will be reasonable, nor am I saying that this House or any House should be blackmailed by unreasonable people, but I am saying that we should be realists, that we should accept the fact that real people behave like real people and that, if we possibly can, we should avoid promoting conflicts unnecessarily.

It seems to me that the National Health Service at the moment already has enough troubles of its own without having extra ones added to it by precipitating some kind of confrontation. Indeed, to me, the timing of this measure seems to rank in folly with Mr. Heath's decision to take on the miners at the time when we had suddenly become totally dependent upon coal. I hope 1518 that my fears are groundless and that we may not have difficulties of that kind, but, if we do—and I believe that we probably shall—the trouble will be that that will make it much more difficult to do the things that really are necessary.

I agree entirely with those noble Lords who have said, and said rightly, that something must he done to deal with abuses that exist in a system in which private and National Health Service practice exist side by side. I am talking about queue-jumping and the other undesirable—indeed, deplorable—things that have been suggested. I believe that the way to get rid of them is by agreement. I do not believe that we shall get rid of them all by Statute or by a policing system, but I feel that the more we can retain the mood of co-operation with those upon whom we are dependent, the more chance we have of getting rid of all those abuses by agreement and conciliation, given time. My theory is that some of the effects of the Bill may make it difficult to get rid of this kind of abuse and to get the degree of co-operation we undoubtedly need to get in order to drive out the abuses.

My next objection to the Bill is that it does nothing to create new resources. The plain fact is that there is a global volume of medical work to be done and that the total volume of resources to do that work is at present inadequate. We must accept that. No amount of manoeuvring within the limitations of those resources will create new resources. I believe that there are a lot of fallacies about the extent to which we can somehow draw new resources from the abolition of private practice. Indeed, I wandered into the other place the other day to hear the Third Reading debate, and Mrs. Short was talking about queues of private patients going along to the laboratory for a blood test. So what? Is it suggested that these many private patients having successions of blood tests to the point of extreme exsanguination are somehow having them for fun, or is it accepted that they need blood tests? If they need blood tests, they must have them, and whether they have them privately or publicly makes no difference at all to the total amount of resources that are available. I believe that there is a kind of assumption that if a patient has his appendix out privately he occupies two beds instead of one and makes work for two surgeons. All right, 1519 the queue-jumping point is a real one and must be dealt with, but do not let us run away with the idea that this kind of manipulation with a very small number of beds within the private sector will somehow liberate a tremendous amount of new resources and that that will put the Health Service to rights.

Lord WELLS-PESTELL

My Lords, will the noble Lord allow me to interrupt him? He knows better than most people what is the average bed occupancy in the course of a year. When we are talking about 2,500 to 3,000 private beds that are occupied for private purposes, I wonder how many patients he would say would occupy those 2,500 beds in the course of a year, an average bed being occupied by, say, 12 different people in the course of a year.

Lord WINSTANLEY

My Lords, I do not think that I can venture on doing public arithmetic with the noble Lord. I take his point, but the real point is, by whom are these beds occupied? Are they occupied by patients or a sort of hotel visitor? If the people concerned need medical treatment, they will occupy a bed whether they are private or National Health Service patients. Admittedly, the queue-jumping point comes in, but the point of total resources remains. Let us accept that the queues are too long and that waiting lists are too long. I say this to the noble Lord, Lord Ferrier, and Lord Amulree, who mentioned this point: in parts of the country, waiting lists are deplorable. There are people waiting for two years for so-called "non-urgent" operations. The degree of urgency or otherwise of any operation depends on who is to have that operation. If it is one's own operation, one tends to feel that it is not so non-urgent after all.

There are other aspects of this matter. When the wage earner has an uncomplicated, non-urgent, irreducible inguinal hernia and has to wait for two years to have it operated on, there will be economic effects. He will be a burden upon the social services and so will his wife and his family while he is waiting. I agree with every noble Lord who has said that we must do what we can to get rid of waiting lists. I agree, too, that we must 1520 do what we can to get rid of queue-jumping; but let us not run away with the idea that, somehow, new resources will suddenly become available and that the Health Service in some of the worst areas—and I practice in Salford, which is not the best—will somehow magically become better. I do not think that it will.

I come now to my last point, a point that was made by the noble Baroness, Lady Young, who referred to the introduction of apartheid in our medical services. I think she has a point. There may be difficulties in having private and public practice side by side in the same hospitals, but at least people can see what is happening and do something to control it. But when one has once separated the two and built up outside the National Health Service a wholly separate private service and that wholly separate private service is flourishing, it will bleed the National Health Service white.

We have already heard about consultants on nine-elevenths of time. I can tell you that I know many consultants who would like to go full-time. One may talk about their private earnings but they say that they would love to have a full-time contract. However, in many cases hospitals cannot offer them a full-time contract. Perhaps that is in part because the hospitals are already getting full-time work out of them although they are paying them for ten-elevenths. They will not get full-time work out of them when the consultants are on two-elevenths and not in the same hospital but a very long way away.

So I put that forward as a little bit of a fear: deliberately and as a matter of policy to build up two separate services, one the Health Service and one a private service outside, is I believe, inviting resources to go to the private service. Money will go to it; money for research will go to it; many workers will leave the one and go to the other because, perhaps mistakenly, they think that they will have more freedom, better opportunities or better facilities. There will be many reasons, but I nevertheless predict that, if we ever establish this "apartheid" system of a private sector outside the National Health Service, it will bleed that Service white.

I have said enough. But it seems to me rather sad that in my day, working in this area for the National Health Service, we began with a private sector which was 1521 then terrified by the prospect of the introduction of a new, free public service. We have arrived at a situation where we now have a public sector free, which is now so frightened of an expensive private sector that somehow it feels that it has to hide it away. The wheel has turned full circle indeed. It is my view that with the right priorities, with the right use of our resources, with efficient administration and the abolition of waste and duplication, it would be perfectly possible for our nation to mount a fully comprehensive health service, free at the time of use to every man, woman, and child in this country. It is on that that we should be concentrating our attention.

After I sit down, my Lords, you will hear many eminent doctors speak and, if I may say so, you will also hear many eminent patients speak. The views of both sides are equally important. But I hope that at least all of them will be speaking from the point of view of preserving and cherishing and maintaining our National Health Service.

Lord HUNT of FAWLEY

My Lords, I, too, should like to thank and congratulate my fellow general medical practitioner, the noble Lord, Lord Stone, on his maiden speech. I much enjoyed listening to what he said, and I hope that he will speak to us often in future. Many points in this Bill are complex and a large proportion of doctors will agree with my noble friend Lady Young when she said that not enough time has been given for their proper consideration by the medical profession and by your Lordships' House. The British Medical Journal, in a leading article (10.5.76) has called the Bill, "hasty, ill-considered legislation". With this and the guillotine imposed in another place there is an element of truth and some significance in the colloquial question put to me recently: "Are the Government pulling a fast one on the medical profession by introducing this Bill just now?" In some ways many doctors think that they are.

We owe a great deal to the noble Lord, Lord Goodman. We realise that the Bill now contains much that has become known as "the spirit of Goodman", and we all thank him for this and for the hard work he has done for us. But— 1522 and it is a big "but"—we must appreciate that at no time has the medical profession as a whole (as represented by the Royal Colleges and Faculties, and by the British Medical Association) accepted any compromise over its total opposition to this Bill, even with the Goodman proposals incorporated in it.

Last week I met the President of the Royal College of Surgeons, Sir Rodney Smith, who is chairman of an important Working Party (of the Royal Colleges and of the BMA) which is studying the ethical responsibilities of the medical profession within the framework of the National Health Service. I met also Dr. James Cameron and Dr. Elston Grey Turner (Chairman of Council, and Secretary of the BMA). They all told me that the Royal Colleges and Faculties, and the BMA are still implacably opposed to this Bill. They sincerely believe, for reasons with which your Lordships are by now familiar, that it will do British medicine, the National Health Service, patients and doctors a great deal of harm; and they rely on Parliament to have the good sense not to pass it in the face of this strong medical opposition. The suggestion which I have heard, that we should accept the Bill for fear that if we do not do so something worse might be proposed next Session, is to my mind a weak one. To accept it meekly now might easily encourage our opponents to add something very much more unpleasant soon.

What my profession has said is that if the day is lost and the Bill receives Royal Assent (when the doctors could not then act against the will of Parliament), they would do their best to make it work, provided it includes the negotiated Goodman compromises which are better than those suggested in the original Consultative Document. The word "compromise" implies agreement, and this is the only agreement which my profession as a whole has made so far; and it will act on this only if and when, against its wishes and advice, this Bill becomes law.

The right honourable Mrs. Barbara Castle, in another place on 12th October—only nine days ago—issued a warning to your Lordships' House. She said: I issue a warning … If this compromise is to be challenged and injured … there will be no 1523 peace in the NHS. Their Lordships will have reopened the gates for industrial action, and it will be upon their own heads …"—[Official Report, Commons, 12/10/76; col. 306.] That would not be on our heads alone, my Lords, for no one has forgotten that it was her Government which started all this trouble over a mere 1 per cent. of the beds in the National Health Service. She has thrown down the gauntlet at your Lordships' feet, and we shall have to decide quite soon whether or not, on behalf of the medical profession, we accept her challenge.

If this Bill is passed and we act along the lines of the Goodman proposals I, as a practising doctor, am particularly interested in three points in them. First, the phasing out of pay beds in National Health Service hospitals, if and when this takes place, must be done in an orderly and reasonable manner, and only when consultants are convinced that good altertive private bed accommodation of equal quality and availability for patients and doctors is provided. This alternative accommodation must be in addition to the beds at present in private nursing homes and hospitals which are, in Central London anyway, already fully occupied (but not always so in the Provinces); and this is before any phasing out begins. This is an important point which I do not believe is fully appreciated.

Secondly, the proposed Health Services Board must be seen to be truly independent politically, and unbiased. Thirdly, the Government, trades unions, local authorities and others must agree that there will be no interference in future on political or ideological grounds with the building, staffing or running of any of the private hospitals mentioned in the Bill, nor with private beds and facilities which remain in NHS hospitals during the period of phasing out. And there must be no interference, either, with private medical insurance organisations.

I know, my Lords, that this Bill aims to take private practice out of the NHS and not to abolish it; and I agree with what the noble Lord, Lord Goodman, said about this. Many senior members of the Labour Party, including Sir Harold Wilson, Mrs. Barbara Castle, the noble Lord, Lord Wells-Pestell, and the present Secretary of State for Social Services have 1524 said time and time again that they wish to preserve a healthy private sector of medicine in Britain. I gave some of these references to this House in my speech on 3rd December 1975, and here are two more. Mrs Barbara Castle, at the first meeting of the Select Committee on this Bill said: It would be intolerable in a democratic society to prevent people buying private medical care if they felt that it was an essential part of their personal interest."—[Official Report, Commons, Standing Committee D, 18/5/76; col. 38.] The present Secretary of State for Social Services, the right honourable David Ennals, confirmed this attitude on 27th April this year, at the Second Reading of the Bill in another place: This Government have said … that it is no part of their policy to abolish private medicine."—[Official Report, Commons, 27/4/76; cols. 207–208.] If the National Health Service does not improve soon, it will need a great deal of help from the private sector in these days of financial stringency. The private sector will then gradually and reasonably expand. I am in full agreement that the quality and standards of hospitals both within and without the National Health Service should be kept under careful scrutiny, and that some equilibrium must be maintained between the two sectors. Every patient who chooses to be treated privately saves the National Health Service money, equipment, personnel and much else, and standards of total pateint care depend on both sectors. If any Government in future, for politically motivated doctrinaire reasons, try to strangle the development, by quantity licensing, of private hospital beds, that will be a most damaging action to prevent the private sector playing its proper role. Sooner or later, and the sooner the better, everyone must accept that the public and private sectors of medicine in Britain must learn to work together in harmony, helping each other with good will and understanding, with reasonable and friendly liaison between the two, each making a useful contribution, as happens with public and private transport on our roads. This symbiosis should logically take place within the walls of our large and famous hospitals, and in many smaller hospitals too throughout our country. It will be much to my regret if Party politics and this proposed Bill make this impossible, so that they will have to work 1525 from separate establishments, to the detriment of both.

My Lords, during the last few minutes of my speech I should like to ask you three questions: Should my profession ever accept, without a struggle, politically-motivated direction imposed upon it by any Government? If doctors dislike that direction strongly, should they fight and, if so, how? Or should they emigrate in appreciable numbers? First, should the medical profession accept quietly, without opposition, arbitrary doctrinaire control imposed upon it by Government or trades unions? Such unopposed direction must lead to impairment, or loss, of professional independence of action and judgment, with curtailment, too of clinical freedom both for patients and their doctors. One example of this would be a patient's freedom of choice as to who would operate on him, and when and where?

Second, should my profession fight for these freedoms and, if so, how? If a Government, for Party-political ends, is dictatorial and unreasonable with a great profession, forcing through a Bill like this, which the noble Lord, Lord Goodman, himself agrees was not really necessary in the first place, that profession must defend itself, as would any other. The legal profession, for instance, has been considering this problem seriously, as the President of the Law Society has so clearly pointed out recently. What he said was published in The Times on 8th October. But what can we do if discussion is cut short, our views are ignored and agreement cannot be reached? Most doctors would agree with the principle proposed by the President of the Royal College of Physicians, Sir Cyril Clarke, when he wrote in a letter to The Times of 30th July about his Royal College: We do not believe it is right to take any action which may bring harm to patients. But what effective practical alternative has been put forward? None. The Royal College of Physicians has suggested a, "Council of Conciliation", the Working Party of the Royal Colleges and of the BMA (which I have already mentioned) has not reported yet, and the Government have refused to put the pay bed dispute to the Royal Commission, as many doctors thought they should have done.

1526 During the past 12 months, my Lords, the mood of my profession has hardened, and it has learned how to fight. Medicine is not an industry, so "industrial action" is an incorrect, inappropriate, and misleading term when applied to doctors. They are learning how to take what is better called "professional action"—highly-selective action of various kinds—within the law and within their contracts and terms of service, which they can take either individually or collectively with the support of the British Medical Association.

In December 1975, it was the collective professional action of doctors which played a large part in persuading the Government to introduce Lord Goodman's proposals into the Bill. More recently, it was collective professional action which helped the junior doctors to obtain what they wanted in their dispute with the Department of Health and Social Security. No doctor wants to inconvenience or harm his patients in any way which can be avoided. Neither does a surgeon who operates, say, to remove an abdominal tumour, want to hurt his patient; but, as Hamlet says: Diseases desperate grown, By desperate appliance are reliev'd, Or not at all. The surgeon and his patient appreciate and accept that a certain amount of temporary inconvenience and pain are necessary for a cure. So it is with doctors taking collective professional action. The President of the Royal College of Surgeons wrote to The Times of 2nd August an immediate addition to that of his fellow President, pointing out the dilemma facing the medical profession now: If a Government acts in a manner so damaging to the practice of medicine that harm to patients must result (and one must include in this measures that reduce the morale of those working in the NHS) how can doctors oppose if the most effective means of opposition might itself harm patients? It is the conviction of many thousand members of my profession, now, that collective professional action may be justified, under certain circumstances, for the benefit of British medicine in the future. These circumstances arise when there is a serious risk of erosion of our professional freedoms by Party-political moves such as the forcing through of a Bill like this, and when no conciliatory mechanism exists which will ensure that both sides will listen to reasonable arguments and respond to them. The 1527 noble Lord, Lord Taylor, who as a young doctor and Labour M.P. for Barnet—Stephen Taylor—was responsible to a considerable extent for the inception of the N.H.S. by influencing and advising Aneurin Bevan, wrote this about doctors on 10th March this year in the journal World Medicine: Doctors must remember that Parliament cannot bind its successors in perpetuity. If future legislation were to threaten their essential professional freedoms, they would be justified, in the long-term interests of their patients, in fighting the proposals by every means in their power. My third and last short question, my Lords, is, "Should our doctors emigrate?" Inevitably, better facilities, conditions of service and freedom from political and trade-union interference are attracting gifted medical men and women to other countries, as my noble friend Lady Young has already mentioned. Many of us firmly belie