HOSPITAL SERVICE AND MEDICAL CENTRES

Lord AMULREE

My Lords, we are very pleased that the noble Lord, Lord Auckland, has referred to so many of the problems which confront the Health Service at the present time, and I do not propose to follow along exactly the same lines and repeat what he said. But I have been a firm supporter of the Service from the moment it started. I worked as part of it for about 20 years, and it was with a great deal of sorrow and regret that I saw the first Act of Parliament which came in to reform the Health Service about five or six years ago. The sole effect of that reform has been an 353 enormous increase in the administrative side of the Service. Between 1966 and 1974, which is the last year for which I have a figure, the number of full-time administrators increased by 77 per cent., whereas the figure for general practitioners was about 7 per cent. and for consultants about 13 per cent. One would not object at all had that large increase in administration led to a 77 per cent. increase of good for patients. But I do not believe, in general, that it has done anything at all to improve the lot of the patient; and, after all, the Health Service was intended for the care of the sick and those in need, not for the administration.

I know perfectly well, and I am sure that the noble Lord, Lord Wells-Pestell, will agree, that we are extremely short of money, and that we shall have to make do with what we have. Therefore, I have not for quite a long time been in favour of pulling down old hospitals and building new, larger and more splendid ones.

I did my work for the National Health Service in what was the infirmary of the old St. Pancras workhouse, which was built in the 'fifties or 'sixties of the last century. It was extremely well built and we spent a certain amount of money upon improving it internally. So, internally, it was a good, modern, attractive building, although I am afraid that from the outside it still looks like the infirmary of the old St. Pancras workhouse. However, that does not matter. That is why I wonder what people are frustrated about when they say that their hospitals are not modern. Provided that there is the will to work well and a certain amount of money so that equipment can be kept up to date, it does not seem to me to matter a great deal what kind of building one works in. That is why I am interested in what the noble Lord has said about the fate of the small hospitals.

At one time, there was a feeling that the small hospitals should be shut down and that all work should be done in district general hospitals with a minimum of 500 beds. I believe that there has been a change of heart. Now it is felt that more can be done with the small hospitals, provided that they are linked in all kinds of ways with the district general hospitals. I have been convinced for a very long time that it is most therapeutic for anybody who is in a hospital bed to be visited by his 354 relatives and friends. Quite often that will do him far more good than the care that my profession and the other professions can give, because the general tendency of most illnesses is towards recovery. Therefore, I should like as many as possible of these small hospitals to be retained, so that visitors can reach them regularly and easily, and to be linked with the larger district general hospitals which can do work, particularly in this rather specialised world of medicine into which we are now moving, that cannot be done by the other hospitals.

There was an inquiry regarding nurses, the name of which I cannot remember at the moment but which sat at the same time as the social worker inquiry. It was accepted by the Government of the day that if nurses wish to rise to the top of their profession they should do so on the administrative rather than the therapeutic side, where the primary aim is to take care of sick people. That has done nothing to improve the quality of nursing or to make it a more attractive profession for young people.

One of the places where the reconstruction of the National Health Service went wrong—and here I agree entirely with what was said by the noble Lord, Lord Auckland—concerns the value of the hospital management committees. Both the noble Lord and I have served upon hospital management committees and we know that their value was enormous. One was in contact with the hospital staff and one knew what was going on. Also, one was in touch with the patients. All that has now gone. Instead we have bodies called area health authorities. Therefore, personal contact between those running hospitals and the patients has been lost. The local management committees have been replaced by a third administrative tier. I am certain that it would be no loss if one of the administrative tiers were to vanish, and I hope that it will.

So far as I can remember, when Aneurin Bevan introduced the National Health Service the original concept was that the Regional Hospital Boards and the teaching hospitals should have the real authority, that very largely the Service should be run by local committees, under the Regional Hospital Boards and the teaching hospitals, and that the Ministry should 355 not be so powerful a body but one which formulated general policy for the country, so that the Regional Boards and boards of governors knew what was expected of them. Unfortunately, however, the power of the Treasury proved to be too strong. Therefore the Ministry of Health, or what is now called the Department of Health and Social Security, has retained an enormous amount of control, although I do not believe this to have been the intention when the National Health Service was set up.

There is one minor point which I should like to make on the financial side. It is a pity that arrangements cannot be made whereby money which is granted to a hospital authority in a certain year can be carried over to the next year. It happens from time to time that money which has been granted to a hospital cannot, for very good reasons, be spent in one year. If a hospital cannot spend the money during the year in question, I believe I am right in saying that it has to be returned to the Treasury. So when March comes the hospital authorities say, "Goodness! We have £5,000 to spend. What can we spend it on?" And they spend it upon many extravagant items which are not required. My Lords, those are the few random points which I wanted to make. I have made them before and, if I am spared a little longer, I shall probably be called upon to make them again, for it will be quite a long time before a good number of these points are taken up and put into effect.

Baroness YOUNG

My Lords, I am sure that we are all delighted that my noble friend Lord Auckland has introduced such an important debate this afternoon. It is timely. Although the Royal Commission is sitting, we do not know when it is to report, nor, so far as I know, is it to issue an interim report. Even more important, we do not know whether, when the Royal Commission does report, its findings will command acceptance. In the meantime, to put a self-denying ordinance upon any discussion of the National Health Service or the medical services would not be helpful. It seems to me to be right that this House should debate the National Health Service, especially at a time when morale is so low 356 and anxiety so widespread. The National Health Service, once the pride of our country and the envy of the world, is not what it was. At the very least, the debate today will reassure the many thousands who have been working so hard and so long in the National Health Service that there are noble Lords on all sides of the House who care deeply about the service and its problems.

My Lords, I regret that I must begin my speech with an apology to the House. Unfortunately, I shall not be able to stay until the end of the debate. I apologise in particular to the noble Lord, Lord Wells-Pestell, for I shall not hear his winding up speech. However, months ago I agreed to attend the centenary celebrations of my old school which fall this evening and I do not think that I can go back on the agreement that I made. Therefore, I apologise to the House, but I shall read with great care what is said.

My Lords, in preparation for this debate, I re-read the debate in your Lordships' House on 3rd December, 1975. There was much discussion then on two particular topics: the start of the National Health Service and Pay Beds. Unlike many speakers in today's debate I was not in politics at the start of the National Health Service and my only comment is that I am one of its beneficiaries. However, I should like to emphasise at the outset that my Party is firmly committed to the maintenance of the National Health Service. We believe that the first task of any Government, at present, is to restore morale in the Service and I shall return to that point later in my remarks.

As regards the phasing out of private beds in National Health Service hospitals, I wish to make only one remark. During the long debates on the Health Services Act, this House carried an important Amendment to the effect that those private beds which were phased out should be used by National Health Service patients. The spirit of this Amendment, although not its precise wording, was actually accepted by the Government in another place, no doubt because it would have been highly embarrassing to have to admit that, far from preventing queue jumping—ostensibly the reason for the Health Services Act—the Act would have actually had the effect of lengthening the queue.

357 Let us consider what has, in fact, happened. As far as I can ascertain, the private beds which have been phased out have not been used for National Health Service patients. I think that I can do no better than quote a letter from a doctor which appeared in the British Medical Journal on 28th May, 1977. He writes: On 20 May this year 10 beds on the private ward at the Gordon Hospital, a part of our hospital group, were due to be closed down. These beds will lie empty and gradually collect a veneer of dust. There is no question at—all of their being used for NHS patients and to help reduce our rapidly lengthening waiting list. Inquiries among my surgical colleagues throughout Britain have failed to reveal any example where the closure of a private ward has released a single bed for a NHS patient". My Lords, I believe this to be an indictment of the Bill and its consequences. I think that it is particularly serious if it is taken in conjunction with a report that has recently been issued called Common Waiting Lists for NHS and Private Patients in NHS Hospitals. If we look at the principal recommendation of this Report, which appears in paragraph 9 and which states: We recommend that all other private patients should be placed on the same waiting list as comparable NHS patients in the care of the same consultant"— a recommendation which I believe to be completely sensible and with which I personally agree entirely—we shall see at once that, if more patients go on to the waiting lists and there are fewer beds in the hospitals, the effect will be to lengthen the queue. I sometimes feel that we are in an "Alice in Wonderland" world and, as someone who believes that the object of this exercise is, at the end of the day, to help National Health Service patients, I think that it is a very sad reflection that the consequence of all this has been as I have stated.

The facts for the ordinary patients are now very serious indeed. There are over half a million on the hospital waiting lists in England alone, of whom 30 per cent, are, I believe, people who have been waiting for over a year. At the same time, there is a rise in the waiting time for out-patient consultations and a fall in the number of cases treated per doctor in the Hospital Service of over 7 per cent. As one doctor wrote to me—and I quote his letter— It is still possible, as a result of the commitment of all kinds of staff, to offer a good service to 358 those needing emergency treatment, a fair service to the seriously ill with conditions imperilling life or health, but for those with conditions which although troublesome and debilitating do not carry a danger to life, there is a diminishing prospect of any treatment at all". My Lords, I hope that that doctor is taking too gloomy a view. However, I believe it to be true that, for example, for those suffering from arthritis who want what has now come to be considered a relatively common operation, the waiting time is, on average, 14 months. Sometimes, patients need to wait up to five years for such an operation.

What, then, are the causes of these problems and can we offer any remedies? The first, and obvious, cause of trouble is that the National Health Service is under-financed. When all the figures are juggled about there is simply not enough money for an effective, comprehensive Health Service. We have created an indefinite demand with a finite amount of money. This is made abundantly clear in all the Government reports on this matter. It seems to me that the first thing to he done is to explain the realities of the situation to the public so that they know what to expect in the present economic situation and for some time to come. Otherwise, the public are simply encouraged to blame the staff for the shortcomings of the Health Service and that, I feel, is completely unjustified because the staff are working very hard in difficult circumstances.

I hope very much that the Royal Commission which is looking, among other matters, at the financing of the National Health Service will look to see how the health services are financed in other European countries. I think that it would be extremely helpful for us to see how it is done. I think, too, that we ought to look at charges to see whether they really keep up with the rate of inflation. Certainly some of the charges have done so. For example, the income from dental charges has risen from 16 per cent. as a whole in 1975–1976 to 24.3 per cent. as a whole in 1977–1978. The income from optical charges has likewise gone up from 28.5 per cent. to 37.7 per cent. The income from prescription charges in relation to the gross cost of the pharmaceutical services has actually dropped from 5.8 per cent. to 4.6 per cent. I do not know why, but it seems to me that that is something that is worth looking at.

359 My Lords, I also believe that it is worth looking at the whole problem and question of encouraging more people to take out private insurance. It is an extremely curious fact that if one looks at the group of people who actually have to pay when they go into hospital, one finds that it is that group—those on retirement pensions, or sickness, invalidity or injury benefits—who are in the hospital for more than eight weeks. After that period, their pensions are reduced. The total number of retirement pensioners in hospital who have had their pensions so reduced has risen from 86,000 in 1973 to 88,000 in 1975. When one looks at the most up to date figures for the total sum of money involved, one discovers that the money going back into the Health Service for retirement pensioners alone has risen from £21 million in 1973, to £40 million in 1976. If we include in that sum of money those who have sickness, invalidity and injury benefits, the total for a full year would probably rise to £60 million or more. Of course, those figures take no account at all of supplementary benefits.

The argument that is put forward for removing pensions when people have been in hospital for more than eight weeks is that it would be wrong for them to have, as it were, pay twice—once by way of a pension and once again in hospital. Yet, when one has ceased to play with the words, the fact is that they are contributing to their cost. If what might well be described as the most needy group in the population—the elderly, the disabled and the injured—are required to do this, would it not be sensible at least to encourage the fit and the able to take out private health insurance schemes and so take away from the national health services some of the expense of the operations and other treatment required?

One concrete method of encouraging more private insurance schemes would be by way of tax relief for employers and employees. I think that this is something that it would be well worth the Government examining. I hope that the Royal Commission is looking at it very seriously indeed in order that all the patients in the National Health Service may benefit.

Finally, on finance I think we need to look at a much better use of resources 360 and I know that my noble friend Lord Sandys, who will be winding up for us on these Benches, will be speaking about this. Both the noble Lord, Lord Auckland, and the noble Lord, Lord Amulree, spoke about the complaint, which indeed I have heard many times, that there are far too many administrators in all areas of the National Health Service and the National Health Service reorganisation is always blamed for it. In fairness to the Act, I believe that when the National Health Service Reorganisation Act came into force in 1974 not a single extra person was employed in the Health Service who had not previously been employed in the National Health Service or in the local authority services which were incorporated into the Service at that time. There were a number of redundancies and a special staff commission was set up to look at the problem of people who might be affected adversely as a result of the reorganisation.

The way in which the Service has developed since then cannot be blamed on the Act itself, and we recognise that there is a position which I myself much regret in which there is now one administrator for every four hospital beds. Surely this cannot be right, and we need to look at our resources to ensure that money is going in the right place. Therefore, I think there is a case for looking at the proportion of administrators.

The third area where I think there has been a great loss of morale is in connection with the staff. I should like only to say this about the nursing profession, which I believe is one of the great professions in this country. It is absolutely deplorable that nurses are so badly needed in hospitals and yet, at the same time, there are now 3,821 registered as unemployed, although fully qualified. Indeed there are many nurses in training who know that when they have completed their training they will not have a job. This goes side by side with empty hospital beds and ever-lengthening waiting lists. It is an Alice-in-Wonderland situation; something which would he a comedy were it not in this case a tragedy.

Equally serious has been the way the doctors and consultants have been affected by the various incomes policies over the last two years. Nobody who takes a serious interest in this matter can fail to 361 have read the 1977 Review on Doctors' and Dentists' Remuneration. I believe its publication was somewhat delayed, and that is hardly surprising when we read the facts contained in it. The facts are that between April 1975 and April 1977 the average fall in living standards for the average wage and salary earner was about 6 per cent; the average remuneration for doctors and dentists fell by at least 10 per cent. and in some cases by 14 per cent. and, due to a number of anomalies, even more than that. The only other group of people whom I believe have fared equally badly have been university teachers. It seems unfortunate that this group of professional people seem to have been singled out for this unfortunate treatment. Although the review body does not suggest that there will be anything like a strike—and the last thing anybody would wish would be something like that—there is no doubt that there is considerable concern among professional people that, because of the dates at which the reviews have taken place, they have found themselves in a pay trap with their remuneration falling steadily behind that of others. After all, they work very long hours, they have to spend years studying in order to gain their qualifications and it does not help anyone to believe that at the end society feels they are of such little worth that they should be paid relatively less and suffer relatively more than other groups in the population.

Perhaps it is not surprising that a recent report in The Times of 2nd March showed that, in inquiries made of nine of the 14 Regional Health Authorities, for a total of 612 registrars' posts, only 1,009 applications were British and 7,796 applications came from overseas. Of those who were finally appointed, 385 were from overseas, representing 62.9 per cent. compared with 37.1 per cent. who were British. So we see a pattern emerging in which the opportunity to go into the National Health Service is not one which British doctors are seeking. It seems to be one which is more popular with those from overseas. Again we have the pattern emerging of ever-lengthening queues, unemployment among the nurses, demoralisation among the doctors and the filling of the posts in the hospitals by those from overseas. All this adds up to a very sorry tale indeed. They are serious facts and I think they explain the loss of morale in the National Health Service.

362 Therefore, I should like to finish on a constructive note. I believe we ought to be thinking constructively about the improvement of the Service. I hope the Government will look seriously at the question of pay anomalies, at the question of fully employing fully qualified nurses. In order to help the patients, I hope the Government will look carefully at the relationship between the National Health Service and the social service departments of local authorities. That is something which could be done without extra cost in money and it would help the discharge of patients into their own homes to come about more quickly and more satisfactorily for both parties.

In a debate like this, it is easy to talk about the National Health Service, the doctors, the nurses and the ancillary workers, and yet at the same time to forget the patients. At the end of the day, they are what it is all about. Perhaps I might quote one short story about the National Health Service which applied to myself. Not so long ago the school which my daughter attends telephoned me to say that she had had a very slight accident in the gymnasium and they thought I ought to take her to have her foot X-rayed. I collected the child from the school and I took her down to the casualty outpatients department of our local hospital. There is no car park so I had to leave her in the outpatients department while I went off to park the car. When I came back, to my surprise I found her outside the hospital, sitting on a chair. She had fainted from the heat and had now bruised her head very badly and so she had been put outside to recover. At any rate, I collected my child and we went back into the casualty outpatients department, and the House will be pleased to hear that in fact her foot was not very seriously hurt and three hours later we went home.

I have no complaint of the treatment. The doctor we saw could not have been kinder or more helpful. He looked quite exhausted; he told me that if I was not satisfied I was not to hesitate to come back again, but it emphasises the difficulties of old buildings, of hospitals without adequate facilities, of the difficulties of people who have to take children to hospital and of the time that it takes. I quote the story simply because these are the matters which people think about when they consider the National Health 363 Service. I quote it not as a criticism but as a typical example of the use by patients of the National Health Service.

I hope very much that the point made by the noble Lord, Lord Auckland, and the noble Lord, Lord Amulree, about better relationships in hospitals will come about. I believe the worst possible situation for the Hospital Service would be for there to be further disputes between the consultants and the ancillary workers, because at the end of the day the health of the patient depends entirely upon the work and the skills of everybody in the hospital from the consultant to the doctor, to the person who provides the meals, the person who cleans the rooms. All are needed and all have their part to play. I believe that all in the Service should recognise that they are working for a Service in which the good of the patient must always come first.

Lord SEGAL

My Lords, I take part in this debate with a good deal of diffidence and some degree of reluctance, but if the whole trend of the debate tends to he somewhat critical, perhaps it may afford a degree of comfort to my noble friend who is to reply that I am to be the last speaker from these Benches who is to take part. When I first rose to speak in your Lordships' House, now over 12 years ago, it was on a similar Motion, also introduced by the noble Lord, Lord Auckland, and I am grateful to him once again for having raised this subject in today's debate.

That occasion 12 years ago was also notable for the maiden speech of the noble Baroness, Lady Brooke of Ystradfellte, who, I am glad to see, has been with us until a few moments ago. My subject 12 years ago was the existing malaise in the medical profession, particularly among general practitioners. That malaise has been a favourite theme of many maiden speakers since. I recall especially a striking maiden speech by the noble Baroness, Lady Stocks, who, alas, is no longer with us. This malaise in the National Health Service, however, is still with us, if anything to a far greater extent today than it was 12 years ago. What is so regrettable is the fact that it has since spread to the ranks of the con- 364 sultants as well, in fact throughout the National Health Service, affecting nurses and hospital employees alike.

Our National Health Service may still be the best in the world, as we have grown so accustomed to reiterate, but it is nevertheless a service in the ranks of which enthusiasm is somewhat lacking. That perhaps is an understatement, but it is an understatement made deliberately. Of late we have seen many attempts on the part of the Government, sincere and well intentioned as they undoubtedly are, in our present difficult economic climate, to remedy the present state of affairs. I feel that every credit should be given to the efforts of Ministers and their staffs to solve the heavy problems with which they have been faced.

But, after all, the legislation for the abolition of pay beds, I suspect, precipitated a mountain of labour and produced only a mouse, and a somewhat impoverished church mouse at that. It has certainly made, I suspect again, no impression on our lengthening waiting lists. It has even given rise to the sad joke that our abortion Acts have added such a burden to the waiting lists of some hospitals that their waiting lists for abortions have now grown to over nine months. But all the attempts at creating common waiting lists for private and National Health Service patients, as the Wigoder Committee's Report only proved, have ended in failure. The only conclusion they reached was that in the last resort the waiting lists of our hospitals had to depend mainly on the medical staffs—a conclusion they might have known before they began their deliberations. So the whole issue of common waiting lists is back now to square one.

Meanwhile abolition of pay beds, phased as it was, has not added materially to our hospital resources, but only impoverished the health services still further. And has it finally brought peace to our hospital staffs? I suspect, again, the contrary. It has only maintained the spirit of discontent, created an attitude among the staffs dangerously close to beggar-my-neighbour, and certainly done nothing at all to shorten the waiting lists or to improve the lot of our long-suffering patients. I make this assertion subject to correction by my noble friend the Minister who is to reply, and I hope in his reply he will be able to 365 prove me wrong and give us the exact figures of the reduction in hospital waiting lists following the first phase of the closure of 1,000 pay beds.

The uncertainty that prevails about recruitment of new students to our medical schools, fortunately, has not affected the quality of new entrants to the profession. There, at least, competition for entry is intense, morale is high, and the quality of intending students is as excellent today as it has ever been in the past. The desire to serve, to join the ranks of those who are striving to alleviate pain and conquer disease—that urge among our young people today is one of the most heartening factors in the gloom which at times tends to surround the outlook of our National Health Service. It is a factor which must be maintained during the years of training and apprenticeship, and afterwards harnessed for the benefit of our patients.

I would far rather we created too many new doctors than too few, and used our existing medical schools to the utmost of their capacity, despite the anticipated fall in our population. There is a crying need today all over the world for more doctors, and doctors of the highest quality, not only in the oil-rich sheikhdoms of the Gulf but in all the poverty stricken developing countries, with their teeming millions of population and their appallingly high birth-rates, so that, unlike our teachers, no doctor need ever remain unemployed. There are so many outlets through international sources, through the World Health Organisation, through our missionary societies abroad, where the services of any medical men found surplus to our own internal needs can be usefully employed. Look wherever you will—Africa, India, the Far East, South America, the Caribbean—the medical services are poorly developed per head of the population, and the need for medical aid is more insistent than ever.

What then is to be done in this country? I would suggest that three things are urgently necessary, though hard enough to achieve. First, to restore morale throughout the health services not only by means of pay, prospects and career structures, as has already been mentioned by the noble Baroness, Lady Young, but also by infusing among hospital staffs a new spirit of service and dedication with a realisation that, however, severe their own economic 366 hardships, they are less than the physical sufferings of the hospital patients whom they have been recruited to serve. There is need today for a higher spirit of teamwork, even of self-discipline, for without these no hospital can prosper; and for recognition that the medical staffs are the keystone of the hospital arch, eroded though it may have been of late. For if the keystone crumbles the whole edifice will collapse.

Secondly, even today in the midst of our strained economic situation, more financial help for our hospital services is unavoidable, and excessive cuts in some directions could only lead to further deterioration. Thirdly, known glaring instances of waste in the National Health Service, especially in the hospitals, must be dealt with. Here constructive suggestions by the hospital staffs should be invited and a spirit of co-operation encouraged throughout medical staffs to remedy known waste both of manpower, especially on the administrative side, and of material resources. I hope that many more discussions on the National Health Service will take place from time to time in your Lordships' House, and that all our future debates may he held in a far more hopeful atmosphere than that which surrounds us here today.

Lord PLATT

My Lords, ever since 15th February 1967 I seem to have made periodic speeches on the subject of the National Health Service. The date is firmly in my mind because it was then that I made my maiden speech on the subject, and the noble Lord, Lord Auckland, said that he was the first to congratulate me from those Benches. Now I can tell him I am the first to congratulate him from these Benches. I think he made a splendid speech. He raised matters of great importance, some of which have also been mentioned by other speakers and some not. I should like to refer to one or two things he said. He referred to what I call the two recent disasters to the National Health Service; namely, the reorganisation, and the phasing out of pay beds. He spoke especially for long-stay patients. I hope that the noble Lord who replies on behalf of the Government will be able to say something helpful to him on this subject. 367 It is one about which I have no really practical experience.

The noble Lord, Lord Auckland, also mentioned two other matters to which I should like briefly to refer before I make some more general remarks. He spoke of kidney machines. I should like to ask the Minister pointblank: Is this not the only case since the introduction of the National Health Service in, I believe, 1948, where a deadline has been set, so that if one is below the age of 15 or above a certain age one cannot have a kidney machine or a transplant? I think that it is the only case.

That is not to say that people have not died through lack of facilities in hospitals. For instance, the local community or village hospital could not have the very latest facilities for cardiac surgery. There are plenty of instances where the patient has been unable to receive aid in time. There have been instances—and the discovery of penicillin was one—where a new and important remedy has been discovered and for a time was in very short supply. Those things cannot be helped, but I should like to know whether anyone can quote an instance where a cut-off has been made because we cannot provide the service, and where people have been turned down for treatment simply because they are above or below a certain age.

I wish to refer again to questions which others have raised and which I did not intend to mention because I have spoken on them in previous debates. I shall not bore noble Lords with all the details on the issue of foreign doctors. This problem exists at registrar level—that is, sub-consultant level—in other countries. In the United States of America 50 per cent. of those doctors come from overseas and only very few are from Britain; in Western Germany and all parts of the world where medicine has developed so rapidly that it needs a staff of people with this particular level of expertise. This is not simply due to a shortage of doctors, because if sufficient doctors were to qualify to fill all those posts, most of them would have nothing else to do for the rest of their lives.

We must remember that a consultant holds his post for an average of 30 years, during which time perhaps 20 or more young men will pass through his unit as 368 registrars or in similar posts. When the consultant finally retires he leaves but one vacancy. The very simplest arithmetic will show that we must fill these posts in some other way. Many of these young men will, rightly and properly, go into general practice, where I am sure they will be very welcome. Nevertheless, there is this arithmetic gap which most people seem to pass over and say, "We do not have enough doctors because of all the foreign gentlemen around". That is largely, though not entirely a fallacy.

Noble Lords will be glad to know that I shall not repeat all that I have said on previous occasions. However, I must reiterate one or two remarks because there are certain principles of which we are in danger of losing sight. In this to a considerable extent I shall be drawing on personal evidence, which, I have given to the Royal Commission on the National Health Service. The Health Service has been a boon to millions of people; that is a truism or, as some noble Lords may prefer, a platitude. This is in danger of being forgotten, especially by those who did not know what the medical profession and the service to the patient was like before the introduction of the Health Service. In the old days we had the bankrupt voluntary hospital and a low standard of hospital service in a large number of provincial towns, with the exception, usually, of their teaching hospitals.

There are two reasons why people do not seem to bear in mind the boons of the Health Service. One is the constant denigration of the Service by the British Medical Association and similar organisations, and the fact that right from the beginning the then secretary to the BMA, who shall be nameless, told all the doctors to boycott the new Service and not join it.

Lord HILL of LUTON

My Lords, the noble Lord will go down in history as a distinguished diagnostician, but not as an accurate historian.

Lord PLATT

My Lords, I listened to some of the speeches myself. I do not want to dwell on that. These tactics are bound to have at least two effects. The first is that they build up a grievance, because one cannot get doctors to boycott a Service without building up a grievance. Then one is never quite sure how much of 369 the discontent is due to the grievance and how much is real and due to the defects of the Service, of which, of course, there are plenty. This leads to a lowering of morale and the maximum of between the Government and the doctors, whereas the maximum amount of co-operation is the only solution to most of the problems facing the Health Service.

I think that I may now skip some of my notes, although not because of any interventions that have been made. We should bear in mind three important principles. One, which I have just enunciated, is that we shall never succeed without the maximum amount of co-operation between the Government and the doctors. I am not convinced that in the 30 years since the setting up of the Health Service we have had maximum co-operation on either side. I blame neither the doctors nor the Department.

The second principle is that, whatever may be the calls from the far Left for a wholly illusory egalitarianism, one just cannot mount a good Health Service without the willing participation of the doctors, even though one's political views may not always coincide with theirs. In that context the phasing out of pay beds has been an absolute disaster. Various speakers have said that it does not seem to have done anyone any good.

If the noble Baroness, Lady Lee of Asheridge, were present, she would remind us that when the Health Service was introduced it was decided that there should be amenity beds and that by paying a modest fee—which I believe was five guineas a week (which sounds like pocket money for a child nowadays)—one could have the benefit of privacy and so on, though it would not lead to better treatment or to jumping the waiting list. I should like to point out that, from a practical point of view, that is quite impossible. Presumably amenity beds are set aside for patients who want to pay to have amenity beds. Either we have enough or more to spare of those beds, in which case patients will jump the queue, or else we do not have enough, in which case those amenity beds will be filled by National Health Service patients who are not paying for amenity beds in any case. Even that does not solve the question of queue-jumping.

370 Certainly the phasing out of pay beds does not solve any of those questions. For the phasing out of pay beds to be introduced by a Socialist Government is quite surprising. One would think that it is almost a deliberate attempt to divide medicine into one kind for the rich and one kind for the less rich—one cannot say poor nowadays. It is the most dangerous development in medicine. You appoint the very best people, who build up tremendous reputations for themselves, sometimes for their hospital, for their patients, and you want them to work in the hospital to which they owe their loyalty. Let us suppose, for instance, it is St. Bartholomew's Hospital; do you say that if you see private patients you must see them in St. John's Wood, or something like that? The whole thing is so ridiculous that I cannot think how it ever came about. However, it did, but I am glad to hear that it is believed that it is not a success. I wished the noble Lord, Lord Wigoder, the very worst success for his committee the other day, which he took with very good grace.

On the doctors' side there has been a lack of co-operation among themselves. There are obvious ways of reducing waiting lists. I do not say that they can be done in every hospital or done in a matter of weeks, but wherever a deliberate challenge has been made and doctors and hospital staffs have got together to reduce waiting lists, they have always succeeded in doing so. What is more, a lot of the waiting lists are to some extent bogus. Large numbers of them are for children waiting for hospital beds for tonsils and adenoids, which, in most instances, would be better left where they are. I think the doctors have not collaborated even among themselves to try to abolish other abuses. This question of queue-jumping is in some hospitals, I am sure, quite serious and should be tackled within the profession, because I do not see how administrators are going to tackle it at all.

That leads me to another very important principle. It is absolutely naive to imagine that the faults of the Health Service can be put right by administrative action. They cannot. I think that the so-called reorganisation, which I often call the disorganisation, of the Health Service, is a good example of this. In that respect, I should like to read a 371 short extract from one of the famous CIBA Foundation conferences on health care, which was held in 1976, in which one of the members of the conference, himself a hospital administrator, said about the reorganisation of the National Health Service: The main aims are presumably operational integration and better planning of services…The main problem was whether it could achieve these aims…without introducing a stultifying and expensive bureaucracy…on the evidence of the first 18 months the basic problem has not been overcome and an administrative bureaucracy, in the pejorative sense of the word, has been created". Another principle which I think we should embrace—perhaps that is the word—is that, if you are to judge any new venture in the Health Service, the best criterion on which to judge it is what effect it will have on the reputation of British medicine at home and abroad, because in the long run the benefit to the patient depends on that. The reputation of British medicine, in spite of all that you hear said about it almost every day, is still very high both at home and abroad. It is high for its honesty, its integrity, and the skill of the people who work in the hospitals.

If we were to forget about equal opportunities, which are impossible to achieve, and were to think now of what effect this will have on the reputation of British medicine, we might get a little further in the way of co-operation between the profession and the Department. One final point. The noble Lord, Lord Auckland, referred to strike action and picketing. I was not quite sure why he did not condemn what I call the strike action by junior doctors, and the work to rule—fancy having to use that expression about my profession!—of the consultants. I think that those were two big blots which the profession should never have allowed to materialise.

Lord HAWKE

My Lords, having no administrative experience of the National Health Service I feel some degree of temerity in getting up to talk about it. However, I am a user, and on the whole it has not done me too badly; but I admit that some of my more serious complaints have been dealt with in the 372 private sector. Nobody can deny that some of the delays are rather horrible, and my medical friends say that the whole Service is going downhill. They blame first of all the Conservative Government for their passion for reorganisation, and the Labour Government for their passion for egalitarianism.

I am rather inclined to think that there may be deeper factors still at work, and they are that medical science is progressing at a far faster rate than the national product, and also that we are an ageing population. The net result of this is that the traditional proportion of the national wealth which has been devoted to health in the past is now proving quite inadequate. It has to go round a larger number of people, and if they are to have the best and most modern treatment it has to provide much more expensive treatment. Therefore, we have to find a lot more money. Of course on health the sky is the limit. I do not hold myself up to adjudge exactly how high the sky should be, but there has to be a lot more money. It cannot come out of the Budget because the British people are already grossly over-taxed in the Budget. There would be a revolt. We have to find new sources which would be acceptable to the British people.

The idea would be if people paid a considerable, or a definite, proportion for all the services they received, but great complications arise there. There are the exceptions. There is the splendid myth about the old age pensioners. We are all supposed to be paupers, and those hundreds of thousands, and perhaps even millions of us who are not paupers benefit greatly from this myth because we get a lot of things at the public expense which we do not in the least deserve. Nevertheless, this myth persists, that anybody who is on an old age pension cannot afford anything, and therefore they would have to be excused charges. Then of course the Left Wing would create a tremendous rumpus. Nye Bevan would be quoted and misquoted ad lib, notwithstanding the fact that, as regards incomes and wages, he lived in a completely different era from the present. Moreover, and perhaps most important of all, the doctors might create a fuss about collecting the money in their surgeries, and so on.

373 No, we might try something better. I suggest that we might have an accident levy. After all, the National Health Service spends a lot of money on rehabilitating people who half kill themselves on the roads. Why not put 1p on petrol as an accident levy? It spends a great deal of money easing the dying from lung cancer. Why not have a levy of 1p per packet on cigarettes, and call it the lung cancer levy?

I suggest that in addition we should have a national lottery in aid of hospitals. This has been done in Rhodesia and, I believe, in certain countries in Europe. If we are not prepared to stomach any of those sources of revenue, the next best I can think of is an increase in the employee's portion of the National Insurance stamp; the employer's portion is already much bigger than that of the employee's and, in any event, an increase in the employer's contribution goes straight on to prices and sends them up, so for this reason it should be an employee's levy.

As my noble friend Lady Young rightly said, all these things would have to be explained to the public. It would have to be made clear that the money was for doctors, nurses and other facilities, and not for spoiling a new brand of bureaucrats, which I am afraid is what the British people may suspect. We need more doctors, nurses and ancilliary services so that people may be given a better service generally; one gets a very quick examination from the doctor these days, and it is intolerable that hospital waiting lists for diseases which, in medical parlance, are called not dangerous but which may be hideously uncomfortable, are months' long. If the results are seen and if such matters are properly explained, the end will be considered to have justified the means and the British people will not grudge the extra they have paid by way of some additional levies.

Baroness FAITHFULL

My Lords, I seek to speak briefly on two aspects of the National Health Service, a Service which has been, and even now should be, something of which we can be proud. Nevertheless, we should surely temper our pride with self-criticism, and we are grateful to the noble Lord, Lord Auckland, 374 for giving us this opportunity to look at the present difficulties, of which there are many.

I wish to touch on two aspects, first the recruitment, training and morale of the nursing profession, and secondly an aspect of management as between hospitals and the Regional and Area Health Boards. Let me first, however, take up a point made by the noble Baroness, Lady Young, concerning the nursing profession. I also seek to know from the Minister why there are 3,821 trained nurses out of work on the one hand, and why, on the other, on 11th May 1977, at their congress in Bournemouth, members of the nursing profession posed certain difficulties of which I will mention a few. For example it was said by a nurse that it was ridiculous that untrained staff should still be left in charge of wards. Later somebody at the congress said that nurses knew that proper standards of care were not being met and that grave injustice was being done to patients and their relatives who did not realise the situation.

Although Lord Auckland spoke about hospitals, I wish to draw attention to community care and preventive work in the community. At that congress it was said by a community nurse that in 1975 his department made 147,000 visits with a staff of 61 and that last year they made 159,000 visits with a staff of 57. If the hospitals cannot cope with all the patients, then surely—in any case it would be right—we should carry out preventive medicine with community nurses in our areas.

There is a real difficulty here and I seek the Minister's views on the Briggs Report in which it was recommended that the age of entry for training should be reduced. Would that be wise? There are two channels of entry; the girl of 18 who has 0 and A levels, and the girl of 16 leaving school who, at the age of 17, wants to train as a nurse. The latter, if helped in the right way, has much to offer. However, in my view they should not start their training until 18, first doing two years in allied professions—working in a children's or old people's home or perhaps as nursing auxiliaries in specialised hospitals—thus experiencing gradual exposure to the responsibilities and emotional shocks of illness. Of the 18 year olds, I would say that they also need a time of adaptation to the rigours and joys of nursing.

375 The early achievement of qualification often places responsibility too soon on too young a nurse at too early a stage, and in her own interest this is perhaps not wise nor in the interest of the patient. Indeed, I would say that it is far better for a girl to feel she is working towards a career.

There seems to be a slight dilemma which I hope the Minister can explain. Have we in this country an adequate number of tutors in nursing qualified enough to teach, to inspire and have time to support each individual nurse in training, thus ultimately turning out nurses of the highest and best quality? If highly trainined nurses are removed from the wards to be tutors, what then happens in the wards when there are not enough adequately trained older women to supervise the patients? It seems from the figures that this is a very real dilemma, and I hope the Minister will explain how we are to overcome it.

I support the noble Lord, Lord Segal, because I, too, am not in the least worried at our having more nurses in training, and afterwards trained, than we can use. I am sure that throughout life the nursing qualification for any woman is a great asset. It is unlikely in this country, though not impossible, that we shall at any time have an epidemic, but how glad we should be of any trained nurses More important perhaps, the Third World needs the kind of skilled nurses whom we produce in this country

My Lords, I turn to an aspect of management. I should like to ask the Minister whether he would agree that there is too wide a gap between, on the one hand, those responsible for patients in a hospital and the day-to-day running of that hospital—and I include all members of staff—and, on the other hand, the budgeting of the needs of that hospital. Would it not make for flexibility, efficiency, and a sense of responsibility, for each hospital to receive an allocation of finance each year and leave it to the hospital board, which might consist of all staff across all areas, to use the money as they see the needs? At present they are allocated money from the Area and Regional Boards, which are not involved in the day-to-day needs of the hospital, and with the best will in the world, they cannot see exactly what are the needs of a hospital at any point in time.

376 The hierarchical structure is causing frustration, and diminishing a sense of responsibility. Of course there would need to be inbuilt safeguards. In my view the sector administrator should be in the hospital, and not at the Area Health Board. This may be a naive recommendation; it is a simple recommendation, but I believe that responsibility should be put where responsibility belongs.

Lastly, I should like to say that the hospitals have always belonged to the people—and they should belong to the people. We are short of money, and I do not recommend that there should be vast extra sums spent. But any community that has a hospital in its area, and which has a very good and committed hospital league of friends, will seek to raise money for areas where the National Health Service cannot meet the needs; and in this way the community are involved in the National Health Service, in the hospital in their area, and with the patients who are in that hospital.

Baroness WARD of NORTH TYNSIDE

My Lords, I am very glad that we are having a Royal Commission on the National Health Service, because from all the very interesting speeches made this afternoon one realises how many very important aspects of the National Health Service require investigation. I have quite a number of points that I should like to talk about, and I will try to be as brief as I can; but I should warn the House that I could speak for two hours on this subject—not that I am in the least likely to do so. As I have, for a very long time, and very proudly, been a vice-president of the Royal College of Nursing, I have had sent to me—as I think my noble friend Lady Faithfull has, too—the evidence from the Royal College of Nursing that has been submitted to the Royal Commission. When one sees the size of that document, one realises that for a very long time the nursing profession has required many things to be done for it which no Government apparently have been able to do.

I should like to add one other point here. For a very long time when I was in another place I represented the physiotherapists who, very cleverly, I thought, 377 had a special committee with a well-trained and highly respected secretary to deal with the requirements and needs of the physiotherapists. As a matter of fact, I do not think that anybody has mentioned the physiotherapists and their problem in the debate today. They are very important people in the Hospital Service. So I should like to ask the noble Lord who is to reply, whether the Royal Commission will have taken, as I am sure it will have done, evidence from the physiotherapists' organisation, because it is most important that when the Royal Commission reports it deals with all these very important matters which will, as I believe, make all the difference in the world—

Lord WELLS-PESTELL

My Lords, I hesitate to interrupt the noble Baroness, but in case she intended to put similar questions to me on other disciplines, I should like to say that it is for the Royal Commission to take evidence from any person, or from any source, and it is for any professional organisation, or for any individual, to submit written evidence, or even ask to give oral evidence. This is not a matter over which my Department or the Government have any jurisdiction at all.

Baroness WARD of NORTH TYNESIDE

My Lords, I am very grateful to the noble Lord for intervening. Having been in another place for 38 years, I know only too well that it is most important to get those who answer from the Front Bench to debates of this kind to take an interest in what those who contribute to the debates say. I have a great respect for noble Lords who answer from either Front Bench, because I know that if they take an interest, and if they interest the Cabinet also in all the points made, it makes a considerable difference. Although I am not expecting that the noble Lord will answer the point that I made, I should like him to know that at some time or other I may ask him to answer a question which may have been considered by the Royal Commission. I cannot ask the Royal Commission now to give me an answer, though I could write to it. However, I am not very keen on writing. I like to see things in print, which I can quote if I wish. I thank the noble Lord very much for intervening, but I shall hold him partly responsible, in any case, for the interests of the physiotherapists whom nobody has mentioned this afternoon.

378 I now want to turn to another point. I have quite a few points that I want to make, but I shall not be very long. I want to refer to the question of food in hospitals. Fortunately for me, I have been very healthy over the years, but I had an emergency operation for an appendix the other day, and I very nearly passed out. It struck me at the time that while some of the food which is provided in hospitals is very good indeed, it is a little worrying for people if, when they are feeling so ill that they can hardly read it, they are given a huge menu which suggests all kinds of things that can be ordered. So far as I was concerned, I could not eat any of it. So I had to have simpler things, such as scrambled eggs, fruit, and so forth, which I could enjoy.

There has been considerable criticism about hospital food. Much of it is probably unnecessary criticism because I think that the catering staffs in hospitals do their best to provide the nicest food that they can for the patients. But to have a choice of four or five main dishes every day seems to be going rather far from the point of view of Hospital Service expenditure. I wonder whether it would be possible to have simpler, more suitable, food which the patients would probably prefer if they are really ill. I hope that the noble Lord will not want to say in reply that it is somebody else's duty to raise this question; if nobody else has raised it, then at least I have raised it here, and I put it forward as a suggestion.

I turn to the next point that I want to raise, which I also believe is very important. I think it is fair to say (though, naturally, it does not rest on the noble Lord who is to reply) that the country is very grateful indeed to all those who serve in the National Health Service. We are very proud of them. Wherever they come from, they do their best; but there is no doubt that there is a great deal of criticism of the general administration at the top.

I want to go on to the next point, which is that, when the National Health Service was set up, it took over, so far as I can understand it, all the private hospitals and the private endowments, too. I should like to know whether we could have a list (I would not mind if the noble Lord had it printed, because he obviously could not provide it otherwise) 379 showing how much money was taken over by way of endowments to private hospitals which came into the National Health Service. I should like it in detail; and I should like then to know, if we could be told, how that money has been spent. Because I may be wrong, my Lords, but my own view is that regional hospital services are sometimes so short of money that they spend endowments which have been made to private hospitals which they have taken over rather than maintain those private hospitals, many of which have done wonderful work for the people for whom they were provided. So perhaps in the Recess, when he has not quite so much work to do, the noble Lord will circulate in an appropriate manner a list of all the private hospitals and the endowments which were taken over, how much they amounted to and how the money was spent.

I ask the noble Lord that because, of course, upon that information I want to raise, as I always try to, a case in my own part of the world. I know that your Lordships sometimes get very tired of my referring to that part of the country from which I come, but I am a great believer in experience, and experience in my own part of the world has given me quite a lot of knowledge—and I now come to the point I want to raise about what was known as the Sanderson Home for Crippled Children. This home was built by a very well known family in the North, and was heavily endowed. It had lovely grounds and gardens. It is still there, but there has been a lot of controversy about it recently. There are still a large number of crippled children in that home, but, fortunately, with the improvements in medical science not quite so many homes especially for crippled children are perhaps so necessary.

However, although there are other beds in that hospital and there is a wonderful staff working in it, it was suddenly decided by the Regional Board that the crippled children should be transferred to the new Freeman Hospital, for which I may say we in the North of England have waited, waited and waited—your Lordships know what I mean: it is almost there, but not quite. Now it has been reported that these children are going to be transferred to rooms on the fifth floor of this hospital, where there are no balconies. There is 380 no garden at this hospital, and the children do not want to go there. Certainly the people who were interested in the Sanderson Home do not want them to go there, because the Sanderson Home has a lovely garden; the children were always able to be pushed out into the garden, and they enjoy it. I think this is an absolutely immoral decision, and that is one of the reasons why I am asking about the endowment of private hospitals which have been taken over by the National Health Service.

In addition to that, when this matter was raised by me and other people in my part of the world—and I think my noble friend Lady Masham is also very interested in this hospital; she has done a great deal of work making inquiries about it—one of the reasons given to me was that the second floor in the Sanderson Home was not filled up by crippled children. I was told, in fact, that there were vacant beds. If there were vacant beds, why were those beds not filled by many of the people who have waited so long for beds in my part of the world? We have a very big waiting list indeed. Why could those beds not be filled? They have a very good nursing profession in the hospital, they have very good physiotherapists, and everything appears to be available. Yet that hospital is to be closed down, while those crippled children are going to be stuck in a new hospital, five floors up, I think, with no balconies and no ability to enjoy themselves in the garden. It seems to me to be a most regrettable position, and I should like to know the answer to it.

In addition to that, we had another big children's hospital in Newcastle-on-Tyne, the Fleming Hospital. Curiously enough, many years ago, when I was in the VAD, I did my first service as a VAD in the Fleming Hospital, so I have always taken a great interest in it. Then, suddenly, just like that, it was announced that it was going to be closed. I of course cannot tell whether that hospital is not really needed for children; but there it is. It is a perfect hospital, and it could have been used for housing people who want beds. I was up North last week-end, and I was told that it had been announced on the radio and in the paper that both the Fleming Hospital and the Sanderson Home were going to be pulled down. To me, that really seems a most unfortunate situation. Your Lordships know very 381 well how outspoken people are up in the North, but their view of the National Health Service is anything but friendly, is perhaps even accurate, and certainly is not flattering.

My Lords, we in the North have a very good Regional Health Service Board. We have a very distinguished chairman indeed; and I am glad to say that on that Board in the last few years, for the first time, we have had a State-registered nurse from the Royal College of Nursing. We are very proud of this; and I think that a State-registered nurse on a Board of that kind can do a great deal of good and be very helpful indeed. What I am not sure about is this, because, of course, being only a Back-Bencher when I was in another place, I have not seen all the papers. Now we scramble around trying to get the facts and trying to see if anybody can give us a little bit of additional information about what is going on. Was it not realised by whoever it was who took the responsibility of announcing over the radio and in the Press that this action was going to be taken what effect that would have on the local people?

I think that whoever took that decision cannot be very much in tune with what local people feel about matters. We feel tremendously involved in what happens to people living in my part of the world; and I know that some of the officials, who are very good—and if one knows them very well they are kind enough to say, "How awful!"—feel the same. One never knows, of course, what representations they are able to make, to whom they make them and what action is taken. I think that communication in these great matters of the Health Service is very important, because these things matter tremendously to the local public. I should therefore like to know the answer to that.

I think I have covered everything although, as I say, I could go on talking for about two hours; but I should like to know about some of these matters. I hope the noble Lord who is to reply will not say anything about this not being his responsibility. I think that Cabinets of Governments of all Parties have a very real responsibility. Perhaps the noble Lord could tell me whether he will read all the evidence that has been given, because then perhaps he would know a 382 little more than he does about all the problems that have cropped up in my part of the world. I am glad we have had this debate and I thank the noble Lord, Lord Auckland, for having thought of it. Perhaps we shall not have to wait too long before hearing from the noble Lord on the Front Bench about what has happened to all the important and interesting suggestions and recommendations that have been made.

I am glad to have been here today. I have a great admiration for the Royal College of Nursing and for the physiotherapists, for the consultants and for the doctors. I should like to say how sorry I am that the name of the noble Lord, Lord Hunt of Fawley, is not on the list. He is probably too busy to speak. That happens to a great many very important medical men; they have not the time to do all the work they are called upon to do. I should have liked to hear his contribution. Perhaps I shall go to see him. He sometimes gives me injections against flu. I will go to see him one day and ask why he was not able to be here and what he would have said had he been here.

I hope that the next time we have a debate on this important matter of the Royal Commission inquiring into all the necessities in the National Health Service, it will have gone forward a long way; so that we can continue to find out what the recommendations were and whether the Government have been able to implement them.

Lord WELLS-PESTELL

My Lords, if the noble Baroness is really in need of seeing her doctor, she will find that he is behind her.

Baroness WARD of NORTH TYNESIDE

My Lords, all I can say is he is a very nice doctor. I am delighted that he occasionally can look after me. His name was not on the list and I shall not forget to ask him all the questions that I said publicly that I would ask.

Viscount WAVERLEY

My Lords, in 1959 my noble friend the late Lord Stonham initiated a debate to draw attention to the problems of the Hospital Service. He excluded the teaching 383 hospitals from his survey knowing, as he said, that others with more intimate professional relationships with them would do so, and do it better. He preferred to confine himself to consideration of what are now called district general hospitals. His administrative talents and charitable attitudes served numberless of those hospital committees. He understood. He was a link between my profession and the public. May I join other noble Lords in thanking the noble Lord, Lord Auckland, for contriving today's debate. I hope that it will bear fruit for the matter is most urgent.

At the time of that debate, in 1959, I was consultant physician on the staff of one of our larger district general hospitals and had been so for ten years. I am proud that I retain such a position today. We realised that not only the welfare of patients but our whole reputation in the field of international medicine was increasingly dependent on those hospitals. They were acquitting themselves most admirably. We were all intensely proud. This pride and the high morale it engendered gradually became eroded over the years—increasingly after the reorganisation of the Health Service in 1971.

Your Lordships debated this reorganisation on a Motion by the noble Lord Lord Aberdare in 1971. If your Lordships will bear with me for a moment I should like to repeat what I said then. I said: Since the appointed day the status of district hospitals has been steadily rising. They have therefore been able to attact consultants of the highest calibre. This in turn has attracted correspondingly excellent junior medical staff. Success breeds success. Medical students have increasingly been seconded from their teaching schools to district hospitals for elective or longer periods. All in the present district hospital garden may not be lovely, but there is at least a garden. If, unhappily, my anxieties prove well-founded, and if, for administrative and financial reasons—or both—the status of district hospitals declines, the future will be grim indeed. In truth, my Lords, there will be no future, only a progressive slither of a vital part of this country's hospital services into mediocrity, and no chance then of recovery in any foreseeable future; for emigration of too many of our brightest young medical people will, I fear, have seen to that." [Official Report, 29/11/71; col. 117]. The noble Lord, Lord Aberdare, when winding up that debate, took me gently to ask for being, as he put it, 384 a little too gloomy about the future of the district general hospital". I only wish that my anxieties had proved unfounded, but, alas! they have not. Administrative unwieldiness coupled with insufficient money to maintain existing services, far less expand them, generated a crisis of morale and a loss of pride in the Hospital Service particularly among those medically qualified in all seniority grades and in all specialities.

A most significant attribute of such a crisis of morale may be found in the consideration of numbers of applicants for vacant appointments. I shall do no more than to quote from the letter to The Times newspaper to which the noble Baroness, Lady Young, has already referred, from the President of the Hospital Consultants and Specialists Association. It was headed: No Britons apply for National Service posts". It went on: In 1964, a training post in general surgery at Wolverhampton attracted 26 applicants. These registrars were trained at the following medical schools; St. Thomas's Hospital, 15; Melbourne, 1; Saint Bartholomews Hospital, 1; Charing Cross Hospital, 1; Birmingham, 2; Newcastle, 1; University College Hospital, 1; St. George's Hospital, 1; Manchester, 1; Guy's Hospital, 1; and the Middlesex Hospital, 1". It went on: The latest advertisement for the identical post has attracted 21 applicants from the following countries: Iraq, 5; Afghanistan, 1; Sudan, 2; Pakistan, 1; India, 3; Egypt, 5"— and, rather quaintly— USSR, 4". Although, my Lords, this refers only to surgical registrars similar disastrous reports may be obtained from all specialities and the calamitous trend is mirrored in applications for consultant vacancies.

My Lords, the district general hospital service must be salvaged. It requires much more money. It requires more imaginative administration. It requires more representative administration. It especially requires more medically qualified members of administrative committees. But, above all, I plead with ferocious humility—I am sure these can co-exist—for the utmost harmony in a common endeavour to restore our district hospitals to their former happiness and stature. Nothing less will suffice. They deserve this from us, and if we succeed we shall be esteemed by people coming after us.

Baroness HORNSBY-SMITH

My Lords, I join in congratulations to the noble Lord, Lord Auckland, on having introduced this debate, and, indeed, admire his persistence in sticking to a topic and raising it as he has on more than one occasion—a topic and a subject to which he and his family have devoted so much public service. It took a long period of years to produce the plans for the reorganisation of the Health Service, from which we now suffer. They were well advanced under the late Mr. Richard Crossman when he was in the Ministry and before Sir Keith Joseph set foot in the Ministry of Health. Both Governments share some responsibility for the bureaucratic colossus which, rightly or wrongly, has evolved from the revised Health Service.

I welcome very much the Royal Commission which can take a long hard look again at what has been the result in practice of the high hopes that we had for the reorganisation of the Health Service. First, I think it has destroyed the democratic and local participation which was so valuable under the old hospital management committees. Today, in control locally, there are district committees composed entirely of officials and medical staff within the Service. We have lost the devoted laymen with vast practical experience in finance and working relations, experience in community and social problems, who so ably served—as have so many Members of this House—Regional Boards and/or hospital management committees under the old régime. They knew their local community; they were a contact between the community and the officials. The current community health councils on which the laymen, the doctors and others are represented, are no substitute. They are without teeth. They are frustrated and just about as powerful in influencing policy as are the unfortunate users' associations attached to the nationalised industries.

As one who in six years in the Ministry of Health visited over 300 of our hospitals and met as many boards and hospital management committees, I deeply regret that the revamped Health Service, instead of being a vast human operation in touch with people, has become as remote and bureaucratically controlled as a nationalised industry. The Area Boards control 386 vast catchment areas, from about the largest, around 2 million people, down to the smallest, about 150,000. They meet once a month; they have to deal with a colossal programme concerning dozens of hospitals, ambulance services, welfare services, all at a meeting which may take three hours. So more and more decision rests with those six officials on the district committee. The lay approach, had a vast field of experience. If the noble Lord who is to reply differs from me on other items, I am sure he will agree with all his experience of the Service about the enormous wealth, contribution and contact that the professional laymen brought to those committees. Today, trying to get hold of one of the god-like officials of the district committees is like trying to telephone the noble Lord who adorns the Woolsack at any given time. So we welcome the Royal Commission.

We want the Health Service to regain its human face; we want community contact through those public figures to represent us and speak for us, and bring their considerable expertise in varying forms to bear upon the use of the Service. Nowhere has there been a greater lowering of morale than among the medical professionals in the hospitals. The medical brain drain is a disaster, as was so ably detailed by the noble Viscount, Lord Waverley. The new proposals of the EEC for harmonisation will exacerbate the problem. I cannot see many highly-paid doctors on the Continent opting to come here. I fear that many of our doctors will opt to practice on the Continent and add to the brain drain which we already have to Canada, Australia, and, in particular, America.

When Mrs. Barbara Castle was Minister of Health, while she denied the consultants their legitimate increases, she yielded—not, I am suggesting, without justice—on the question of under-manning and the consequential abnormal hours worked by junior doctors. But instead of giving them increased salaries commensurate with their skill and training, she gave them overtime. I wonder whether she then envisaged what damage she was doing to the future of the consultants' service. What is happening now is that the junior doctors, experienced and qualified after several years, who are capable of being offered consultants' posts, are refusing them because it will 387 mean a cut in pay. This is a disaster for the Service which has always prided itself on its highly skilled and professional consultants' service. I agree with the noble Lord, Lord Segal, that many of the waiting lists in many areas are not due to lack of beds, they are due to a shortage of specialists to perform the operations and treatments needed.

Then, how we treat our specialists! In one great London hospital the consultants are denied a private room where they can get together and discuss their cases, new methods and new treatments in privacy with their professional colleagues. Yet, the NUPE representative has asked, demanded and received a room to himself to conduct his union affairs. For a year he has claimed that his union duties take up 100 per cent. of his time. Ten hours a week—a quarter of his weekly time—would have been adequate to look after the needs of 200 members of his union in that hospital. The hospital pays his full wages for not performing any of his hospital duties. He also represents staff in other hospitals, where his employing board of governors have no jurisdiction and he claims overtime from that board for the visits and times that he spends at the other hospitals. If the union want a full-time official, they should pay his wages from their own funds and not from the hard-pressed funds of the teaching hospital.

This brings me to the cuts in expenditure. The same hospital has had a 10 per cent. cut imposed on it, but it has also decreed that there must be no redundancies whatsoever. Where do the cuts fall? They fall on patient treatment, on food, on cleaning, on vital repairs—all items which affect the patient. The patient is the most important person in the hospital.

Now I turn to the leagues of friends. Minister after Minister, radio programmes, television programmes galore on Sunday, exhort us to do voluntary service, to help the old, to help the handicapped and to fill in the gaps in the system that the National Health Service cannot provide. Just listen to how some of the friends are treated. I am a founder member of a league of friends and proudly we raised the money for telephone trolleys that could go round the hospital so that patients, early every evening, could keep 388 in touch with their relatives at home and tell Johnny to be a good boy and go to bed when his father told him and, if he was a good boy, he might have a brother or sister in about 10 days' time. We had a team of 40 volunteers who took these trolleys round the wards in the evenings, at no expense whatsoever to the hospital.

Then NUPE step in and demand to take the trolleys round—on overtime, of course, from six to eight—a complete and utter waste of public money, when that money could have been far better spent on providing the additional nurses that we need. There were heartbroken members of the friends who had spent 15 years giving their services, keeping to their rotas, refusing to do anything else on their rota night and providing additional comforts particularly for the geriatric wards—for example, they would write a letter for the old lady with arthritic hands to keep her in touch with her son in Canada; they would bring in a card that she wanted to send to her grandson for his birthday. None of these services NUPE do, and if we really want the great fund and wealth of warm-hearted volunteers that we have in this country to contribute in this fashion, as I am sure we all do, then, please, see that when they have not only initiated but wholly financed and serviced a service like this, we do not kick them in the teeth in this way.

Medically, we still have great consultancy services and we rival the most advanced countries in most medical research, but we are seeing now the human face of the Health Service being steadily obliterated. It is no longer the people's service; it has become the bureaucrats' paradise. And until we restore the community contact the Service will continue to decline, and, tragically, I believe we shall continue to lose some of our finest doctors, and medical and professional technicians as well, to countries abroad. We are proud of our Health Service, but unless we restore public and professional confidence in it, we shall no longer be worthy of the Health Service.

Lord GISBOROUGH

My Lords, when I took advice for this debate I asked what the problems were. The answer came in 389 one single word—money. I thought, therefore, that savings would be a good theme to try to speak on, and the first saving it appears one ought to look at, to my mind, is whether or not there are too many tiers. With the Area Health Authority, someone has to co-ordinate the districts and there are too vast a number of districts for the region to co-ordinate, so that therefore the area is a necessity. But one must question the need for the Regional Health Authority.

As I understand it, the Regional Authorities do strategic planning, which increasingly can be and is being done by the DHSS, particularly if they were to be devolved round the country to a greater extent. The other thing, of course, is the consultants' contracts which they would like to be done by the region, but one wonders whether, if they were done by the areas, the world would stop for them and whether that would not be perfectly adequate. After speaking to various people, I seriously wonder whether the regions could not be disbanded. I should be most interested to see whether it is possible to get an answer as to what it would save if the regions were to be disbanded.

The value of the return, where possible, of the hospital management boards has been mentioned by the noble Lord, Lord Auckland, and the noble Baroness, Lady Hornsby-Smith. Hospitals will increasingly get bigger and bigger and so the hospital management boards will increasingly be missed. Unfortunately, one inevitably gets the staff upset by people applying for their old jobs again, as happened with reorganisation, and so politically (with a small "p") it may never be possible. As new hospitals are built, one wonders whether at least the bigger hospitals could not be administered by hospital management boards rather than the districts. There is certainly a great need for the tidying up of the tier system and at the moment there is quite a lot of overlap between the Area and the district authorities, particularly on the development of services.

The noble Lords, Lord Amulree, and Lord Auckland, mentioned cottage hospitals. Although these are technically uneconomic to keep going, they provide a most valuable service for old people and for people recovering. One finds 390 remarkably good relations with the staff in many of these hospitals, where they are known by their Christian names by the people who live there and by the families, relatives and friends who call. The benefit of all that may well outweigh the disadvantages of the small hospitals.

One then goes to the community health councils, which were set up comparatively recently, with their paid secretaries, paid assistants, members' expenses, and so on. They go so far as to advertise for complaints of the Hospital Service. One wonders what is the area chairman for and what is the Area Authority for. There is a team of officers: the medical officer, the nursing officer, the administrator, the treasurer, and, in our particular case in the Northern Area, we have 38 local authority representatives on that Area Health Authority. What need is there for yet another council breathing down the necks of the Area Authority? If it is necessary to have publicity so that people may know where to ring up and to invite complaints, surely the Area Authority can do what is needed and can publicise the names of the elected local authority people who are on that Area Authority. The public view is becoming increasingly known on the Area Authorities, and surely it is just as easy for somebody to contact a councillor as to contact a member of the health council. Also, of course, all planning by the Area Health Authority has to go to these community health councils and that results in delays, with inevitable expense. What happens is that things tend not to get done as a result. I should be most interested to hear whether it is possible to be told the cost of all these community health councils. Are they really necessary?

The abolition of pay beds has been mentioned. I am afraid this is a political matter (with a capital "P"). Wherever one goes and whoever one talks to in the Health Service, all doctors say the same thing: that private beds never held up or delayed public patients. There really was no logic to the demolition of the private beds. It was purely a political demand by ancillary staff, porters, cooks and so on. Now, in our area we have only 22 private beds out of a total of 4,600, and there is a likelihood that these will be further cut down. The reason is that statistically the occupancy of these beds is under 50 per cent. But, of 391 course, that is not quite correct, because that occupancy is calculated on the number of nights occupied. These private beds are more and more occupied for day surgery and therefore do not show up in the figures. So it will be a great pity if the figure of 50 per cent. occupancy is used to demolish yet more private beds.

Inevitably there is a value in cash to the Health Service through these private beds, and it would be most interesting to know, if possible, how much money is now being sacrificed by the Health Service through the loss of the beds which have already been taken away. They constituted no loss to the public's use of the Health Service, and indeed I think that there was a gain to it. The ancillary staff insisted that they should be reduced, but surely the views of the thousands of people who wanted to use the pay beds should have been listened to as well.

The next saving consideration that I should like to mention will, I am sure, be most unpopular. When people who pay for rent, rates, light, food and so on have to go into hospital, they continue to make most of those payments, and they still get their pension, their pay, their unemployment money or whatever it may be. But I see no logical reason why they should not make a contribution towards the food that they eat in hospital. I do not suggest that they should make a contribution towards their accommodation, in addition to their rent. But, after all, in old people's homes they have to pay for their board and lodging, so why should they not contribute towards their food in hospital? The Hospital Service is not meant to be a social service in order to provide people with more cash; it cannot afford that. It is a means for getting people right—although we all know that there is more to it than that, with welfare and so on—and if people contributed towards the cost of their food, not even up to the full rate, it could bring in something like £200,000 annually in many areas, which would no doubt be most welcome.

I was most interested to hear my noble friend Lady Young speak about insurance and, being of the same political persuasion, what she said appealed to me. I was interested to hear about the Swiss system. Switzerland is a very old democracy—I think it is fair to say that it is a classless 392 democracy, and a rather egalitarian country—and everybody there has to insure and they have to pay for their hospitalisation. If they cannot pay, their sons or parents are asked for the money and, if they cannot pay, cousins, friends and so on are asked. But if nobody can pay, the bill is torn up. It is a rugged but efficient system, and it seems to work. I am not advocating it here, but it is interesting that, in a country which can by no means be called Right Wing, that is a system which seems to work well.

I should like to say a word on drugs, because we all know that they are extremely expensive. I heard of one bottle of pills which cost more than £100. While one can debate the profits of drug companies, one is also very aware of the cost of research and development which is extremely high for drug manufacturers. But I still wonder whether there is enormous wastage of drugs through over-supply. One puts a bottle of pills in the cupboard, takes out two or three, and leaves the rest. When I have something wrong with me, which is very seldom, I may go for some pills. I take one, I think that I have cured myself and am all right, and all the rest are not used.

I remember that I once went to a boxing match, and the doctor who was sitting next to me said that the Norwegian, who had just won a match, had been to see him that morning and asked for a pain killer, because he had hurt his wrist. So the doctor gave him a pill and told him that, if he took it exactly half an hour before the boxing match, he would be all right. After this Norwegian had completely felled his English opponent, the doctor went around to see him and the Norwegian thanked him and said that what he had given him was absolutely marvellous. The doctor told me that what he gave him was half of a vitamin D tablet, which was equivalent to an orange, but the Norwegian was convinced it was what he needed and it worked.

There is also the question of the cost of modern drugs. I am sure that many doctors, in particular young doctors, read the appealing literature and the rather attractive names of some of the modern drugs, and are rather inclined to prescribe them because they are most fashionable, although in many cases they could recommend much cheaper but equally 393 effective drugs. However, this is a technical matter and I am not qualified to form a strong opinion on that.