Neighbourhood Health Councils

NATIONAL HEALTH SERVICE REORGANISATION BILL [Lords] – in the House of Commons at 12:00 am on 12th June 1973.

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"(1) The Secretary of State shall on an application in writing made to him by the council of a local authority district, being a district the area or part of the area of which is co-extensive with the area of a parish or community (as defined by the Local Government Act 1972), direct that there shall be a neighbourhood health council for the said parish or community on and after 1st April 1975.

(2) The Secretary of State may, without any application under subsection (1) above but after such consultations as he thinks proper, direct, not later than 1st April 1975, that there shall be a neighbourhood health council for any parish or community as is referred to in subsection (1) above if he is satisfied that the conditions laid down in subsection (1) exist.

(3) It shall be the function of a neighbourhood health council to represent the views of the parish or community with regard to the operation of the health service in their area.

(4) Subject to subsection (3) above, the Secretary of State shall by regulation lay down the composition and functions of such neighbourhood health councils".—[Mr. Blenkinsop.]

Brought up, and read the First Time.

6.10 p.m.

Photo of Mr Arthur Blenkinsop Mr Arthur Blenkinsop , South Shields

I beg to move, That the clause be read a Second time.

I trust that I shall have the leave of the House in moving the clause with a minor change in the wording from the clause as tabled, which referred purely to Wales. It is my intention that the clause should apply to Great Britain as a whole. That I have achieved by inserting the words "parish or" before the word "community" wherever it appears. It is a minor change. The principle remains identical. It would be for the benefit of the House to agree to that inclusion. I take it that there is no objection to that being done.

Photo of Mr David Gibson-Watt Mr David Gibson-Watt , Hereford

I do not see any of the hon. Gentleman's Welsh hon. Friends behind him at present. Can he assure me that some of his Welsh hon. Friends will be speaking on the new clause? Because of the way in which it has been worded I, as Minister of State for Wales, will reply.

Photo of Mr Arthur Blenkinsop Mr Arthur Blenkinsop , South Shields

We accept that the hon. Gentleman intends to reply. There was great anxiety that the admirable proposals put forward for Wales—this was the position when the Local Government Bill was being considered—should be made full use of for England. Unfortunately, that was not accepted when the Local Government Bill was considered. In order that the point that we are raising should clearly be seen to apply to the whole of Great Britain, I move the amendment that I have described. I take no offence because the hon. Gentleman intends to reply. This is an instance when the word "community" relates particularly to Wales. It is unhappy and unfortunate that it should not also apply to England.

I wish to refer to the House to the stimulating and interesting intervention of my right hon. Friend the Member for Deptford (Mr. John Silkin) in Committee when we discussed Clause 9, which refers to community health councils. My right hon. Friend made clear our deep anxiety and concern about the provision for the establishment of community health councils. He made clear that that opposition was fundamental. The Opposition dislike the whole provision, because it refers to an appointed as against an elected body. We dislike it because it is likely to relate to a larger area than we believe suitable. We dislike it, in particular, because of the problems which such a provision must create.

There is no doubt about our views on the overall proposition put forward in the Bill and the kind of National Health Service that is likely to develop under the Bill's provisions. The pattern proposed is a managerial pattern, which is unsuitable for the health service. It is rigid and damaging in many respects. I noticed the effective letter in The Times from my hon. Friend the Member for Halifax (Dr. Summerskill). It is because we fear the dangers of this kind of health service organisation that we want to ensure that there is an effective challenge or voice from the ordinary people who are using the health service as well as those working in it.

We profoundly doubt whether any kind of challenge can be developed to the community health councils as proposed in the Bill. The Minister may say that he takes power to establish a community health council in areas no larger than a district. Indeed, he made that point when the matter was discussed in Committee. He said that it was his intention to try to ensure that the areas would not necessarily be the same as the area health authorities, although in some cases the area health authorities may run in parallel with the new districts in metropolitan areas. He said that elsewhere they would not.

6.15 p.m.

The Minister made it clear that it was his intention to ensure that there was provision at a district level. So far, so good. In our view, as my right hon. Friend the Member for Deptford said, that is by no means good enough. We still regard the districts in most cases as areas far too large for proper representation of the public's point of view. If there is anxiety about the workings of the health service, we must ensure that in future it can be voiced by people at a real neighbourhood or local level.

Many of us have made the case vigorously, in the House and in Committee, for the establishment of neighbourhood councils. We were modestly encouraged by the fact that the Local Government Act did not specifically prevent neighbourhood councils from being established. Indeed, in a sense it gave authority for that to happen by way of what might be called an urban policy if a district council should wish to establish such a council.

There are examples of district councils electing neighbourhood councils which are to be established in London and, we hope, in other parts of the country. How encouraging it would have been had the opportunity been taken to give the new concept of local bodies the authority and right to intervene and ex- press opinions on health service issues which are of paramount concern to people living in an intimate area in the immediate neighbourhood.

It can be envisaged that as we develop health centres there will be a natural and suitable link between those centres and the local communities around them. The health centres provide for some of the initial contact of ordinary people about their health needs. It is to be hoped that not only their direct medical health needs but some of their social needs will be met rather more widely. What could be better than to encourage the link between the local communities and the health centres and the wider health services around the centres? In that way, we could really get an uninhibited local voice about what was happening.

We are told by the right hon. Gentleman that he is proposing to set up community health councils. He tells us that he is ensuring that there will be provision on those councils for representatives of locally elected authorities. We think they should be locally elected people. We believe this is an area where a locally elected member ought to have his full voice and full authority.

As matters stand, the representatives will be appointed. The right hon. Gentleman says that almost certainly the appointments will not be directly made by him. Indeed, a good deal of humour was caused in Committee in trying to work out how he might conceivably do the job of making appointments to all the bodies being established. We are told that the appointments are likely to be made by the regional body. That does not encourage us very much. We do not believe it helps the kind of case that we are concerned about. We say that the Government are imposing an authoritarian system on the health service. Therefore, we want all the more to ensure that there is an elected body to make effective complaint.

We put forward in the new clause modest proposals. We would prefer the local district authority to make the application or proposal for the small authority for the neighbourhood to be established. But if the district did not do this—if it were for any reason unwilling to do it, the Secretary of State could step in to act. Powers would be reserved to enable him to specify the detailed functions of the new neighbourhood health council, its composition and its functions, but it is our clear intention that it should be a locally elected body.

In our view, this is an exciting opportunity for us to introduce this new kind of public intervention. We wanted to see it included in the Local Government Act. We were denied that full opportunity, though there may be some experiments. This is an area where, above all else, local, people should have a new opportunity of expressing themselves.

We fear very much that, even with the best will in the world and with the best efforts of the right hon. Gentleman to select representatives from a wide range of voluntary and other bodies, there will be the suspicion in the minds of local people that this is just another part of the establishment. We want to see a breakthrough, a new opportunity for local people to express themselves.

We often hear in the House, unhappily, that there is a good deal of cynicism, especially among younger people, about the functioning of some of our authorities. Here, surely, is a way in which we can introduce an opportunity for fresh expression of ideas. It is on that basis that I move the new clause with the modest amendment of inserting "parish or" in front of the word "community", where that word appears.

Photo of Mr Ken Lomas Mr Ken Lomas , Huddersfield West

I know that I am sitting on the horns of dilemma, and may well be close to being out of order, but it will not be for more than three or four minutes. This is the only way in which it is possible to express, on Report, my view, which I sought to put over in Committee during many arguments and discussions, on the composition of the various types of authorities. It has been ruled by you, Sir, that Amendment No. 52 should not be called this afternoon. That concerned itself with the composition of the regional health authorities. I stress that in my opinion the nuts and bolts of the Bill is really the composition of the regional area and other committees. What I hoped we would do was to ensure that on the area and regional committees non-medical and ancilliary workers, nurses and midwives and the medical profession would be represented in the functional councils of the Whitley system. That has not been possible. I declare an interest as a sponsored Member of Parliament in respect of the National Union of Public Employees.

Recently, at the union's annual conference at Eastbourne, it passed a resolution in strong terms: That this conference calls upon the Executive Council to do all within its power to introduce amendments to the Act reorganising the National Health Service to ensure the adequate representation of all Health Service employees, including ancillary staffs and trade unions, on the new health councils and area health authorities. There is a strong case for such representation on the new bodies proposed in new Clause 2. Those in the health service who constitute about one-fifth of the labour force have been praised by hon. Members opposite many times and we are grateful for their comments. These workers have had a lot of tributes but not a lot of money. Earlier this year, the Under-Secretary of State said: The hospital ancillary worker has a crucial role to play in the complex range of services performed by a hospital in securing the patient's full restoration to health. It is none the less vital for being less spectacular and glamorous than the role of the nurse or the doctor."—[OFFICIAL REPORT, 31st January 1973; Vol 849, c. 1410.] I therefore fully support new Clause 2, particularly subsection (3) which says that It shall be the function of a neighbourhood health council to represent the views of the community with regard to the operation of the health service in their area. We must pay some regard to the views of those who work in our hospitals, and who are involved in the day-to-day running of the health service, because without them the service would collapse. Equally, there is a case for some kind of representation from local authorities. The Huddersfield Trades Council made that abundantly clear in a resolution it sent to me recently, advocating that there should, for example, be at least two full members elected to the area health authority. I accept that the type of council now under discussion is low down the scale in terms of decision-making, but this would be at least some form of participation.

When we talk of the National Health Service we sometimes forget the patients, although they are the most important people in it. We should find some method of ensuring that their voice is heard. The simple way, at all levels of the structure of the NHS, to ensure that the workers and others involved are represented adequately is to make provision for each of the functional Whitley Councils to appoint a member. That should be left to the various unions to decide. Indeed, this should apply at all levels in all the various parts of the NHS. I hope that I shall have an opportunity on Third Reading to say more about that aspect of it.

6.30 p.m.

Photo of Mr Ted Rowlands Mr Ted Rowlands , Merthyr Tydfil

As I did not have the pleasure of serving on the Committee, this is the first opportunity I have had of speaking on the Bill. I believe the debates in Committee and now on Report show that the Bill misses the very point which should be dealt with. It should be a question not of managerial decision in the three arms of the service, but of a new definition of the relationship between members of the public, as patients, and the administrative staffs and the medical profession. That is essential to the whole reorganisation of the service, but it is missing from every aspect of the Bill. Indeed, the Bill appears to have been specially designed to avoid trying to deal with the new relationship.

For far too long a whole generation of people were so grateful for the service that they accepted the minimum from it, but now a new generation has come along and those in that generation feel that they have rights in the health service and have not just to express gratitude for some sort of service rendered to them. That is the basis on which we judge the proposals in the Bill. Gone are the days when the medical profession and medical administrators could expect such an attitude. Gone is the day when we were expected to be grateful if the doctor turned up and dealt with a complaint, or a consultant deigned to act on our behalf. That is the reason why this new clause is so necessary. The Bill avoids all these issues and prevents the views and opinions of the public and patients from being fully expressed and heard throughout the administration.

I am afraid that in many cases the image of the medical consultant is still that of James Robertson Justice—a "Carry On" sort of consultant who marches down the ward as if patients are something ancillary to his pride and importance. At the out-patient department level patients can sit waiting for hours without receiving a word of explanation of why they have to wait, and why appointments have not been kept. Often those in authority do not have the courtesy to explain why those patients have had to wait. My hon. Friend the Member for South Shields (Mr. Blenkinsop), opening the debate on this issue, spoke about health centres. A large number of GPs, against the wishes of their own patients, will not work in health centres. They will not establish a decent group practice to provide the best cover and service for a local community. We have the right now to expect much more from the service, and that it should be more accountable and more sensitive to the wishes of the public. Because of that a clause of this nature is necessary.

I am afraid that in some areas the methods of representation adopted after 1947 have proved a failure. Some hospital management committees have not been the sort of power of local representation they should have been. In most cases I am afraid the committees have been ruled by the group secretary. At local GP level there is not a sufficient system of accountability, or a sufficient feeling of relationship between patients and GPs. As a result, there are many complaints such as that of a pregnant woman who has to wait for hours in an ante-natal clinic. There are growing complaints from a large number of people about the way in which GPs fail to perform their services to the community, and those complaints go unheard. The medical profession ought to start listening to what is being said—not loudly but quietly—in informal discussions. General practitioners are not held in the same reverence as they might believe.

Because we need to establish a new relationship between the public and the service—between the patient and the medical profession—this clause is necessary. I should have liked the rôle of the health councils to be spelled out in greater detail. I do not want their functions to be dictated and determined by the Secretary of State. They should have been included in this clause. The whole of these health councils elected by the people locally, should be the chief instrument for dealing with individual complaints as well as for general representation. I should have hoped that these new neighbourhood health councils would have greater power to investigate complaints. The odd letter sent to the health authority or the family practitioners' council would not be sufficient. They should have the right to investigate to find whether a complaint was genuine and could be sustained and to have it rehearsed in detail. It is not satisfactory to leave the solution of such complaints to a health commissioner who is more of a eunuch because he is so restricted in what he can investigate. It would be far better for the individual complaint against the service provided by the GP or the hospital authority to be dealt with by the neighbourhood health council which I hope will cover the health authorities as a whole. This could be more effectively dealt with through elected groups.

This new clause is important because without it nothing in the Bill will ensure that there is an administrative system by which the voice of the people and of the patients can be heard and understood. The whole organisation pattern in the Bill is designed to do the direct opposite. The Bill is designed to muffle the voice of the public and to ensure that the patient is kept at arm's length. This is a conspiracy to keep the patient and the public away from decision making. Neighbourhood health councils of this kind are essential for the healthy democracy which we believe is an intrinsic part of the health service, as of every other aspect of community life.

Photo of Mr Caerwyn Roderick Mr Caerwyn Roderick , Breconshire and Radnorshire

It is important to establish bodies in this sphere which will be independent of the area health authorities, of the Minister, and the regional health authorities. The AHAs and the RHAs are not independent of the Minister because appointments are made by the Secretary of State. I want to see someone at some level directly representing the consumer. Elected bodies should be used for this purpose whether they are elected specially to look after health matters or have several duties.

In Wales we could use the new county councils or district councils. They should be the "watchdogs", looking after the interests of the public and prepared to argue with the Minister and area health authorities and to represent the public at all stages. They should be able to speak frankly to all who are involved in the service. Such a council should not be housed in AHA premises. It should be quite independent of the area health authorities and not staffed by area health authority staff.

The public must see that the councils are completely free to act as they wish. They must not be seen to be subject to pressures from within. If the same staff and premises are used they will not be seen to be independent. So often in Committee the Minister rested his case on "He who pays the piper calls the tune." No one will deny that in the end the Secretary of State will have the power to overrule decisions taken below. This happens in so many spheres of activity. But the Secretary of State will need to have a good case to do this. It will be no excuse for him to reply that he must be in full control at every level.

The Bill establishes community health councils, to be co-terminous with districts and the districts are to be as defined in the Bill, not local government districts. I am being a little parochial here, but it is relevant. Until now the district defined for the area I come from has been a district of over 2,000 sq. miles, Powys, in Mid-Wales. How can a watchdog body be set up for such a large area? No decision has yet been taken to split that area. This new clause suggests that there should be at least three neighbourhood councils for such a large area, based on the district authorities of local government. If that were done there would be a far better chance of knowing what was going on from day to day in the Health Service.

I would break it down even further and go to the new community health councils as the watchdogs. Then we will certainly have day-to-day contact. I deplore the present situation when so many parts of the country will suffer because community health councils will be meaningless on such a large scale.

Photo of Mr David Gibson-Watt Mr David Gibson-Watt , Hereford

Did the hon. Gentleman make a slip of the tongue when he said "community health council"? I think he meant "community council".

Photo of Mr Caerwyn Roderick Mr Caerwyn Roderick , Breconshire and Radnorshire

Yes, I did mean community council. They are mentioned in the Bill and are quite different bodies from community health councils. I would not quarrel with the community council being used as a vehicle for our aims. I certainly would not quarrel with the idea of using the new district local authorities as that vehicle. I embrace the point made by my hon. Friend the Member for South Shields (Mr. Blenkinsop), who suggested that people working in the health service should be represented.

There would be no difficulty in co-opting members as we do at present, with education committees, for example. We co-opt teachers and others working in the service and we could easily do it in this case. I hope that the Minister will be able to accept this clause. It will be a matter of two years at the most before it can be implemented. He may as well take this little step along the road. The Government have adopted so many of our ideas in the last couple of years that they certainly cannot object to adopting this useful one.

Photo of Mr Laurie Pavitt Mr Laurie Pavitt , Willesden West

My hon. Friend the Member for Merthyr Tydfil (Mr. Rowlands) outlined the principle underlying this new clause and a good deal of the debate we have had about the whole of the Bill when he referred to the patients as being ancillary props against the background of the professionals, the doctors and so on, exemplified in the television "soap operas" when the patients are part of the scene rather than anything to do with the story.

I want to introduce a little fresh evidence on this subject from a rather unusual source. A strong plea was made by the clerk to the governors at one of the London teaching hospitals—a hospital considered to be one of the finest and certainly one of the most important in the country. This is from a person who has been working with an administrative machine. What is happening—and the clause seeks to remedy it—is that as a result of the obsession with the managerial machine and the efforts to secure efficiency, the impact of reorganisation on the people is being wiped out.

There is no better way of reversing this than by adopting the clause. We are seeking to bring the service and its administration under the control of people who are in physical and geographical proximity to it. These are the people who know their own general practioners and their own hospitals. The community health council area will cover 200,000 to 250,000 people. If we could start to reach down to a neighbourhood unit about the size of a London borough ward—say, 10,000 to 20,000 people—we would be talking in terms of practical experience, about a particular general practitioner, immunisation service, antenatal clinic.

6.45 p.m.

What the clerk to the governors puts most strongly is that the managerial concept being put forward by the Government is the basic building block for all the district. That will be governed by a district management team of six people, who will be entirely outwith any control except that of the area authority. If the real power is to rest at district level the proposition of the neighbourhood unit is one of the most essential checks and balances. It will be interesting to hear in the Minister's reply why he under-values nurses on the district management team of six. They receive £1,000 a year less than the administrators serving on the same area health management team. That is a considerable amount. I do not know why it is that nurses are always reckoned to be cheap labour. On that team of six the area nursing officer will get much less than any other members of the team.

A large London area with five or six districts is likely to have a budget of between £40 million and £50 million, and to employ between 20,000 and 30,000 people. That kind of organisation should not be divorced from the people it is serving. There must be some system whereby the voice of the people can be heard, whereby they can make some impact and bring about change if necessary. They must be able to place pressure on a machine that has been described by the newspapers as a bureaucratic monster, entirely geared to the idea that what is good for industry is good for the National Health Service.

In opening the debate on Second Reading my right hon. Friend the Member for Deptford (Mr. John Silkin) spoke about shedding tiers, because the five-tier structure was too large. It is interesting to note that the clerk to the governors, whom I have mentioned, says that responsibility at the level of district must have public participating support and that it would be far better for one of the two higher levels, possibly the regional level, to be disposed of to make room for the neighbourhood councils. I hope that the House will support the clause.

Photo of Mr David Gibson-Watt Mr David Gibson-Watt , Hereford

I shall endeavour to reply to most of the points that have been raised, but if I do not satisfy the inquiries of all those who have spoken I hope that I shall be forgiven. I intend to aim specifically at what has been my particular responsibility for the past three years—the hospitals and the health services of Wales.

We would certainly all endorse the basic aim that the patients and the communities for which the National Health Service exists shall have effective means of influencing its planning and operation. I am bound to advise that the new clause, however well intentioned, is not well calculated to advance this common purpose. The House will probably agree that to be effective the bodies set up to represent the interests of the people as patients—or consumers, as some hon. Members have described them—must have a common interest in the health service. It is often true that the smaller the community of people the closer is the general community of interests in all aspects of life. This is, perhaps, particularly true of small rural communities, and it is certainly true of some of our valley communities in Wales. There is a sense of belonging and a sense of shared problems and shared purposes, which is both admirable and enviable.

However, there is a basic dilemma here, because bodies designed to bring a real influence on all aspects of running and planning the health service must be conceived on a pattern which has a meaningful relationship to the way in which the health service itself is organised. They must be sufficiently broadly based to recognise the competing calls on health service resources and to be able to make informed judgments on what the priorities should be so that their representations will deserve and command the respect and attention of the area health authorities. What I am saying is that those who are going to make the inquiries and those who will complain must themselves be armed with some expertise if they are to be able to stand up to and argue with the area health authorities. Indeed, we believe they would lose much of their force and effect if they were to be a multiplicity of small bodies as the new clause suggests.

In general, the Government believe that the best pattern will normally be for the community interest to be focused through a community health council coterminous with a health district, which is the administrative unit on which much of the health planning will be based and in which the district management team will exercise a large measure of delegated responsibility for running the various services. These are the smallest units in which a reasonably comprehensive range of health services can be provided and the smallest practicable units for integrated management of the health service. Indeed, a community health council matching such a health district will normally represent the smallest true denominator of the community interest over the whole range of the health service and will be in the best position to take a balanced view and to speak effectively to the district management team on all the day-to-day problems as well as to the area health authority in matters where it cannot get satisfaction at this more local level.

We recognise that there is need for some flexibility in the pattern of community health councils.

The hon. Member for Brecon and Radnor (Mr. Roderick) referred to this problem in his own constituency, which I know well. I assure him that my right hon. and learned Friend is very ready to accept that some flexibility of pattern in Powys and Gwynedd, with their wide areas and scattered populations, and where health administration cannot meaningfully be broken down into districts, is very necessary. When, in Committee, we were examining the provisions for community health councils, my hon. Friend the Under-Secretary suggested that one possibility in such an area as that might be one community health council with a larger membership than usual, with groups of members having a special concern for particular localities and, perhaps, coming together as sub-committees of the main council.

Some Opposition Members have said that they do not believe that this would be a satisfactory way out. If that proves to be the considered view of the communities and interests most directly concerned my right hon. and learned Friend, who intends to consult the relevant local authority and other interests in each area before making any decisions, would not wish to force this solution on them. He is more than prepared to consider flexibility in this respect. He would be quite ready to consider setting up two or more community health councils in Powys and, indeed, Gwynedd. He has commended a proposal in the Welsh "Red Book" that in order to achieve as much local delegation of health administration as is practicable in these circumstances both these areas might be managed through a number of geographical divisions—something less than a health district in the comprehensiveness of resources and functions—and there might usefully be a community health council for each such geographical division.

The neighbourhood health councils which the proposed new clause contemplates would, in our opinion, be far too small to be effective. For example, my right hon. Friend might find himself required to set one up for the present parish of Pennant in the rural district of Llanfyllin in north Montgomeryshire, or the present parish of Isygarreg in the rural district of Machynlleth in west Montgomeryshire, each with a population of less than 200 people. He might be required, with no option to refuse, to set up 10 neighbourhood health councils in the Gower. I do not honestly believe that hon. Members would like to see that. Potentially, this could mean 760 neighbourhood councils of this sort in Wales. Coming back to the English pattern for a moment, if this proposal were carried through over Offa's Dyke and applied in England there might be around 10,000.

I am perfectly prepared to accept that this new clause is a probing amendment. I accept that. The speeches which have been forcefully made in this debate have, I hope, elicited reasons why the Government think the best answer in all the circumstances lies in the proposals we have put forward in the Bill. Therefore, I would propose to the Opposition that they should not pursue this new clause tonight, and I would certainly hope they would not pursue it to the point of a vote upon it.

Photo of Hon. John Silkin Hon. John Silkin , Deptford

Running through the whole of the Opposition case, as first put by my hon. Friend the Member for South Shields (Mr. Blenkinsop), and later by all my hon. Friends, from slightly different standpoints, has been dissatisfaction with the proposed reorganisation of the National Health Service on a managerial basis. I suspect that the Minister of State sees perfectly clearly that there are difficulties about it. Indeed. I thought he went out of his way to be very conciliatory and to accept that there is a dilemma in which he and his hon. and right hon. Friends have been placed. This is the question of responsibility of management, and so on. To come to what he thinks is the best solution, I think that most of what he said, if not all, was perfectly applicable to the United Kingdom as a whole—certainly to England—as well as to Wales. I thought he made the best case he could. We, on our side, do not apologise for having strayed across Offa's Dyke, because this Bill does it frequently, as does the Local Government Act.

The Government have proposed to the House and the nation a reorganisation of the National Health Service based on a managerial and what I have called a monarchical principle. This has been the whole basis of it, and the Government themselves, understandably—and, perhaps, commendably, once one accepts the first wrong assumption—have said that they want to introduce, somewhere, an element of accountability to the public; that they agree that the organisation is too rigid, too monarchical, and too tyrannical, and that somewhere the public must be represented. The Government have, in consequence, looked all along the various stages of the monolithic system and have evolved a system at district level called the community health council, and it is that council which is given the function of barking—of acting as a watchdog and saying where management has gone wrong.

7.0 p.m.

The community health council operates for the same unit or area as does the district management team, which is a managerial unit composed of doctors, one nurse, and administrative workers. It is because this district management team is accountable to no democratic element that the community health council has been injected. In a properly-run National Health Service the community health council would be democratically elected and would operate the health service in the district. The district management team would be its experts and officials, and the community health council would inevitably have to be guided by what they said. The final decision, however, would be made by people who are responsible to the electorate.

The politician gets a lot of kicks—sometimes from himself. In these days he is considered to be out of touch with the public. Nevertheless, it is the politician who has to justify his policies, to make them, to be responsible for them, and never to be ashamed of them, and he must allow the electorate to say whether they think he is right. That is the function of all hon. and right hon. Members, and it is the function of every councillor.

The administration of a health service is no different from the administration of a local council, this House, or Government. It concerns a vital function, which affects every man, woman and child in this country. Because the managerial concept took possession of the Department of Health and Social Security and successive Secretaries of State, we are landed with a system that has no democratic accountability in it.

The object of the clause is to introduce a degree of democratic accountability somewhere. It is not a very great stride forward. It produces a neighbourhood health council. My hon. Friend the Member for Merthyr Tydvil (Mr. Rowlands) said that he would like it to have far greater powers, but one realises that at this moment it cannot. What it can have is the right to say in such an area, however small it may be, "We think things are going wrong and something should be done about it."

The Minister of State has got hold of the wrong end of the stick. May I give him a small lecture in democracy? Democracy consists of voters—ordinary men and women, our fellow-citizens, who have no informed judgment, who are not armed with expertise but who are the people who live in our country and for whose happiness we are supposed to be legislating. The very fact that they do not have this informed knowledge or expertise is their strength. They are the people who have to put up with things. They are the people who should be given a chance to express their feelings of disapprobation when they feel that something is going wrong—a grumble perhaps, but a pressurised grumble. They are the people who have to complain about how long they have to wait in hospital, and many other things that fall within a tiny local area. The strength of the neighbourhood health council is that it is not informed and that it has a right to grumble. It is then up to those who administer the health service to deal with that grumble.

I am not frightened of 10,000 neighbourhood councils, but I do not think that there would be anywhere near that number—that is perhaps a pity. I am not even frightened of the 760 in the Principality, but I am afraid that it would not be anywhere near that number. Only in a few wide-awake districts would an application be made to the Secretary of State for the creation of a neighbourhood health council. Judging by what the Minister of State said, in no case would a Conservative Secretary of State for Social Services or Secretary of State for Wales set one up on his own accord. So we know how many there would be. At least there would be this addition to a managerial, purely administrative, purely Whitehall-run health service. Somewhere, ordinary people would feel that there was some institution elected by themselves that was listening to their complaints. That is the purpose of the neighbourhood health council.

The Minister of State heard arguments about the Principality and about England in the long nights and days of the passage of the Local Government Bill in Committee and on Report. The same basis applied there. I have said that the neighbourhood health council owes its proposed existence to the fact that the health service is not a democratic institution. If it became a democratic institution under local government control, as mangy of us hope it will one day, the neighbourhood health council would merge simply and easily with the parish council or the community council. It would simply become an arm of it—an elected body at local level which would have its say and be able to make its point in the running of the health service. I have spoken about the ordinary people. At least once in their lives, either at the beginning or at the end—and sometimes in between—they are patients as well as voters.

There is another body that is totally neglected. Under successive Governments and successive Ministers of Health of whatever party there has been the great omission of the health service workers. Labour Governments were as guilty of this as were Conservative Governments. It is a factor that should have been understood but was not.

My hon. Friend the Member for Huddersfield, West (Mr. Lomas), by slightly bending the rules of order, made a telling intervention. He argued that the health service ancillary workers have been particularly neglected in the running of the health service. He supported the idea of the neighbourhood health council because it could include in it the health service workers whose voice could be listened to there. We have all neglected the health service workers, and we paid the penalty for it earlier this year. All those who are engaged in or interested in the health service know how devoted was the service of these workers and how successive Governments have relied too much on their good will and devotion to the public in the running of the hospital service. They have much more to contribute. We have also neglected their expertise, which is extremely valuable.

We do not consider this clause to be just a probing clause. Its purpose is to inject an element of democracy into the health service. My hon. Friend the Member for Brecon and Radnor (Mr. Roderick) showed us how ludicrous might be a "community" under the community health council. The Minister of State did not give a universal reply to that. What might be true in one case would not necessarily be true in others. I am not suggesting that my hon. Friends should treat this merely as a probing clause. They should show by their votes in the Lobby that it is a constructive improvement to a badly reorganised health service.

Photo of Mr David Gibson-Watt Mr David Gibson-Watt , Hereford

With the leave of the House, may I, having had a lecture on democracy from the right hon. Member for Deptford (Mr. John Silkin), be allowed to reply. I thought I had given my own Member of Parliament, the hon. Member for Brecon and Radnor Mr. Roderick), a general answer on the problems of Powys. I assure him that my right hon. and learned Friend the Secretary of State for Wales will take carefully into consideration the problems of Powys. If it requires two councils, as I understand it may do, it will get two from the Welsh Office.

Photo of Mr David Gibson-Watt Mr David Gibson-Watt , Hereford

The hon. Member has already made an extreme speech, more extreme than usual, and I remind him that one cannot run a health service without doctors.

If the right hon. Member for Deptford wants this many neighbourhood councils, there is nothing to stop them being set up. There is nothing to stop an area of the size of a parish council deciding that it cares so much about the hospitals in its area that it should have its own organisation. But in the Bill we are setting up by statute organisations which can argue on proper professional advice against the area health authority. There, with respect, lies the fallacy of the right hon. Gentleman's argument. I remember that at one time a hospital near my home was about to be closed by the Labour Government. A body was set up to consider the matter, and, although it had no professional advice, it operated skilfully and adequately. But it was not thought necessary to prescribe that in a statute.

The hon. Member for Huddersfield, West (Mr. Lomas) asked about NUPE. The set-up of the district health council will be as follows. There will be 50 per cent. members appointed by the county councils and the district councils. One-third of the members will be made up of members of voluntary bodies concerned with health matters; the final sixth will be provided by voluntary bodies not specifically concerned with health. I hope that what I have said will go a long way to meet the hon. Gentleman's points.

Photo of Mr Ken Lomas Mr Ken Lomas , Huddersfield West

I accept entirely what the Minister says but I believe that it does not go far enough. Both my union and I say that the trade unions and workers in the National Health Service should be represented on the district councils and others as of right, and should not just come together in some other way.

Photo of Mr David Gibson-Watt Mr David Gibson-Watt , Hereford

I see the hon. Gentleman's point. If I cannot go all the way

to help him, I hope that what I have said will give him some assurance on the points he raised.

Question put:

The House divided: Ayes 245, Noes 271.

Division No. 148.]AYES[7.15 p.m.
Abse, LeoFletcher, Raymond (Ilkeston)Mackenzie, Gregor
Allaun, Frank (Salford, E.)Fletcher, Ted (Darlington)Mackie, John
Archer, Peter (Rowley Regis)Foot, MichaelMackintosh, John P.
Ashley, JackFord, BenMaclennan, Robert
Ashton, JoeForrester JohnMcMillan, Tom (Glasgow, C.)
Atkinson, NormanFraser, John (Norwood)McNamara, J. Kevin
Bagier, Gordon A. T.Freeson, ReginaldMahon, Simon (Bootle)
Barnes, MichaelGalpern, Sir MyerMallalieu, J. P. W. (Huddersfield, E.)
Barnett, Joel (Heywood and Royton)Garrett, W. E.Marquand, David
Baxter, WilliamGilbert, Dr. JohnMarsden, F.
Beaney, AlanGinsburg, David (Dewsbury)Mason, Rt. Hn. Roy
Bennett, James(Glasgow, Bridgeton)Golding, JohnMayhew, Christopher
Bidwell, SydneyGordon Walker, Rt. Hn. P. C.Meacher, Michael
Bishop E. S.Gourlay, HarryMellish, Rt. Hn. Robert
Blenkinsop, ArthurGrant, George (Morpeth)Wendelson, John
Boardman, H. (Leigh)Grant, John D. (Islington, E.)Mikardo, Ian
Griffiths, Eddie (Brightside)
Booth, AlbertHamilton, James (Bothwell)Millan, Bruce
Boothroyd, Miss B. (West Brom.)Hamilton, William (Fife, W.)Miller, Dr. M. S.
Bottomley, Rt. Hn. ArthurHamling, WilliamMilne, Edward
Boyden, James (Bishop Auckland)Hannan, William (G'gow, Maryhill)Mitechell, R.C. (S'hampton, Itchen)
Broughton, Sir AlfredHardy PeterMolloy, William
Brown, Hugh D. (G'gow, Proven)Harper, JosephMorgan, Elystan (Cardiganshire)
Buchan, NormanHarrison Walter (Wakefield)Morris, Alfred (Wythenshawe)
Buchanan, Richard (G'gow, Sp'burn)Hart, Rt. Hn. JudithMorris, Charles R. (Openshaw)
Butler, Mrs. Joyce (Wood Green)Hattersley, RoyMorris, Rt. Hn. John (Aberavon)
Callaghan, Rt. Hn. JamesHealey, Rt. Hn. DenisMoyle, Roland
Campbell, I. (Dunbartonshire, W.)Heffer, Eric S.Murray, Ronald King
Cant, R. EHoram JohnOakes, Gordon
Carter, Ray (Birmingh'm, Northfield)Houghton, Rt. Hn. DouglasOgden, Eric
Castle, Rt. Hn. BarbaraHowell, Denis (Small Heath)O'Halloran, Michael
Clark, David (Colne Valley)Huckfield, LeslieO'Malley, Brian
Cocks, Michael (Bristol, S.)Hughes, Rt. Hn. Cledwyn (Anglesey)Oram, Bert
Cohen, StanleyHughes, Mark (Durham)Orbach, Maurice
Coleman, DonaldHughes, Robert (Aberdeen, N.)Orme, Stanley
Concannon, J. D.Hughes, Roy (Newport)Oswald, Thomas
Corbet, Mrs. FredaIrvine, Rt. Hn. Sir Arthur (Edge Hill)Padley, Walter
Cox, Thomas (Wandsworth, C.)Janner, GrevillePaget, R. T.
Crawshaw, RichardJay, Rt. Hn. DouglasPalmer, Arthur
Cronin, JohnJeger, Mrs. LenaPannell, Rt. Hn. Charles
Crosland, Rt. Hn. AnthonyJenkins, Hugh (Putney)Parker, John (Dagenham)
Crossman, Rt. Hn. RichardJohn, BrynmorParry, Robert (Liverpool, Exchange)
Cunningham, Dr. J. A. (Whitehaven)Johnson, Carol (Lewisham, S.)Pavitt, Laurie
Dalyell, TamJohnson, James (K'ston-on-Hull, W.)Peart, Rt. Hn. Fred
Davidson, ArthurJohnson, Walter (Derby, S.)Perry, Ernest G.
Davies, Denzil (Lianelly)Johnston, Russell (Inverness)Prentice, Rt. Hn. Reg.
Davies, G. Elfed (Rhondda, E.)Jones, Barry (Flint, E.)Prescott, John
Davies, Ifor (Gower)Jones, Dan (Burnley)Price, William (Rugby)
Davis, Clinton (Hackney, C.)Jones, Gwynoro (Carmarthen)Probert, Arthur
Davis, Terry (Bromsgrove)Jones, T. Alec (Rhondda, W.)Radice, Giles
Deakins, EricKaufman, GeraldRankin, John
de Freitas, Rt. Hn. Sir GeoffreyKelley, RichardReed, D. (Sedgefield)
Delargy, HughLambie, DavidRees, Merlyn (Leeds, S.)
Dell, Rt. Hn. EdmundLamborn, HarryRhodes, Geoffrey
Dempsey, JamesLamond, JamesRoberts, Albert (Normanton)
Doig, PeterLatham, ArthurRoberts, Rt.Hn.Goronwy(Caernarvon)
Dormand, J. DLawson, GeorgeRobertson, John (Paisley)
Douglas, Dick (Stirlingshire, E.)Lea, Rt. Hn. FrederickRoderick, Caerwyn E.(Brc'n&R'dnor)
Douglas-Mann, BruceLeonard, DickRodgers, William (Stockton-on-Tees)
Driberg, TomLewis, Arthur (W. Ham, N.)Roper, John
Duffy, A. E. P.Lewis, Ron (Carlisle)Rose, Paul B.
Dunnett, JackLipton, MarcusRoss, Rt. Hn. William (Kilmarnock)
Edelman, MauriceLomas, KennethRowlands, Ted
Edwards, Robert (Bilston)Loughlin, CharlesSandelson, Neville
Edwards, William (Merioneth)Lyon, Alexander W. (York)Sheldon, Robert (Ashton-under-Lyne)
Ellis, TomLyons, Edward (Bradford, E.)Shore, Rt. Hn. Peter (Stepney)
English, MichaelMcBride, NeilShort, Mrs. Renée (W'hampton,N.E.)
Evans, FredMcCartney, HughSilkin, Rt. Hn. John (Deptford)
Ewing, HarryMcElhone, FrankSilkin, Hn. S. C. (Dulwich)
Fernyhough, Rt. Hn. E.McGuire, MichaelSillars, James
Fisher, Mrs. Doris (B'ham,Ladywood)Machin, GeorgeSkinner, Dennis
Small, WilliamTinn, JamesWells, William (Walsall, N.)
Smith, John (Lanarkshire, N.)Tomney, FrankWhite, James (Glasgow, Pollok)
Spearing, NigelTope, GrahamWhitehead, Phillip
Spriggs, LeslieTorney, TomWhitlock, William
Stallard, A. W.Tuck, RaphaelWilliams, Alan (Swansea, W.)
Steel, DavidVarley, Eric G.Williams, Mrs. Shirley (Hitchin)
Stewart, Rt. Hn. Michael (Fulham)Wainwright, EdwinWilliams, W. T. (Warrington)
Stoddart, David (Swindon)Walden, Brian (B'm'ham, All Saints)Woof, Robert
Stonehouse, Rt. Hn. JohnWalker, Harold (Doncaster)
Strauss, Rt. Hn. G. R.Wallace, GeorgeTELLERS FOR THE AYES:
Summerskill, Hn. Dr. ShirleyWatkins, DavidMr. Ernest Armstrong and Mr. James A. Dunn.
Swain, ThomasWeitzman, David
Thomas, Jeffrey (Abertillery)Wellbeloved, James
Adley, RobertFarr, JohnLamont, Norman
Alison, Michael (Barkston Ash)Fanner, Mrs. PeggyLane, David
Allason, James (Hemel Hempstead)Fidler, MichaelLangford-Holt, Sir John
Amery, Rt. Hn. JulianFinsberg, Geoffrey (Hampstead)Le Merchant, Spencer
Archer, Jeffrey (Louth)Fisher, Nigel (Surbiton)Lewis, Kenneth (Rutland)
Astor, JohnFookes, Miss JanetLloyd, Rt.Hn.Geoffrey(Sut'nC'field)
Atkins, HumphreyFortescue, TimLloyd, Ian (P'tsm'th, Langstone)
Awdry, DanielFoster, Sir JohnLoveridge, John
Baker, Kenneth (St. Marylebone)Fowler, NormanMcAdden, Sir Stephen
Baker, W. H. K. (Banff)Fox, MarcusMacArthur, Ian
Balniel, Rt. Hn. LordFraser,Rt.Hn.Hugh(St'fford & Stone)McCrindle, R. A.
Batsford, BrianGalbraith, Hn. T. G. D.McLaren, Martin
Beamish, Col. Sir TuftonGardner, EdwardMaclean, Sir Fitzroy
Bell, RonaldGibson-Watt, DavidMcMaster, Stanley
Bennett, Sir Frederic (Torquay)Gilmour, Ian (Norfolk, C.)Macmillan, Rt.Hn.Maurice(Farnham)
Bennett, Dr. Reginald (Gosport)Glyn, Dr. AlanMcNair-Wilson, Michael
Benyon, W.Godber, Rt. Hn. J. B.McNair-Wilson, Patrick (New Forest)
Berry, Hn. AnthonyGoodhart, PhilipMaddan, Martin
Biffen, JohnGower, RaymondMadel, David
Biggs-Davison, JohnGrant, Anthony (Harrow, C.)Marples, Rt. Hn. Ernest
Boardman, Tom (Leicester, S.W.)Gray, HamishMarten, Neil
Body, RichardGreen, AlanMather, Carol
Boscawen, Hn. RobertGrieve, PercyMaude, Angus
Bowden, AndrewGrylls, MichaelMaudling, Rt. Hn. Reginald
Braine, Sir BernardGummer, J. SelwynMawby, Ray
Bray, RonaldGurden, HaroldMaxwell-Hyslop, R. J.
Brown, Sir Edward (Bath)Hall, Miss Joan (Keighley)Meyer, Sir Anthony
Bruce-Gardyne, J.Hall, John (Wycombe)Mills, Peter (Torrington)
Bryan, Sir PaulHall-Davis, A. G. F.Miscampbell, Norman
Buchanan-Smith, Alick(Angus,N&M)Hamilton, Michael (Salisbury)Mitchell, David (Basingstoke)
Buck, AntonyHannam, John (Exeter)Moate, Roger
Bullus, Sir EricHarrison, Brian (Maldon)Monks, Mrs. Connie
Burden, F. A.Harrison, Col. Sir Harwood (Eye)Monro, Hector
Butler, Adam (Bosworth)Haselhurst, AlanMore, Jasper
Campbell, Rt.Hn.G. (Moray & Nairn)Hastings, StephenMorgan-Giles, Rear-Adm.
Carlisle, MarkHavers, MichaelMudd, David
Carr, Rt. Hn. RobertHeseltine, MichaelMurton, Oscar
Channon, PaulHicks, RobertNabarro, Sir Gerald
Chapman, SydneyHiggins, Terence L.Neave, Airey
Chataway, Rt. Hn. ChristopherHiley, JosephNicholls, Sir Harmar
Chichester-Clark, R.Hill, John E. B. (Norfolk, S.)Noble, Rt. Hn. Michael
Clark, William (Surrey, E.)Hill, James (Southampton, Test)Normanton, Tom
Clegg, WalterHolland, PhilipNott, John
Cockeram, EricHolt, Miss MaryOnslow, Cranley
Cooke, RobertHordern, PeterOppenheim, Mrs. Sally
Coombs, DerekHornby, RichardOrr, Capt. L. P. S.
Cooper, A. E.Hornsby-Smith Rt.Hn.Dame PatriciaPage, Rt. Hn. Graham (Crosby)
Cordle, JohnHowe, Hn. Sir Geoffrey (Reigate)Parkinson, Cecil
Corfield, Rt. Hn. Sir FrederickHowell, David (Guildford)Percival, Ian
Cormack, PatrickHowell, Ralph (Norfolk, N.)Pike, Miss Mervyn
Costain, A. P.Hunt, JohnPink, R. Bonner
Critchley, JulianHutchison, Michael ClarkPounder, Rafton
Crouch, DavidIremonger, T. L.Powell, Rt. Hn. J. Enoch
d'Avigdor-Goldsmid, Sir HenryIrvine, Bryant Godman (Rye)Price, David (Eastleigh)
d'Avigdor-Goldsmid,Maj.-Gen.JackJames, DavidProudfoot, Wilfred
Dean, PaulJenkin, Patrick (Woodford)Pym, Rt. Hn. Francis
Digby, Simon WingfieldJessel, TobyQuennell, Miss J. M.
Dixon, PiersJohnson Smith, G. (E. Grinstead)Raison, Timothy
Dodds-Parker, DouglasJones, Arthur (Northants, S.)Ramsden, Rt. Hn. James
Drayson, G. B.Jopling, MichaelRawlinson, Rt. Hn. Sir Peter
du Cann, Rt. Hn. EdwardJoseph, Rt. Hn. Sir KeithRedmond, Robert
Dykes, HughKaberry, Sir DonaldReed, Laurance (Bolton, E.)
Eden, Rt. Hn. Sir JohnKimball, MarcusRees, Peter (Dover)
Edwards, Nicholas (Pembroke)King, Evelyn (Dorset, S.)Rees-Davies, W. R.
Elliot, Capt. Walter (Carshalton)Kirk, PeterRenton, Rt. Hn. Sir David
Elliott, R. W. (N'c'tle-upon-Tyne,N.)Kitson, TimothyRhys Williams, Sir Brandon
Emery, PalerKnight, Mrs. JillRidley, Hn. Nicholas
Eyre, ReginaldKnox, DavidRippon, Rt. Hn. Geoffrey
Rodgers, Sir John (Sevenoaks)Stokes, JohnWalker, Rt. Hn. Peter (Worcester)
Rossi, Hugh (Hornsey)Stuttaford, Dr. TomWalker-Smith, Rt. Hn. Sir Derek
Rost, PeterSutcliffe, JohnWall, Patrick
Royle, AnthonyTapsell, PeterWalters, Dennis
Russell, Sir RonaldTaylor, Sir Charles (Eastbourne)Ward, Dame Irene
St. John-Stevas, NormanTaylor,Edward M. (G'gow,Cathcart)Warren, Kenneth
Sandys, Rt. Hn. D.Taylor, Frank (Moss Side)Weatherill, Bernard
Scott, NicholasTaylor, Robert (Croydon, N.W.)Wells, John (Maidstone)
Scott-Hopkins, JamesTebbit, NormanWiggin, Jerry
Shaw, Michael (Sc'b'gh & Whitby)Temple, John M.Wilkinson, John
Shelton, William (Clapham)Thatcher, Rt. Hn. Mrs. MargaretWinterton, Nicholas
Simeons, CharlesThomas, John Stradling (Monmouth)Wolrige-Gordon, Patrick
Sinclair, Sir GeorgeThomas, Rt. Hn. Peter (Hendon, S.)Wood, Rt. Hn. Richard
Skeet, T. H. H.Thompson, Sir Richard (Croydon, S.)Woodhouse, Hn. Christopher
Smith, Dudley (W'wick & L'mington)Tilney, JohnWoodnutt, Mark
Soref, HaroldTrafford, Dr. AnthonyWorsley, Marcus
Speed, KeithTrew, PeterWylie, Rt. Hn. N. R.
Spence, JohnTugendhat, Christopher
Sproat, IainTurton, Rt. Hn. Sir RobinTELLERS FOR THE NOES:
Stainton, Keithvan Straubenzee, W. R.Mr. Kenneth Clarke and Mr. Paul Hawkins
Stanbrook, IvorVaughan, Dr. Gerard
Stewart-Smith, Geoffrey (Belper)Vickers, Dame Joan
Stodart, Anthony (Edinburgh, W.)Waddington, David

Question accordingly negatived.