The background to the debate is a crisis within the National Health Service. Apart from the disputes which have occurred over the past month, even more fundamental problems arise. Lack of resources means that new hospitals cannot be built, that much-needed extensions cannot go ahead and that new equipment cannot be bought. Lack of resources means that medical staff are working in conditions that no one can consider ideal and that are often blatantly inadequate. Lack of resources means that nurses who finish their training are unable to find posts in the hospitals in which they have trained, not because they are not needed but because there is no money to employ them.
Let us be clear. These problems will not suddenly be cured, and it is no part of the Opposition's case to suggest that in the present economic crisis this position will be quickly changed. Regrettably, all the signs are that the position will get worse. Once again, we are dealing with the familiar problem of inflation, and inflation which should have been tackled months earlier by the Government. That inflation has stopped progress dead.
When we talk of resources within the National Health Service we are talking not merely about physical resources such as new buildings and equipment but about human resources—namely, hospital staff, including nurses, doctors and consultants. Our case against the Government is fundamentally directed at how the Government have managed these resources. The truth that we should recognise first is that the National Health Service has been kept going because of the devoted work of those working within it. If their morale is eroded, the service is put at risk. That is exactly what has taken place over the past 18 months. By the right hon. Lady's own admission, the result is that there is now widespread demoralisation.
The reasons for the demoralisation are not difficult to discover. One of the chief reasons is the overwhelming irrelevance of what the Government are doing. Let us take, for example, the manner in which the Government have handled agency nurses. These nurses fulfil a vital rôle within the service. They help staff hospitals which find it difficult to attract nurses because they are unable to offer accommodation or because the accommodation locally is expensive and poor. They help to staff crucial specialist units, such as intensive care units, where the work is particularly exacting. Those are units which sometimes find it difficult to find staff. Agency nurses provide an invaluable reserve of experience.
Faced with this situation, what has the right hon. Lady done? She has issued a circular aimed at eliminating the use of agency nurses within the service. The Government are implementing that policy by deliberately reducing their pay, a step which is not even favoured or supported by those who support the general policy. At a time of unprecedented inflation the Government have reduced the pay of the agency nurses. Of course that policy is having its effect. It is true that it is eliminating the agency nurses from the service. It is doing so for the very good reason that many of the nurses concerned are leaving the nursing profession altogether and taking other jobs.
How does the right hon. Lady justify that situation? In her circular she simply says that she
appreciates that a short-term risk may have to be accepted to achieve the longer-term aim.
I know of no responsible body of medical opinion that believes that that short-term risk is justified.
Even more worrying is the position within the medical profession itself. In that sector the evidence of a collapse of morale is visible for all to see. Disputes have escalated and, worse than that for the long-term future of the service, more and more doctors are considering the prospect of a career abroad.
The exact figures of medical emigration are notoriously difficult to obtain. The Department's figures operate rather like the presumption of death procedure in that only when a doctor is missing abroad for two years is he presumed to have emigrated. Even on the Department's figures, over 300 British doctors are emigrating per year. That is bad enough, but the indications are that the trend is increasing, A forward indicator is the number of doctors expressing an intention to emigrate to the Overseas Bureau of the British Medical Association in London. The figure is now up to 80 a month. If even half of those doctors put that expression into effect, we shall be in serious trouble.
What is the emigration picture? First, I think we can all agree that many young doctors are now taking their American qualifying examinations as a matter of course and that more young doctors are now considering the prospect of a career abroad than ever before in our history. Secondly, I think we can agree that not only young doctors but senior registrars and consultants are leaving. They are not merely leaving London but are leaving other provincial centres such as Birmingham. That is clear from the results of a survey in the Birmingham Post. Thirdly, I think we can agree that some specialties are particularly affected. According to the Director of Radiology at St. Mary's in a letter to The Times, in the past 18 months 23 senior registrars and eight registrars have left from London for posts abroad.
My hon. Friend the Member for Reading, South (Dr. Vaughan) will say a little more about that when he addresses the House. To put the matter at its most moderate, we are faced with a serious question of medical morale. It was for this reason that we welcomed the principle of a full-scale independent inquiry into the service. It not only allowed the current and underlying—
Not now. It not only allowed the current and underlying problems of the service to be examined but enabled there to be a breathing space. Goodness knows, a breathing space could hardly have been more urgent. The dental and medical professions were united in their desire for such an inquiry provided that it was able to examine the Government's proposal to abolish pay beds.
Is the hon. Gentleman aware that many of the doctors who he says are now going abroad are going to America where they can get much greater pay? Of course that could apply to any other profession in the country. Is this patriotism? Is this putting the interests of the ordinary people first, or is it an example of what Dr. Coggan said—namely, that we suffer from those who look for material gain at the expense of ordinary people?
It ill becomes any of us in the House to give lectures on patriotism to doctors in this country who have worked with devotion for years for the service under very poor conditions. The fact is that the hon. Gentleman—
Perhaps the hon. Gentleman will accept that the position as regards salaries in America has been the same for many years past. What is worrying is that in the past 18 months the position has deteriorated. If the hon. Gentleman does not accept that he will accept absolutely nothing.
It is a great pity that the case of the Government back benchers is so bad that they have to resort to such tactics. We supported the Royal Commission, but we said that it should include the Government's proposal to abolish pay beds. It is that policy which has been elevated by the Government to represent their central health service policy. That policy lies at the heart of the gathering dispute between the medical profession and the Government. It is that policy which has aroused the overwhelming opposition of the medical profession. I would not have thought that that was a matter of any dispute.
The medical profession says that there should be a fundamental review and that pending the conclusion of the review the Government should postpone their pay bed policy. What is the point of having a Royal Commission when the Government intend to press ahead with the issue that is causing most of the trouble? The right hon. Lady has responded with a call to the doctors to give a year to Britain. The Government are very keen on telling other people to give a year to Britain, but when it comes to postponing their plans for 12 months there is a deafening silence. If the Government want a sacrifice, let them set an example.
But on pay beds we are told by the Government that this is a solemn pledge of the Labour Party which is so firm, so fundamental, so loudly proclaimed that no delay of any kind can be contemplated. That, in essence, is the Government's case on this issue. Yet when we turn to the October 1974 Labour Party election manifesto, we read that Labour
…has started its attack on queue-jumping by increasing the charge for private beds in National Health Service hospitals and is now working out a scheme for phasing private beds out of these hospitals.
That is hardly a declaration of policy that can stand no delay.
Perhaps at the last election the Labour Party campaigned in the constituencies on this issue? Not a bit of it. Most of the leading members of the Cabinet in their election addresses forgot to tell the electorate that this was a fundamental part of Labour's policy. So fundamental was the policy that the Prime Minister forgot to mention it, as did the Foreign Secretary, the Chancellor of the Exchequer—and, most surprisingly, the Secretary of State for Social Services. However, she told the good people of Blackburn quite a number of other things. She said that unemployment was "levelling off" and that the Conservatives and Liberals were "itching" to restrain wages by law with all the injustices that that produced, and she declared that "it must not happen again". But of pay beds there was no mention. What she did say was that Labour's policy was based on "conciliation, consultation and consent". If the Government policy towards the medical profession is based on conciliation, consultation and consent, I sincerely hope that we never reach confrontation. If the right hon. Lady believes those words, let her demonstrate, not by her words but by her actions, conciliation, consultation and consent. Let us hope that the terms of reference of the Royal Commission will contain those words.
The Press has not been unstinting in its praise of the right hon. Lady's handling of the situation, but we must make up our own minds. Furthermore, there is one policy which by any measure is even worse than that of the right hon. Lady. The Labour Party conference voted last month not for separation but for the complete abolition of private practice inside the National Health Service and outside it. That vote gave a tremendous fillip to medical morale and increased confidence no end in the medical profession! But it had one effect, in that it led to the intervention of the Prime Minister, who set up a Royal Commission and also put on record the Government's commitment to the right of private practice. Indeed, so great was the Government's commitment that he said that he was prepared to legislate for it. It is equally true that the original policy on pay beds was enshrined in legislation and that succeeding generations of doctors have relied on it. But let us leave that on one side. What is significant about the Prime Minister's statement is that it defines the debate. It rejects outright the policy of the Labour Party conference and sets down that what we are arguing about is not whether private practice should conetinue but how it should be organised.
How do the Government propose that private practice should be organised? The aim is the creation of a separate private health service—or, to put it in the conciliatory words of the Secretary of State, the aim is to remove the
canker of commercialism at the heart of our National Health Service.
However expressed, the right hon. Lady is seeking a fundamental change in the National Health Service. As a joint delegation of medical and dental professions put it:
The issues at stake are of greater importance than any since the formation of the original National Health Service.
What, then, do the Government mean by their policy of separation? Do they mean a complete divorce of the National Health Service from private service? Not exactly. Generally private patients will be banned from National Health Service hospitals, but National Health Service patients will still continue to use private hospitals. As I am sure Labour Members are aware, 3,000 beds are provided in the private sector for the use of NHS patients and that contract arrangement will continue. Like pay beds, it is an example of sensible co-operation between the two sectors.
Does Government policy mean that all private patients will be banned from NHS hospitals? Again, not exactly. British private patients will be banned but those born abroad will be able to come here for treatment for which they will pay and to choose their own consultants. Does the Government's policy mean that the paying principle will disappear for British patients in National Health Service hospitals? Again the answer is, not exactly. If one is lucky enough to obtain an amenity bed and can afford £21 per week—and many people cannot afford it—the paying principle will continue.
But these are just details. What about the central aid? To use the right hon. Lady's words, the aim is to get private medicine
to stand on its own feet".
Whether or not one agrees with Government policy, this is a fairly startling and original way of explaining what is intended. It is true that the private sector will be allowed but it will be licensed not only for quality, but for quantity as well. The Government intend to establish a licensing system to control the
total volume of private provision for medical care. The aim is to ensure that the total provision does not exceed the total provision inside and outside the NHS in March 1974.
In other words, if the new service shows signs of flourishing and developing, it will be prevented. Development is to be deliberately restricted by the State, and what will be restricted with it is the normal freedom of the citizen to spend his own money in the manner he wants. The truth is that private provision is to be rationed, and the Secretary of State claims that all she is doing is to enable private medicine
to stand on its own feet".
It is a policy that is wrong in principle and, most of all, ludicrous in practice.
Let me give an example of this policy. Let us take as an example the Manor House Hospital, Hampstead, an excellent hospital in the private sector. It is run by the Industrial Orthopaedic Society. Its members already make their contribution to the running of the NHS, but they choose to pay extra from their own pockets for extra service and indeed for quicker treatment. It is a sensible scheme, backed by management and trade unions. Last year the trade unions sent £12,000 to that hospital in direct donations. Therefore, its credentials are impeccable.
What is the effect of Government policy in regard to that hospital? If Manor House wanted to expand it would have to seek permission, but if total provision had exceeded the Government limit, it would be stopped. If another group wanted to start a similar scheme, it could go ahead only if the Government gave permission. I repeat that the right hon. Lady says that all she is doing is getting the private sector
to stand on its own feet".
I thought that I had been fair in respect of the general economic climate in which the NHS is trying to operate. I am not trying to say that Conservatives in some magical fashion are trying to transform the situation. Indeed, if the hon. Gentleman had been here earlier he would have heard me deal with that matter in opening the debate.
Let us come to the practical effects of the abolition of pay beds.
No, I cannot give way again.
The Government must provide answers in this debate. The right hon. Lady knows that the pay beds compromise is often the only way at present that private practice can be exercised. If the pay beds go and the private sector is not allowed to develop, consultants will be deprived of that opportunity. Some undoubtedly will go abroad, but others will stay and seek a full-time contract.
Perhaps the right hon. Lady will say how that contract is to be financed, for already the BMA is receiving reports of consultants who, by their own wish, want to go full time and who have been told that there is no money to finance such a move. Does the right hon. Lady intend to make extra money available for this policy? If she does, how does she justify such a policy when by preserving the present compromise that same money could be used to employ extra nurses, and in a hundred other ways?
In our view, pay beds in hospitals represent a sensible compromise which operates above all to the benefit of the patient—and it is, after all, his interests that are paramount in all our debates. It is a compromise which is valued by the medical profession. It enables the consultants to work in the same hospital with the same support team, and it brings in much needed income to the health service. The charge that the Department levies can now be over £35 a day. Surely, of all times, this is not the time at which to turn our backs on that income.
I urge the Government to look at the organisations which oppose them on this policy: the British Medical Association, the British Dental Association, the Royal College of Physicians, the Royal College of Surgeons, the Royal College of Nursing, and the administrators. All are opposed to Government policy here. All they are asking is that the Government should postpone action until the Royal Commission reports. Surely that is not an unreasonable request. Surely we can seek that breathing space while an examination takes place of the fundamental problems inside the National Health Service.
Surely there can be some agreement between the parties on what is needed. Our aim is to encourage our doctors, consultants, nurses and hospital staff not just to give a year for Britain but to devote a career, a lifetime, to Britain. Inflation has halted our plans for the time being, but I believe that medical staff accept this. It would make it easier to accept if the Royal Commission were seen to be examining the future of the National Health Service—how it runs, how it is organised, whether extra resources can be brought in, and the place of private practice.
These, I think both sides would agree, are important issues. In principle the Government have the support of the Opposition in setting up a Royal Commission and, as I understand it, they also have the support of the Liberal Party. All they are being asked to do is to make a concession, to postpone action on pay beds and to postpone action on the agency nurses. If the Government do not make this concession, I believe they will be missing an outstanding opportunity of restoring medical morale in this country and will bear a heavy responsibility for the future.
The motion before us this afternoon is a very interesting one. I gather from my researchers that it is probably unique in regard to the size of the cut proposed in my salary. I am grateful to the Opposition for this distinction, which I find very flattering. I only hope that I can continue to merit the importance that they attach to me.
The speech of the hon. Member for Sutton Coldfield (Mr. Fowler) has been predictable. It has been predictable, first, because he has raised a number of issues causing controversy, and it was quite right that he should raise them. I shall try to deal with them all in my speech. Secondly, and equally predictable, the hon. Gentleman has tried to insinuate—I cannot use the word "substantiate"—that all the current crisis in the National Health Service is due to me. I only know that the hon. Member had to make some justification for the swingeing attack which he has proposed should be made on my already frozen remuneration.
I find the Opposition's myopic self-satisfaction, as reflected in the motion, a bit of cool cheek. If anyone wants to disqualify himself from making a serious contribution to the debate, he will do as this motion does and as the hon. Gentleman did, and insinuate that the current troubles of the National Health Service—and it has some real troubles—began when the present Government came into office and I took over this job in March 1974. [Interruption.] If the hon. Gentleman has not been making that case in his speech, perhaps he will withdraw the motion, because in that case his speech is obviously incompatible with the motion on which the House is asked to vote tonight.
It is equally clear that Opposition Members will try to prevent the House from listening to what I am intending to say. That is why we shall have this barracking.
If we want to reach useful conclusions about what is wrong with the National Health Service and how to remedy it—and I thought that was the whole purpose of this afternoon's debate—we have to begin by admitting, as The Times did in its leader on 21st October 1975 entitled
Clear thinking in the NHS
The Government is not really to blame for the long-term problems that have so greatly undermined morale.
Therefore, I am not to blame either.
I can tell the House what were the three things undermining morale seriously when I took over at the Department of Health and Social Security. The first thing that everybody said to me and my hon. Friend the Minister of State when we walked into the premises was "Morale has never been lower in the National Health Service". I was given three reasons—[Interruption.] I shall merely repeat every sentence that is drowned by hon. Gentlemen, so they will not obviate the necessity of listening to my speech.
They gave me three reasons—and by "they" I mean the deputations that were lining up to see me from the BMA, from the nursing profession, from the radiographers and from the ancillary workers as well as others interested in the welfare of the National Health Service. The first reason that all these people gave me for the collapse in morale under the previous Government was that the rewards of everyone working in the National Health Service had fallen seriously out of line as a result of our predecessors' statutory pay policy. I shall return to this.
The second reason was that the reorganisation of the National Health Service, sired by the right hon. Member for Leeds, North-East (Sir K. Joseph), had caused widespread disruption and uncertainty—to say nothing, incidentally, of the expense. Never let us forget that we are talking about the financing of the National Health Service. We took steps to make concessions in prescription charges, which the hon. Member for Sutton Coldfield tried to insinuate this service could not afford. Never let us forget that the transition to this elaborate new structure brought in by the right hon. Gentleman my predecessor cost the National Health Service a once-for-all payment of £9·5 million in 1974–75, and is now adding £4·5 million a year to the service's administrative bill.
Some of that money goes on trying belatedly to democratise the service through the addition of the Community Health Councils. Some of it goes on its professed aim of improving management. I only know that, in the innumerable talks that I have had with representatives of the medical profession, one of the things they have repeatedly raised with me is that, under this new four-tiered structure, a few doctors are up to their eyes in committee work, while the rest feel more remote from management than they have ever done before. This is confirmed by the University of Hull's illuminating study of reorganisation on Humberside, which I advise every previous supporter of the reorganised system to read.
Of course all changes cause some disruption, but it is remarkable how ineptly the previous Conservative administration handled the three major reorganisations for which they were responsible—the NHS, local government and water supply. There is hardly anyone with a good word to say for any of them.
The third cause of the low morale which I inherited was lack of money. When I took over my job, the previous Chancellor of the Exchequer, now Lord Barber, had just cut the health and personal social services programme by £110 million, involving an almost complete moratorium on major schemes, and the Conservative Government were obviously planning further swingeing cuts. It is interesting to note, in view of recent cries about the under-financing of the National Health Service, that the medical profession took those Conservative cuts very calmly even though they would have reduced spending on the NHS in 1974–75 to £3,756 million—in real terms at 1974 survey prices—compared with the £3,860 million approved by this Government. Of course we actually spent another £750 million to cover pay and price increases, as I shall explain in a moment.
Finally, there was widespread dissatisfaction amongst both consultants and junior doctors with their contracts. I was confronted with demands that they should be renegotiated, and I was prepared to try to do that by agreement even though the previous administration had refused to look at these discontents and anxieties.
Faced with this complex situation, we had to work out a balanced strategy. First and foremost, it was essential to correct the gross inequities in pay which had been caused by our predecessors' statutory pay policy. The sense of grievance that this had caused had inflamed all who worked in the service, from consultants to kitchen staff. But we had to do it in an orderly way so that the disengagement from statutory pay policy—which in my election address I promised that we would undertake and which we did, keeping that promise—did not become a stampede. That is why we felt it necessary to resist the demands backed by industrial action to make interim payments to nurses and radiographers—and a fat lot of help we got from the Opposition.
But the Halsbury Committee had the time which I gave it by this resistance to an interim policy successfully to complete its reviews, and nurses, radiographers and the rest got their biggest ever increase in pay in the first independent and searching review of their pay ever undertaken in the history of the NHS. Later the ancillary workers caught up, and in April of this year consultants, GPs, junior doctors and the corresponding groups of dentists were given a substantial award—from 30 per cent. to 38 per cent.—by their Review Body. True to the Government's promise, which I repeated to the medical profession time and time again in the difficult months of waiting, the Government accepted the award subject only to the cut-off which had operated in respect of top salaries.
I believe that it was essential to relax pay policy at that time in order to enable these fundamental adjustments to be made. Without it there was no hope of peace in the NHS. But it was expensive and, for a time, another cry of alarm went up. Some health authorities actually thought they would run out of money because they said that their allocations were not big enough to meet these massive pay increases and the sharp rise in prices that took place last year. But once again the talk of "crisis" was falsified. The Government made an extra £750 million available through Supplementary Estimates so as to inflation-proof the NHS. This meant that last year the percentage of gross national product devoted to the NHS rose to 5·4 per cent., the highest figure in its history.
We had put people before buildings, as we had said we would. But that meant that we could not restore more than part of the capital cuts which Lord Barber had introduced—only £30 million of them. It also became clear that inflation had become the biggest enemy of the NHS and that the priority had to be switched from the adjustment of pay grievances to the containment of the inflation that threatened the country's whole economy.
Hence the negotiation of the new voluntary pay policy: the £6 limit and the cut-off at £8,500 a year. I wonder whether the House realises what a remarkable victory that was for patriotism and common sense. Look at the people who have been accepting it: powerfully placed people like miners, steel workers and power engineers. Even those few unions which voted against the policy are not defying it. Already, as the Price Commission has pointed out, the policy is beginning to have its effect on price increases.
The prize is a dazzling one. Imagine what it will mean to everyone in this country to halve the inflation rate. Imagine what it will do for the morale of the NHS. But I have had a lot of experience in operating pay policies, and I know that any crack in it soon becomes a yawning gap. Human nature being what it is, everyone watches everyone else like lynxes to make sure that if anyone else gets away with a breach of the policy, the rest will do so too.
That brings me to the junior doctors. On this subject, the only comment that I can make about the speech of the hon. Member for Sutton Coldfield is that he reminded me of the dog who did not bark in the night. We did not have the great leadership on this issue that we were told in the Press that we were to get. Where was it? It is in moments like these, when the NHS is threatened with a serious and a widespread industrial dispute, that we can test a politician's honesty, courage and consistency. We tested the hon. Gentleman today and found him wanting on this issue.
The hon. Member for Sutton Coldfield and the House know that if the Government were to try to reach a settlement of this dispute—on which the newspapers have been conducting this sustained attack upon me to which the hon. Gentleman referred—by allocating additional money
above the pay policy limit, that policy would be in ruins in a matter of months. Newspaper after newspaper has admitted this. Even the Daily Mail, in a leading article the other day, castigated the industrial action by some juniors as
both unjustifiable and irresponsible".
Under the £6 pay limit there can be no special cases.
Why does not the hon. Gentleman have the guts to get up and say so as well? I ask him to tell the House where he stands.
The Secretary of State is asking the Opposition whether we support industrial action. The answer is that we do not support it. That is a point that I have made in this House before, and it is a point that others of my right hon. and hon. Friends have made. But it is a point which the right hon. Lady and her supporters never made when they were in Opposition.
That last statement by the hon. Gentleman is as inaccurate as most of his previous statements. Will he now tell the House whether he supports a breach in the pay policy?
The right hon. Lady really is not listening. We have made this clear. We have said this in the House and on the media and my hon. Friend will be saying it when he winds up the debate. So the right hon. Lady cannot get away with that. For her of all people to talk about courage in this matter is laughable. She and her party have the worst record in history on this issue.
But I thought that the purpose of this debate was to enable us to analyse the problems of the National Health Service and to try to establish who was responsible. Therefore, why did not the hon. Gentleman say what he thought about this this afternoon, when he created his own opportunity? We dismiss him as the contemptible coward on this issue that he is on so much else.
Any reflection of a personal nature is not in order. I am sure that, in the heat of the moment, things are said which are not intended and that the right hon. Lady would like to withdraw the word "coward".
I intend to use the opportunity provided today to look at the junior hospital doctors' dispute, because this is one of the genuine crises and problems now facing the National Health Service.
The hon. Gentleman says that it was made by me, but his Front Bench spokesman did not have a word to say about that. I hope that my answer will be listened to so that the facts can penetrate the hon. Member's mind.
I regret this dispute as much as anyone in the House, and I would say this to the juniors—
"Humbug," the right hon. Gentleman says. Instead of bellowing, the hon. Gentleman should listen and try to let some new thought penetrate that unhappy mind of his.
It was the Labour Government who in 1970 first introduced the principle of extra duty allowance for the juniors who did such long hours and a Labour Government who in 1974 implemented the reduction in the hours at which those allowances became payable to 80 a week. Of course, that position is still unsatisfactory. Junior doctors' hours of duty are on average just under 86 hours a week, although just under half of those hours are spent on standby or on call, and of course these long hours should be reduced.
Last May, the juniors found in me a ready listener when they asked for a new type of personal contract which would clearly set out a junior's commitment in each case and include, in place of the extra duty allowances, payment for all units of medical time contracted for above their standard hours.
The principles of that new contract, which have now been negotiated, mark a vital breakthrough for the juniors in their conditions of work. But it has all along been agreed with the juniors' negotiators that the pricing of the new contract would be done by the Review Body, their own independent body, and that each side would be free to give all the evidence about the costing of it that they thought fit.
By the time that a new contract came before the Review Body in July, the Government had announced their new pay policy and inevitably, therefore, had in their evidence to maintain that any settlement involving new money on top of the 30 per cent. increase in salaries that the juniors had had in April and on top of the £12 million already being spent annually on extra duty allowances would be contrary to that policy. The Review Body accepted this constraint. Hence its proposed redistribution of the available £12 million which has caused so much dissatisfaction, because re-routing the extra duty allowances to finance the new supplements from 44 hours means that, in the Review Body's estimate, about one-third of the junior doctors will be worse off while one-half will gain.
All this was known to the junior doctors' representatives when they met to consider this new deal on 2nd October. In full possession of the facts, the juniors' representatives voted, albeit reluctantly of course, by a massive 49 votes to nine in favour of the deal. That they later had to repudiate their agreement is well known, but let no one be in doubt that the leaders and representatives accepted that even with these limitations the new contract made a big breakthrough for them.
Of course, I understand the feelings of those who find themselves worse off—
I am sorry, I must get on because I have had so many interruptions. If I try to hurry up, the hon. Gentleman may have a chance to get in himself.
But the new contract structure was one which the juniors asked for. I have never sought to impose it, nor do I now. I am ready to explore any ways of overcoming the present difficulties within the money available. I told them that I am willing to see their negotiators at any time. I have been waiting to hear at what time they would like to meet me. I was ready to ask the House to excuse me this afternoon so that I could go and meet them now, but I have now heard that they want to see me to fix a meeting for Wednesday of this week, and of course I have agreed.
I have suggested, as one option, that the implementation of the new contract could be postponed until April, and could then include a "no detriment" clause which would be financed out of money available to doctors for their next pay settlement under the counter-inflation policy. This would, of course, have to be put to the Review Body. But this is not the only course. I have not shut any door. I have made it clear that changes could be made in the distribution of the existing money so as to deal with the problem of "no detriment" provided always that the total sum was not exceeded, and again subject to the Review Body.
If the profession has anything fresh to propose in relation to distributing the existing pay bill so as to introduce the new contract in the way which it believes is fairest and most acceptable to its members, we shall of course be very ready to discuss it. It is going ahead with a ballot of its members. In the meantime I can only remind the House, and the doctors, that the spread of industrial action, unofficial and linked to a welter of conflicting aims and explorations, is causing great inconvenience to patients and may well, before it is through, cause serious hardship.
That is the first crime that I am sup posed to have committed—my loyalty to the Government's pay policy. What are my other crimes? Suddenly, once again—
The successive interruptions mean that I am having to take up more time than I would wish.
What are the other crimes? Suddenly, once again we are deluged with sensational headlines about a crisis in the National Health Service. Morale, we are told, has collapsed. Doctors are said to be emigrating on a record scale, and British graduates, we are told, are no longer coming forward for training in surgery. Standards are supposed to be falling through lack of finance, and the Press is stopping at absolutely nothing.
The Daily Telegraph even carried the story—[Interruption.] I ask hon. Members to listen and judge. The Daily Telegraph even carried the story that a patient had died and two more had been brought near to death at Hillingdon Hospital due to the shortage of nurses, and, despite a detailed and factual refutation by the senior medical staff at the hospital, the district nursing officer and the area health authority, the paper goes on repeating the story.
All this has been remarkably orchestrated, reaching a hysterical peak during the week of the Conservative Party conference to provide an appropriate backing to the speech of the hon. Gentleman. In other words, it has been designed to help him play politics with the National Health Service just as he has been doing this afternoon.
Indeed, the campaign has reached such obscene lengths that some of those who have genuine anxieties about the NHS have become alarmed. They know that continuous talk about the destruction of morale can become a self-fulfilling prophecy. That is no doubt why Sir Cyril Clarke, President of the Royal College of Physicians, called a Press conference earlier this month to dismiss the emigration scare as exaggerated. Of course, as he rightly said, there are no grounds for complacency. As I told the House before, it takes time to check whether intentions to emigrate are carried out, and it may be a year before we can be certain what the current rate of loss of British doctors is and whether it is much up on last year, and, if so, by how much. This has happened under all Governments, but, as Sir Cyril said, we are certainly not faced with the "landslide" that it has suited some people's purposes to suggest we are. Nor are we faced with the crumbling of our nursing services as the hon. Gentleman tried to insinuate. The contrary is the case.
Thanks to the Halsbury award, the wastage of nurses has fallen sharply— they are staying in posts in their own hospitals, so there are fewer posts to fill; that is the answer to the hon. Gentleman's point—and the numbers in training are going up. In many areas recruitment has been increased. In Hillingdon Hospital, for example, contrary to the evil scaremongering of the Daily Telegraph, the nursing establishment is up to strength.
Nor is it true that the steps that we have taken to reduce the dependence of the NHS on agency nurses have led to a crisis in certain NHS hospitals.
It is not true that the steps that we have taken to reduce the dependence of the NHS on agency nurses have led to a crisis in certain hospitals. What the hon. Gentleman does not seem to know is that it has been the policy of successive Governments to reduce the NHS dependence on agency nurses, and for obvious reasons, because it is in the interests of patients to have a stable nursing force. It is not that I have suddenly gone on an ideological rampage. It is that the hon. Gentleman does not understand the simplest principles of patient care.
Does not the hon. Gentleman realise how much patients resented the frequent changes of nurse which they had to face when, as in some London hospitals, one in five of all staff nurses was from an agency? Does he think the patients felt they were getting the proper continuity of patient care? Does he not understand that the steady increase in agency nurses that we were experiencing, mainly in London, weakened the cohesion of the nursing force in the hospital, made the supervision of trainee nurses more difficult and left the regular nurse to carry an unfair share of managerial responsibility?
All those disadvantages have been recognised for a long time by anyone who knows anything at all about the NHS. They have been well recognised by the Royal College of Nursing. The changeover to the new payment arrangement has gone smoothly. There has been no sudden walk-out of agency nurses, and a number of them have transferred to the NHS. I shall continue to watch the situation and adapt my advice to health authorities accordingly.
There have been improvements in medical staffing, too, in keeping with our priorities. Since 1970 there has been a steady overall increase in the number of doctors working in the NHS in England and Wales, both in hospitals and in general practice. Up to September 1974 it amounted to a rise of 11½ per cent. Firm figures since then are not available, but the provision of quarterly returns up to June 1975 shows further gains at well over 2 per cent. for senior hospital staffs for the nine months. In view of the concern that has been expressed this afternoon about emigration, it is encouraging to note that the improvements of previous years are being maintained.
As the years pass, a higher proportion of these increases is coming from the increase in output of our own medical schools since the Labour Government's decision, following the Todd Report, to build the new medical teaching complex at Southampton, which has been followed by Nottingham, whose first graduates emerged this summer, and Leicester, whose first intake started this autumn. Whatever financial difficulties we face, my hon. Friend and I will continue to give this expansion of medical school intake a high priority.
It is a travesty to suggest that the NHS is breaking down. Why are we getting all this latest talk about catastrophes? Some of it, of course, is engineered for political purposes, but some is genuine. There is, of course, the hang-over from reorganisation to which I referred earlier. One of our difficulties in dealing with this is that even the supporters of that reorganisation are now beginning to question it. What is one to make, for instance, of the hon. Member for Reading, South (Dr. Vaughan), who supported the new four-tier structure of his right hon. Friend my predecessor in the 1970–74 Parliament and who in the columns of Hospital Life in August told us and the devoted men and women who are trying to make this structure work that we ought to abolish one of the tiers, probably the regional tier? What kind of effect does the hon. Gentleman think that has on the morale of the service? And he tries to censure me tonight for my handling of the NHS. I should not dream of doing anything as irresponsible as his casual gesture, and again I indict the Opposition Front Bench for being out of touch with the NHS.
The House knows that the Labour Party officially opposed the system of reorganisation proposed by our predecessors. None the less, we on the Government side would consider it irresponsible, and immensely damaging to patient care, to try to reverse that structure in the cavalier way in which the hon. Gentleman tosses off his reforms. A lot of people are now giving a lot of time, energy and devotion to making the new structure work, and it would be wrong to halt them in mid-course by suggesting that they are wasting their energies because they are about to be reorganised once again.
What we want to do is to work out with them how a better system of management might gradually evolve and how we can immediately streamline some of the administrative costs of reorganisation. I think that the Royal Commission can help us with our longer-term aim, but meanwhile we must—and I do—give these people the assurance that, unlike the hon. Member for Reading, South, we are not proposing to drop the regional tier or to make any sudden, drastic change in any of the tiers. Within this general assurance, we shall back them in seeking the maximum administrative economies in consultation with the staff concerned.
The second reason for crisis talk is that we have all begun to realise the financial limits on the development of the National Health Service. The sky is not the limit for this or any other public service, particularly in the tough economic situation that we face in the next few years. However, before we get too tragic about this, let us realise that this has always been so. In 1955, for example, the share of GNP allocated to the National Health Service fell to 3·6 per cent., but that was under a Conservative Government, so there was no great outcry by the hon. Gentleman's friends then. Since 1964 the National Health Service's share has risen steadily till it reached the exceptional peak of 5·4 per cent. last year. We have been clocking up the steady advances in medical and nursing staff to which I have referred and in other facilities.
The reductions already announced for 1976–77 by the Chancellor in his Budget speech in April will mainly be borne by capital spending. We do not intend to reduce National Health Service spending in the current financial year, despite pressure by the Opposition for swingeing cuts. We have deliberately chosen to put the cuts on the capital side and not the services side in order to avoid as far as possible any interference with existing services. It is true that the recent growth is likely to be checked in the next few years as part of the Government's need to curb inflation and restore our economic strength.
Again, however, do not let us exaggerated. In the current year we are allocating well over £4,500 million to the National Health Service—an immense sum by any standards. Of course I should like more and could use more with great benefit to the National Health Service, and I shall fight for the health service's rightful share of public expenditure. But to talk of the service collapsing with levels of expenditure like these is sheer scaremongering.
There is, of course, one thing that has changed over the past few years—
I am interested that the hon. Lady supports agency nurses. I shall repeat what I said earlier. We are watching the situation closely. There has been no disruption of the kind that she has suggested as a result of agency nurses walking out and the rest of it. I shall have a careful check made with my Department, and my hon. Friend the Minister will give the hon. Lady a specific answer this afternoon. It would be wrong of me to give her a specific answer until I have checked up. I shall have a check made and the House will be told the answer later in the debate.
Yes, there has certainly been a consistent increase in the number of nurses and doctors. We shall give precise figures, in answer to my hon. Friend's intervention, later in the debate.
One thing that has changed over the past few years is the public's expectation of what should be comprised in the words "health care". Every day the public hear of dramatic new breakthroughs in medical science, skills and technology, sophisticated new operations such as transplants, new forms of treatment and new drugs, and naturally they want to share in them. People's standards have risen. It it this which is putting new pressures on the National Health Service and has led some people to declare that we had better recognise that we can no longer provide a comprehensive system of health care through the National Health Service.
This is really the nub of the hon. Gentleman's attack this afternoon. All this talk of phasing out pay beds is irrelevant, he claims, because what we ought to be concentrating on is getting more resources for health care in any way we can. Of course this separation of the two problems is completely in keeping with the hon. Gentleman's political ideology.
The hon. Gentleman does not see this pressure on resources as a problem we have got to try to solve together, collectively, as one nation. He sees it as an alibi for those who can afford to do so to buy themselves out of the dilemma. He wants more private practice and more queue-jumping. This philosophy was never better expressed than by his own leader in those ringing words at the Conservative Party conference:
We don't accept that if everyone cannot have choice, no one shall
I know that hon. Gentlemen accept that, but the right hon. Lady said it in the context of the argument about phasing pay beds out of the NHS. In so doing she revealed that she is totally out of sympathy with the concept on which the NHS was founded—its aim of providing comprehensive health care for everyone as part of their birthright as citizens of a civilised nation. Of course the fulfilment of that aim has become more difficult, but that is true everywhere.
No Western country today can deliver a completely comprehensive system of health care to its people—not even the United States, which spend so much more than we do on health care. When I visited the United Slates last Easter I discovered, for example, how much the Americans admired and envied the family practitioner service of the National Health Service. I was told that under their system, however much money was poured out on private insurance schemes, it was not possible to get a doctor to visit a patient in his own home. If a child fell ill in the night and was running a high temperature and the doctor was telephoned, he would tell the caller to wrap the child up in a blanket and bring him round to the doctor's surgery.
Therefore, every country faces the problem of priorities. It is just a question whether the priorities should be medical priorities or financial ones. We believe that we should establish medical priorities. Of course it is difficult, but what neither the right hon. Lady nor the hon. Gentleman begin to realise is that just because times are tough the right to buy scarce skills inside the National Health Service, which by definition cares for and belongs to the nation as a whole, becomes intolerable.
Increasing numbers of patients and of National Health Service staff see the defence of pay beds for what it is: the endorsement of the principle of inequality in health care. That today leads on inexorably to a growing intrusion of private money into the provision of health care. It is the beginning of the end of the concept of the National Health Service. Some of the Press are beginning to let the cat out of the bag. As the Daily Telegraph put it a few days ago,
Nothing but deep surgery can put matters right. At the root of the matter is this Socialist insistence on free and equal medical care.
So it is clear that we are talking about a fundamental political principle: not whether we can afford to lose the £24 million estimated revenue from pay beds this year—not, incidentally, the £40 million that has been widely talked about in some places. After all, £24 million out of a budget of £4,500 million will not make the difference between our ability or otherwise to deliver a comprehensive system of health care. The hon. Gentleman conveniently goes silent on the fact that in return we shall be acquiring over 2,500 beds for National Health Service use, as well as the exclusive use of the staff who have been servicing them. This represents the bed complement of four or more district general hospitals, and the capital cost of providing them afresh today would be some £70 million. We can dismiss that argument. What divides us is a fundamental point of principle, and that is why it must be decided by Parliament and not by the Royal Commission, because, as The Guardian put it,
Royal Commissions should not be expected to take political decisions.
But what the Royal Commission can do—and, I hope, will do—is to examine how we can use the large budget of the National Health Service better and guide us as to how we might use it more effectively. That is what my hon. Friend the Minister of State and I have been giving so much of our time to since we came to office.
There is no doubt that even with its present resources the National Health Service could provide a more comprehensive and cost-effective level of health care. Great improvements and savings could be made by identifying best practices and then universalising them. My hon. Friend will be returning to this matter in his winding-up speech tonight, because it is the real answer to the problem that we face. We have not only to choose the right priorities, such as, for example, the expansion of primary care and the emphasis we are laying on the development of health centres, but we must use our money more effectively. We have already found, by the initiatives we have taken, that this can be done. The Royal Commission can help us here.
To return to pay beds, I am anxious to introduce this policy in a planned and reasonable way which will help the patient to have access to private treatment outside the National Health Service if that is what he or she prefers, and in a way which will recognise consultants' anxieties. That is why I proposed a system of licensing, not as a sinister first step to the abolition of private practice but because I want to have the means to encourage the fairest possible distribution of private practice throughout the country to give the maximum freedom of choice.
Moreover, we are already aware of a number of proposals for large-scale developments in the private field which could do enormous damage to the NHS and so to the overwhelming majority of the medical profession itself. I mention just one example—the proposal for a 500-bed centre of excellence, as it is called, in the Bristol area. It would draw its patients from a wide catchment area, being placed at a strategic point on the motorway, but it would obviously recruit most of its nursing and ancillary staff locally, with consequences for the local NHS hospitals which must surely cause all of us anxiety.
These are the sort of problems that I want to discuss with the medical profession, without preconditions of any kind. I want us to try to reach agreement on the best way, from everybody's point of view, of dealing with the situation which will arise when pay beds are phased out. If the professison can convince me that the way I propose is wrong and damaging, I shall be glad to consider other ways.
However, I repeat again, as I have done many times, that our policy is not to abolish private practice, and, as I have told the BMA, we intend to re-embody the existing right to private practice in the legislation that we propose to introduce. So much for the hysterical nonsense about "the watchtower, the searchlight and the Berlin Wall".
I therefore reject with contempt the accusations that have been made against me this afternoon. And I say to the Liberals, who have now apparently joined in the hue and cry—I say it to the Leader of the Liberal Party—that Lloyd George would be ashamed of them. As Frank Owen points out in his biography of their greatest man:
Lloyd George had a far livelier and longer struggle with the doctors before the First World War than even Aneurin Bevan did after the second one.
Nye Bevan was not exactly a hero to the doctors either. We remember some of the violent abuse that was heaped on him. In proposing to phase pay beds out of the NHS which he created, I am completing the work he began, by removing
the defect in the Service which was seen from the beginning
as he himself used to describe pay beds in his book "In Place of Fear". When Nye had established the NHS after a long and bitter battle against misrepresentation and prejudice, he described it as
a triumphant example of collective action and public initiative.
It is that collective action which we on the Government side of the House will be voting to defend tonight.
I am grateful for the opportunity to speak in this debate. I do not normally take part in National Health Service debates, and I declare my interest as a doctor's wife. It is not my intention to make a party political speech. I speak today because I am so deeply concerned by the deteriorating situation in the National Health Service, which I see, if I may say so, at much closer quarters than do many hon. Members.
I must say at the outset that nothing that the right hon. Lady the Secretary of State has said today alleviates my fears in any way, and the manner in which she has said it causes me greater anxieties still. There is a crisis in the National Health Service. There is a crisis of cash and a crisis of morale. There is also a wide variation of effect in what is going on.
I am glad to say that in some areas, particularly perhaps in Scotland, where I have been in touch—covering a considerable percentage of our population—the situation seems less serious than in some other areas of the country. There is, of course, a difference of structure in Scotland, and it may be that we have the better structure. But there is anxiety, for example, in one area where a growth factor of 3½ per cent. per annum is to be reduced to 1½ per cent. in real terms. I am assured that even with these restrictions there will be sufficient money to pay the nurses. I notice that the right hon. Lady the Secretary of State did not tell the House that in some hospitals the cost of the nurses is equal to as much as 80 per cent. of the total hospital expenditure. That is a fact about which many of us rejoice, but it is a fact that must be faced.
However, further inquiry as to how this restriction would affect the area concerned revealed that the nursing staff in the area is much under strength. I was told that certain hospitals were grossly understaffed. Of course, one can make reduced financial provision suffice if the money available is needed to pay fewer people than are required. That is a factor which must always be taken into consideration in the running of any hospital.
The NHS is a labour-intensive institution, to a greater degree than most. When money runs short it may not be quickly obvious, and it certainly is not as particularly obvious to the patient, and where staffing is below establishment it takes longer to become apparent. But, of course, if major economies have to be made they almost certainly have to be made by cutting staff, and because there is a high turnover rate in nursing staff it is, therefore, easy for the administration to require cuts in nursing staff, and this it does.
Moreover, successive financial masters have not recognised some things upon which the right hon. Lady did not touch—the great changes required to keep the standards that we have at present in the—admittedly welcome—face of shorter working hours; increasingly complex medical requirements; and, last but by no means least, new ward design.
If, for example, there is only enough money to pay less than the absolute minimum number of nurses required, a ward has to be closed. I am glad that my hon. Friend the Member for Sutton Coldfield (Mr. Fowler) raised this point, because I intend to say a few words about it. There is a problem of major difficulty concentrated in that decision alone. If, for example, geriatric services are to be reduced, acute beds are likely to become blocked by long-stay patients. If then a medical ward is closed, does the medical staff for the remaining wards continue to be employed to the best advantage? Indeed, do they get their own training? Is it in the economic interest of the service and of the country that this should happen? I can give the right hon. Lady details of at least one hospital where in new ward blocks of over 200 beds only 50 can be used because there is no money to pay the staff who are available to service the rest.
It is totally untrue to suggest that the medical services are working as fully as they can and it is equally untrue to suggest that financial restriction is not very real. "People before buildings", the Secretary of State said. She should view these matters with a clearer eye.
Again, as I have said, inevitably as each ward closes and those remaining get filled up with long-term geriatric cases and the adequate training for hospital doctors becomes reduced, so it moves from physician to surgeon. It is likely that a medical ward—I will not go into the details—will be closed before a surgical ward, but it follows that if one is reduced and the training facilities are reduced, so the Royal College responsible for the training—be it of surgeons or of physicians—will have to withdraw its recognition of that hospital for the training of surgeons or physicians. Thus, doctors are withdrawn and standards fall.
Meantime—here is a point of rare agreement with the Secretary of State—bureaucracy has established itself to an overwhelming degree. I entirely accept that neither political party can excuse itself from this fact. It is absorbing skill and time which would be far better used, as it was intended, in patient care.
Numbers will be given and can be given, certainly in nursing terms, of the effect of part of this bureaucracy. I know of instances where 30 nurses are now required full time on administrative work where previously 10 were used. I know of more than one case where 10 are now required instead of three. Cumulatively this is tragic for the National Health Service. It is tragic and it is also expensive.
For the doctors it is also tragic because it means long hours, endless meetings and the inevitable frustration of a dedicated doctor being thus prevented from following his vocation and his whole life interest which, although this seems to have been forgotten, is to heal the sick.
This aspect is perhaps more pressing on senior doctors, but the junior doctor sees his senior and he knows that he will soon become a senior himself. The juniors' problems are well known, but I do not believe that they are just as the right hon. Lady described them. There is a total misunderstanding about the problems of juniors and about the problems which they in turn create for the wider doctoring staff. I will leave that to others to deal with. I undertook to make a short speech and I have tried to keep within factual limits.
I shall conclude with the only party political point I intend to make. The right hon. Lady recently offered £5 million to cut waiting lists. How utterly absurd to suggest that the cutting of waiting lists demanded this degree of priority. Was it given to cover the fact that we have now reached a stage in many places where acute illness cannot be treated? Or is it right to enable a full establishment of nurses who could be made available to remain unemployed when it would take approximately an extra £100 million—I do not say that this is a limit and I recognise that it is a lot of money—to have nursing establishments brought up to strength for the whole of the United Kingdom?
If that is what is required, I ask the right hon. Lady in conclusion: be it £24 million or be it £50 million, is this the moment to reject that from pay beds?
The right hon. Lady the Member for Renfrewshire East (Miss Harvie Anderson) made some very interesting comments about the problems of the nursing staff in the National Health Service. Her speech was a much more sincere speech than that made by the hon. Member for Sutton Coldfield (Mr. Fowler), who gave an excellent demonstration of the new Conservative Blackpool philosophy—the naked pursuit of inequality for its own sake. The hon. Gentleman spoke for about half an hour and practically three-quarters of that time was devoted to the subject of private practice, to the interests of those with sufficiently large incomes to pay for personal separate treatment.
I have nothing against private practice. From a personal point of view, I am rather in favour of it, but I think that a responsible Front Bench spokesman should at least have some consideration for the great mass of the people for whom the National Health Service has to work—people like, for example, unfortunate cleaning ladies who have painful bunions and who have to wait for two years for treatment because they cannot get any higher on the waiting list, people with all kinds of painful and disagreeable diseases who have no substantial incomes.
We did not hear a word from the hon. Member for Sutton Coldfield about people such as those. We heard only about private practice for the privileged members of society. This is typical of a great deal of the Opposition's thinking.
It would be wrong for any hon. Member to feel or to express any complacency about the present state of the National Health Service. For the first time we have had industrial action by junior hospital doctors or by doctors at all. There is no doubt that the morale of the consultants as well as that of the junior doctors is impaired.
I, being a consultant surgeon, cannot help meeting and talking to large numbers of consultants. There is no doubt that they feel considerable dissatisfaction with their work and with the general state of affairs in the National Health Service. There are some signs of deterioration in the treatment of patients. I admit that this is a purely subjective judgment. However, professionally I am often called upon to treat or to see people who have been treated within the service and I gain the impression that standards of treatment have dropped to some extent. This is a purely subjective opinion and I may be wrong, but one must give one's impression.
My hon. Friend says that he mixes—unfortunately, to some extent, although I do not want to impugn him—with consultants. Does he agree that the disgruntlement among consultants often is because the demi-god-like posture that they adopt has been tarnished and they can no longer lord it over people in the way that they did?
As I have said, I am a consultant surgeon, but I was not aware that I adopted a demi-god-like posture or lorded it over anybody. There is no doubt that there has been a diminution in morale among consultants, and we should try to discover the reasons for it.
I am satisfied that there is no question of my right hon. Friend the Secretary of State being in any way responsible for the diminished morale. There was considerable discontent in the National Health Service when the Labour Party took office in February last year. Much of the discontent—which has spilled over this year—resulted from the reorganisation carried out by the Conservative Government. This was the damnosa hereditas which my right hon. Friend had to take over. There was grave discontent among the nurses about pay and conditions of work.
I am Chairman of the Parliamentary Committee of the Confederation of Health Service Employees and, as my right hon. Friend knows, I had quite a lot to do with the negotiations which took place with her. She behaved with conciliatoriness and generosity on every occasion. There was no question of any confrontation. The pay of the nurses, who were previously the badly treated members of the service, has been increased. It is natural that the junior doctors do not see why they should suffer from similar injustices. It is bad luck for them that just when public opinion is in favour of their having greater remuneration, the £6 pay freeze has been introduced.
It must be accepted that until recently the National Health Service was run on the cheap and at the expense of the people who work in it. It has been run on the cheap at the expense of the nurses. That situation has been largely put right by my right hon. Friend in carrying out the recommendations of the Halsbury Committee. It has been run at the expense of the junior hospital doctors who live under conditions which would have caused the raising of eyebrows among plantation owners in the Deep South at the time of slavery.
My right hon. Friend the Secretary of State talked about junior doctors working an average of 86 hours a week That means that some of them are working 120 hours. That is slavery of the worst type. Last year the Government started to put matters right. It was the present Government that ensured that due consideration should be given to the junior hospital doctors' grievance.
What action should be taken to overcome the problems of the National Health Service? One of the most effective actions taken in the last few months has been the setting up of a Royal Commission. Until now there has been no careful study of the service in depth. That has been a loss to the service. There have been four large-scale investigations into education—the Robbins Committee, the Newsom Committee, the Plowden Committee and the Crowther Committee. They have been extremely helpful and have enabled successive Governments to put right a lot of what was wrong with education. I should have thought that the setting up of a Royal Commission was the most helpful action which could be taken for the National Health Service.
I am not urging that, because I have a great respect for this House. Perhaps it passed over the hon. Gentleman's head, but three years ago a Select Committee of the House made a report consisting of hundreds of pages on private practice. It went into the whole matter in depth and with the greatest care. Why must it be gone through all over again? It has been decided that pay beds must go. That has been the Government's policy since February, and it has been carefully considered by a Select Committee. It would be absurd to inflict on the Royal Commission the need to investigate a matter which had already been thoroughly investigated. This matter needs to be dealt with in the next few months. It cannot wait for the report of a Royal Commission.
We should not accept that report, because the Select Committee divided on party lines. The whole matter has been carefully investigated and all the arguments have been put forward. This country must be governed by the Government, not by Royal Commissions or Select Committees. However, such inquiries have the important advantage of focusing public attention on all the issues.
Something must be done at the earliest opportunity to allay the fears of the junior doctors. My right hon. Friend the Secretary of State said that she would meet them very shortly. Presumably she will meet only their negotiators. Recent events have suggested that communications between the junior doctors' negotiators and the junior doctors are not very good. The doctors have been rather poorly represented. It would therefore be helpful if my right hon. Friend the Secretary of State made a statement after the meeting indicating to the junior hospital doctors throughout the country that they will have better treatment once we are out of the era of the £6 limit. They deserve it. It should be possible for my right hon. Friend to make a statement which would receive wide publicity to allay their fears.
The hon. Member for Sutton Coldfield spoke of the fears of the consultants about the question of pay beds. We must get it into proportion. Only a very small proportion of consultants use pay beds. The suggestion that this is a burning issue and that the consultants will dash on the Palace of Westminster and burn it down simply because pay beds have been abolished is absurd. Nevertheless, that small proportion represents some of the leading members of the profession and their point of view must be treated with consideration and respect.
There should be no compromise on the principle of abolishing pay beds. I think that most people, except those with somewhat reactionary views, agree that it is wrong that there should be two standards of treatment in hospitals—one for the general public and one for those who can afford to pay more. This is a nonsense which should have stopped a long time ago.
When the National Health Service was inaugurated by the late Aneurin Bevan, it was agreed with the doctors that there should be pay beds. That provision was in the founding charter of the NHS. It would not be right suddenly to snatch this concession away without providing compensation. Consultants gaining profit from pay beds should be met with patient negotiations. That applies to most of the top members of the medical profession. I refer to the members of the Councils of the Royal Colleges and to those leading members of the profession who make use of pay beds. It will not help the NHS if pay beds are abruptly eliminated without consulting the people concerned. This is a matter for patient negotiation and compensation for those whose financial interests are affected, provided that the principle that pay beds should be abolished in the near future is accepted without compromise.
It was suggested that consultants are afraid that private practice will be abolished. It is not possible to abolish private practice in Britain. Or, rather, it would be possible only if one could ensure that no United Kingdom resident received a passport without a water-tight guarantee that he would not receive private treatment abroad. People can go abroad for private treatment anywhere. It would be an intolerable infringement of the freedom of the individual if we stopped private practice in Britain. However we must not become so excited on the subject as the Opposition as this problem affects a small number of people with ample means.
There are anomalies in the remuneration of consultants and doctors. Some Government supporters think that consultants are overpaid. However, there is a world market price for the work of consultants. It would be unrealistic not to face that fact. It is common to charge about £200 for a major operation under the system of private practice in Britain. The same surgeon would perform six such major operations in an afternoon in the National Health Service and receive £20. I refer to senior consultants. It is easy to say that they are overpaid.
There is a market price for surgery. It may be disgraceful and distasteful, but the world is imperfect. There is a market price for medical treatment. Attention must be paid to that market price when paying NHS doctors. There are grounds for increasing the pay of consultants.
There is an absurd situation over the remuneration of general practitioners. A general practitioner who avoids as much work as possible, who sends his patients to the hospital no matter how trivial their complaints, who avoids treating his patients whenever possible, receives more pay than a general practitioner who cuts his work to an amount which he can comfortably do, who takes a responsible attitude, who treats the patient himself, and who buys the best possible equipment. These are the economics of Alice in Wonderland. They are absurd. I trust that as a matter of urgency the Royal Commission will look into the ridiculous situation of general practitioners' pay.
There are happier signs in the present situation. For instance the British Medical Journal, the doctors' official publication, suggested last week for the first time that doctors might well consider giving up their long-cherished and fiercely guarded right to prescribe whatever treatment they considered proper irrespective of its cost effectiveness. A doctor, whether in a hospital or in general practice, has in effect a cheque book on which he can draw on the Treasury to an almost un-unlimited extent. Doctors, whether in hospitals or in private practice, can prescribe without hindrance drug A, which costs so much, or drug B, which may have exactly the same effect but cost 10 times as much. Drug B will probably be more attractively packaged and advertised and yield a far greater profit to the pharmaceutical company.
There will be very little suggestion of cost effectiveness in the NHS as long as doctors insist that they have an absolute right to prescribe what treatment they like. That applies to many aspects of medical treatment, including the hospital treatment. Often patients who are moribund are given prolonged treatment at enormous cost which will do them no good and will not affect the result. It may sound inhumane to withdraw such treatment from them. But that treatment has always been given to them at the expense of the treatment to other patients. There is a strong case for a more cost-effective attitude towards medical treatment. It is an encouraging sign that the medical profession is aware of this problem.
There is another cause for the impaired morale of the NHS. The right hon. Lady the Secretary of State can do nothing about it. I refer to the constant denigration of the NHS by the Press. Nearly every day there are newspaper items indicating that conditions in the NHS are deteriorating to a catastrophic extent. Most of such items are untrue. The speech by the hon. Member for Sutton Coldfield embodied a similar degree of irresponsibility. The doctors and nurses of the NHS are devoted to their professions and by and large are not concerned about their remuneration provided that they earn a decent living. It is for Parliament to give them every help and encouragement and above all not to denigrate their patient, hard-working efforts to relieve the sufferings of humanity.
This afternoon the Secretary of State rightly said that she could not be totally and personally blamed for all that was wrong with the National Health Service. That is not the gravamen of the charge made by the Opposition. That was not argued by my hon. Friend the Member for Sutton Coldfield (Mr. Fowler). If we wanted to assess the ingredient that the right hon. Lady had added to the woes and troubles of the NHS, all we needed to do was to listen to her speech.
If she speaks to the doctors and nurses and their representatives in the shrill and hectoring way in which she has spoken to Members of Parliament, she cannot accuse them of leaving her presence with the feeling that she has a mind that is less than open or fair. Indeed, the right hon. Lady has introduced a unique degree of political venom into the troubles of the NHS. It is typical of the right hon. Lady that when she is being referred to, she leaves the Chamber.
The representatives of the doctors and nurses complain that after they have spoken to the right hon. Lady she says that they are unfair. The right hon. Lady says that she is misunderstood by the doctors, the nurses and the consultants. If anyone is misunderstood on that scale, it is a record.
The trouble is that the Secretary of State has exiled the word "sorry" from her vocabulary. Her treatment of the groups in the NHS and the way in which she deals with them personally have added to the woes and troubles of the service. When she asked my hon. Friend the Member for Sutton Coldfield to condemn the action of the junior doctors with warmth and enthusiasm, I hope that she meant the same degree of warmth and enthusiasm as she showed when condemning the action of the miners in 1974. I thought that that part of her speech was humbug.
The question which we must ask ourselves, and which a wider audience is asking in the country, is what is wrong with the health service. The answer is that there is simply not enough money being spent upon it and the country can probably afford virtually no more. In the White Paper published earlier this year we were told that approximately £3½ billion was to be spent on the health services this year. Because of the rate of inflation since January, the amount is probably between £4½ billion and £5 billion, which is an enormous amount. As the right hon. Lady has said, this represents an increase in the proportion of the gross national product spent upon the health service.
However, this money is not sufficient, because the resources are limited. The White Paper said that there would be growth of 2·7 per cent. per year in the health service for the next five years. That is completely out and completely unrealistic. Even with this extra money it will be a struggle to maintain the existing standards of the health services. Everybody knows that that is the case. Indeed, the hon. Member for Lough-borough (Mr. Cronin), who practises in my constituency, made exactly the same point. The House, the Government, indeed the whole country, have to address themselves to how we can maintain and sustain the level of the health services that we have at present when resources are so limited.
At the same time, demand is literally insatiable. Gone are the days of 1946 and 1947 when people believed that if medical sources were freely and readily available, we could virtually do away with waiting lists in a matter of months. We have all learned—both parties and both Governments—since the foundation of the health service that the demands on our health service are almost infinite. We can see this manifested in the various groups that have become eloquent in the past few years.
There has been, quite rightly in my judgment, an enormous increase in the amount spent upon the mentally ill in the past 10 years, a result of sustained pressure from various interested groups. Indeed, the number of psychiatric day release patients increases at the rate of 12 or 13 per cent. a year. Only yesterday I attended a service in my constituency for people with speech disorders—a group whose particular problems are now being more clearly identified and whose claims are being pressed forcefully and eloquently by one of my constituents, namely, Miss Diana Law, who has had a severe stroke and who suffers in this way.
The demands are insatiable and therefore the country has to ask itself two questions, First—a factual question—how much can we afford? Secondly—a more interesting and political question—how much are we prepared to afford? It would be a rash person who was prepared to say that the country was prepared to spend or afford much more on the health services.
Last week we had a lobby of the teachers and a few weeks before that of the disabled. The conflicting demands upon the public purse are such that it would be much more realistic for hon. Members to admit that the public purse in this connection was severely limited. It would require an enormous and probably unachievable exercise of political will to say that an increasing proportion of the gross national product should be spent upon our health services. Individually, we all know that in our own constituencies we want more hospitals. One wants to improve the services for especially deprived or disabled groups. However, is it politically realistic to say that the State is prepared to spend much more?
I believe that we must face the problem squarely. If the State is not prepared to provide more from its own resources, we shall have to say to the people of this country that we shall struggle to maintain the existing services, but we shall probably not be able to do so, because the nature of those existing services is essentially labour intensive. The reason an extra £1,000 million has been spent this year is basically to meet wage and salary demands in the nursing and medical professions.
Will the hon. Gentleman consider more effective methods of spending such money? Will he think in terms of the work done by Action Research for the Crippled Child in "Care with Dignity", which clearly showed that with effective rehabilitation services people can live at home at the same cost?
There is enormous scope for saving within the health services, not only in administration, but in the increase of domiciliary care. There is no doubt that there is a considerable saving in money-terms if pregnancy advice is given in the home rather than in hospital. I take the hon. Gentleman's point.
However, the resources we are prepared as a country to commit to the Health Service are and must be limited. Therefore, one has to accept that standards will at least remain the same or will fall, and one has to try to find alternative sources. I believe that one should be prepared to consider this matter with an open mind.
The only substantial sources of money, apart from the State subvention to the health service, are the optical and dental charges and, of course, the prescription charges. It was only a matter of 20 to 25 years ago that the imposition of prescription charges caused the resignation of certain Labour Members. The present Prime Minister resigned with the founder of the health service on this very issue. I assume that the principle of charges has been accepted by the Government as they have not withdrawn them.
We must examine other areas to see where modest charges can be made. I know how politically unpopular such action is, but we must be frank with the people who send us here. We shall not be able to afford a better standard of health services in our country unless we are prepared to increase the resources that are available.
The hon. Gentleman is making a speech about the economic problems of financing the health service, but he knows that charges are a reduction of personal consumption just as much as taxes are. Any Chancellor, as the hon. Gentleman rightly said, is faced with the overall problem of how much from whatever source of finance can be devoted to the National Health Service.
The Minister of State is making the mistake that all economists make: he is looking at the matter globally and loosely, but not personally. Of course it is economically correct that we are dipping into the same pool, but the willingness of people to give money from that pool is improved if they can see an improvement in the services. It is difficult to persuade them that £40 million allocated by the Minister of Slate is money well spent when they can contribute that sum for something that they can purchase, or for part of the service that they can purchase. That is the difference. It is a psychological difference. Once again the Government have to learn to govern with the grain of human nature and not against the grain of human nature.
Is not the example of other countries of help to my hon. Friend? No other advanced countries with an equal claim to compassion for the sick as the United Kingdom have seen fit to finance their health services out of general taxation and yet they manage to spend more of their GNP on health.
My hon. Friend has made an important point. That is one of the factors that help to inhibit the improvement of the health services in our country. I am one of those who believe that the creation of the National Health Service is one of Britain's greatest post-war achievements. I am also realistic enough to realise that we shall not be able to maintain the services in anything like their existing shape without the devotion of more financial resources to them.
I turn to the pay-bed issue. A small amount of money is made available to the National Health Service from pay beds, but nevertheless £12 million, £20 million or £40 million—it depends which estimate one takes—is not to be sneezed at. The Government's policy of separation will damage the health service. The policy of separating the public and the private sectors in this area means simply that the public sector will lose.
I have a letter from a cardiologist in my constituency who operates from St. Mary's Hospital, Praed Street. He says:
we are equally on call for Health Service and private patients, both of whom get a much better service than if the private patients were housed in nursing homes scattered around London to which one would have to travel, which would then necessitate far fewer hours presence in the Health Service…In other words, one would be forced to one's contractual hours by closure of private beds attached to a hospital such as this one".
That is the reality of what will happen if we separate the two functions. The Government recognise that will happen. [HON. MEMBERS: "It will not:"] It is all very well for hon. Gentlemen to say that it will not happen, but the Government recognise that it will. As a result, they are introducing a licensing system, which will ration the available resources for the public and private sectors in various parts of the country.
I am on this side of the House as a Conservative because I find such a policy of rationing totally unacceptable. The way that the Government intend to carry out this licensing system, according to paragraph 10 of the consultative paper, could not be more explicit. The paper states: "It"—the private sector—
would not be allowed to make it more difficult to provide a comprehensive national health service by absorbing, either nationally or more locally, any undue proportion of scarce skills achieved by training at public expense".
Hon. Gentlemen opposite say "Hear, hear". They ought to recognise what they are saying "Hear, hear" to. They are saying "Hear, hear" to a system of licensing of nursing homes throughout, but based not on the standards and facilities of these nursing homes, but on the right of people to work within them. This is licensing people to work. There is no other work in this country for which one requires a licence from the Government.
The hon. Gentleman is right. [An HON. MEMBER: "Abortion clinics."] Abortion clinics are licensed on the grounds of the medical facilities within them. This is by nature entirely different. It is saying to somebody, "You can work as a doctor in that area, but not in another area". It is rather different for taxi drivers.
I am strongly opposed to the provision of monopoly State services of this kind. We should avoid them. There should be a mixed economy in the National Health Service as there is in the rest of the economy.
What the medical profession finds so objectionable in the administration of the NHS under this Government is that the boundary between the private and the public sectors is constantly being moved towards the monopoly of State services. The Secretary of State today said, "We will do away with pay beds because that was in our manifesto". The right hon. Lady uses the Labour Party manifesto, as does the Prime Minister, as a yo-yo. She pushes it down when she wants it to go down and she pulls it back when she wants it to come back.
The plain fact is that the right hon. Lady has introduced a considerable degree of political turmoil into the Health Service over this issue at a time when it needs a period of stability. When a public service faces a 25 per cent. rate of inflation, it requires stability in its leadership, not the political turmoil that the right hon. Lady has introduced.
At least the hon. Member for St. Marylebone (Mr. Baker) tried to get to the roots of the basic sickness of the National Health Service, which is more than can be said for the hon. Member for Sutton Coldfield (Mr. Fowler) who opened the debate from the Opposition Front Bench. It was a cheap, grubby and squalid little speech from a grubby and squalid little man.
It was a grubby little speech not worthy of the occasion.
We all accept that the National Health Service, like many other public services today, is suffering from a shortage of finance, capital, and, generally speaking, the crisis through which we are all going to a greater or lesser degree. It is a mistake to assume that the problems of the health service, or any other service, can be automatically solved by an injection of cash alone. On the contrary, there is much evidence to suggest that the problem of the health service is not how little we spend on it, but the value that we get for the money that is already being spent.
There is a lot of evidence to suggest that the resources currently being used within the health service are being wasted—not least as a result of its reorganisation by the Tory Government. The health service is choked. Anybody who talks to doctors, nurses, or others actively engaged in the NHS will be told that the service is choked by committees, red tape and paper. I believe that there are 280 doctors within the Department of Health and Social Services dealing with administration. There may be good reasons for that. I should be interested to hear the Minister of State defend having 280 medically qualified people grubbing around with bits of paper within the Department. That number can be multiplied in the various areas throughout the country.
Does the hon. Gentleman accept that reorganisation increased the trend of people qualified in nursing and speech therapy to seek posts as administrators at area or regional level when in fact they should have been encouraged and paid more to use the skills that they had achieved?
The hon. Gentleman underlines my point. We can all quote examples where it pays better to be in administration than to do clinical nursing. That was the direct result of the Tory Government's reorganisation of the health service. I was about to underline that by saying that recently I read somewhere that it can take as many as 28 committee procedures before a consultant can be appointed. That is an absurdity.
In 1963 the total number of administrators and clerical workers in the health service was between 46,000 and 47,000. In 1973 the number had risen to 73,000 plus. I should like to know by how much that figure increased as a result of the reorganisation of the health service. Of course hospitals need clerical and administrative workers, but, as Francis Cairncross pointed out recently in The Guardian, if we go on as we are, in less than 30 years half the British population will be employed in hospitals. That is the rate at which the numbers are growing.
The signs of sickness in the health service are there for all to see—shortages of doctors and nurses, lengthening waiting lists, and an undeniable slump in the morale of staff at all levels. All this is happening despite the fact that we are spending a larger proportion of our gross national product on the health service than ever before. The cost has soared from £503 million in 1951—just under 4 per cent. of the GNP—to well over £3,000 million in 1975—nearly 5 per cent. of the GNP.
The Opposition appear to be putting all the blame on the Labour Government for the present malaise. The Secretary of State is being used to some degree as a scapegoat—a bête noire—by the doctors, although by any test all the staff within the health service have had a far better deal from the Labour Government than they have had from the Conservatives.
In my notes for this speech I have one note which I struck out after I heard the speech made by the hon. Member for Sutton Coldfield, but I propose to read it into the record. In my view, my right hon. Friend is the wrong person for this particularly sensitive job. She sometimes creates an unfavourable impression, not only among doctors, but among nurses, too, by her strident defence of the Labour Party manifesto—as someone put it to me this afternoon, like a cow that devotedly and calmly delivers its bucket of milk and then proceeds to kick it over. That sums up part of the critical situation in the health service.
I say to my right hon. Friend, to the doctors and everyone else concerned that my right hon. Friend is implementing in her way the policies on which we were elected. The doctors, the Tory Party and everyone in the country must understand that, however imperfect our democratic processes, we have a Labour Government committed to certain policies that we shall not be blackmailed into abandoning; nor shall we backtrack on the commitments we made.
Reference has been made to pay beds, private practice and so on. Even if all those policies were fully implemented, they would do little to eradicate the fundamental malaise of the health service. The hon. Member for St. Marylebone came to the crux and then shrank away from it, as all our political parties shrink away from it. We must all recognise that some of the original principles on which the service was initiated have proved to be false. One of those principles was that once everyone had free access to all forms of health treatment, nobody would be ill, or fewer people would be ill, and therefore total expenditure would automatically fall. The result has been the opposite. Demands for health care have grown relentlessly since the health service was inaugurated.
For instance, there has been an increase in the number of old people and in the number of mentally ill. The number of people aged over 75 will increase by one-third within the next 25 years. Two-thirds of total NHS expenditure goes on hospitals, in large part to treat the old and the mentally ill. Both those categories are increasing remorselessly and the demand for services for them is increasing in proportion. That has been made worse by the inflation that we have suffered every year since 1945, but more particularly in the past two or three years. Inflation has hit hardest the most labour-intensive industries, of which the health service is a prime example.
There is a limit to the amount of automation that can be injected into the health service. It will always be a service in which personal relations and dedication to work will remain of supreme importance. That dedication by doctors, nurses and ancillary staff has been exploited by all of us ever since the health service was inaugurated. I fear that there is little prospect of more financial resources being made available in the present economic crisis, and we shall have to draw still more on the dedication of those people. I beg the junior doctors to understand that it is in their interests no less than in the interests of everyone else that we should get on top of inflation and they, no less than anyone else, will have to play their part.
The one worthwhile contribution that has come out of the debate is that the hon. Member for Sutton Coldfield was forced to concede that he disapproved of the unofficial industrial action by the junior doctors and that he approved of the £6 pay limit. That message should go out from both sides of the House. If it does, the debate will have served a useful purpose.
I come to the 64,000 dollar question. Because resources are limited, they must be used more effectively. No Government have yet had the courage to face that issue fearlessly and I suspect no Government will ever have the courage to do so. That aspect was touched on by my hon. Friend the Member for Lough-borough (Mr. Cronin). There are certain subjects on which one is almost frightened to speak.
Let me give my personal experience. Seven years ago my wife died of cancer. She was in a London hospital. I knew and she knew that she was incurable. My hon. Friend the Member for Lough-borough said that somebody should make a decision whether to divert resources from a person like that to someone whose life could be saved. It is all very well in theory. That is the great dilemma of the politician and the doctor. I know no politician or doctor who would have the courage to say that that decision must be taken and that my wife, or anyone else who is known to be incurable, should be abandoned for the sake of someone whose life can be saved.
The Royal Commission may come forward with a cost-benefit analysis of that kind, but in the ultimate the decision will have to be taken by politicians in the House, and it is not an easy decision to make. We have extremely limited resources and a constantly expanding demand for those resources. It is up to the Government not to lessen their regard for priorities, but to increase their regard for priorities. My right hon. Friend is examining this matter on a regional basis, but she will have to examine it also on a medical basis.
Where there are limited resources and increasing demand it becomes imperative that the possession of wealth shall not gain privilege. The sole criterion of medical provision must be the need for it and not the breadth or the depth of the purse. That is the fundamental philosophical difference between the two sides of the House. That difference has been clearly shown in this and every other NHS debate in which I have taken part in the past 20 years. It is there. I am afraid that it is unbridgeable, but I think that the public at large will respect the Labour rather than the Conservative approach.
In the closing paragraphs of his speech the hon. Member for Fife, Central (Mr. Hamilton) referred to a personal experience in dealing with the agonising medical dilemma of who should be treated and how. The hon. Gentleman raised the philosophical issue and thought that it was up to the House to decide to whom the treatment should be given by the provision of more money for medical services. I believe that such decisions should be left to the medical profession. The members of the profession are closest to the patients and the facilities that are available and they know how they should best be used.
I believe that we are not in disagreement about the need for more facilities for the National Health Service, but are we agreed that there is a totally open-ended commitment? For transplants and other surgery, probably the facilities of the service could be doubled or trebled before every possible facility could be made available to everyone who might be in need.
The hon. Member for Fife, Central removed the basis for serious consideration of his speech when he said "We are a Labour Government. We are here with an overall majority of one." Incidentally, that majority is represented by the right hon. Member for Walsall, North (Mr. Stonehouse), who if and when he resigns will make the position even. The hon. Gentleman continued, "As a result of that majority of one, we are entitled to carry out any policy we like whether or not it is hated by the people". Although I did not take note of his exact words, I had the impression that the hon. Gentleman was suggesting that irrespective of what the doctors, the nurses, the ancillary workers, the administrators or the patients think, the Government can and will carry out their policy. It is because that attitude is used to back up the Secretary of State in her antagonistic attitude that we find the service in its present situation.
I would not have wished to speak in this debate had it not been that on the day it was announced, and by a pure coincidence, details of three serious shortcomings in the hospital service came in my mail. I believe that the service is crumbling and that it is up to us to see what we can do to try to provide a better service for our constituents and for the country as a whole.
I shall not give the Minister of State the exact details of the complaints and the difficulties of the patients who have contacted me, as that would be an embarrassment and a breaking of confidentiality, but the information has already been passed either to the hon. Gentleman's Department or to the area health authority.
The first matter concerns Mount Vernon Hospital, one of the country's leading cancer hospitals, which is just outside my constituency. Over the past month a constituent of mine has twice been admitted for a serious exploratory operation, but on both occasions he has been sent home on the day before the operation was due to take place, with all the personal and family anguish that is involved.
My constituent was sent home because of the position concerning the four operating theatres at Mount Vernon Hospital. One theatre is used only for skin grafting operations because the authorities dare not use it for other operations. The second theatre is out of action because of a drainage fault. The third is out of action because of an electricity fault. The fourth is out of action because of an infestation of a particular kind of ant which cannot be expelled. I note that the hon. Member for Ormskirk (Mr. Kilroy-Silk) sits in his place and titters. Does he think it funny that three out of four operating theatres in a hospital should be out of action? He does not seem to think that that is very important.
Of course it is important. It is extremely serious. What is more serious, however, is that many patients throughout the country are not getting the operations that they were expecting and are having their waiting lists extended because of strikes by doctors. What has the hon. Gentleman to say about condemnation of their actions?
If the hon. Gentleman waits for that part of my speech, he will hear what I have to say about the matter. If he intervenes a little less often, I shall get to that part of my speech more quickly.
The reason for the operating theatres being out of action is that, as the right hon. Lady said, we decided that we would spend the money on people and not on buildings and materials. The example that I have cited shows that the policy is already reaping its results.
On three or four occasions another constituent of mine was given a date for an operation which had to be delayed on each occasion. Thirdly, a self-employed removal contractor—those who believe that private practice should be abolished should listen to this—has developed a hernia and cannot do his job. He has been told that he cannot have a consultation for 18 months and that he will have to wait two years for an operation because his operation is considered to be non-essential. The present situation is that it is impossible for him to carry out his job normally. That has nothing to do with the present situation but it is none the less relevant. Perhaps the Minister of State will ensure that his Department lets me have answers to those questions by letter.
The eye unit at the Central Middlesex Hospital at Neasden is being closed because it is unsafe for inter-ocular eye surgery. It is unsafe because of a shortage of good equipment and a shortage of proper facilities. It is rumoured that the unit will be brought to Northwick Park Hospital. Is that in the mind of the Department? If that is so, what will be displaced?
The Bushey Maternity Hospital is a very under-employed hospital on which, sadly enough, quite a lot of money seems continually to be spent in the provision of minor improvements.
I believe that the hospital difficulties in the neighbourhood of my constituency can be echoed throughout the country. I attribute these difficulties, as did my right hon. Friend the Member for Renfrewshire, East (Miss Harvie Anderson), to a loss of morale and a lack of money.
The hon. Gentleman must have been deafened by the hon. Member sitting behind him, the hon. Member for Meriden (Mr. Tomlinson) who was speaking so loudly. I said that the cause of the trouble flowed from a lack of morale and a lack of money—money to be spent on the proper maintenance of operating theatres and other equipment. There is no doubt that the morale of the National Health Service as a whole would be revolutionised overnight if the Secretary of State were to disappear from office. She has a conflict of disloyalties in her mind—her disloyalty to the sick and her disloyalty to the NHS, both of which are subordinate to her loyalty to her Socialist principles.
My hon. Friend the Member for Harley Street—I should have said the hon. Member for St. Marylebone (Mr. Baker)—remarked on the right hon. Lady's hectoring manner, as we know so well having seen her in Committee. A senior distinguished surgeon told me that what offended him most was her patronising attitude. She knew better than anybody else, knew all the reasons and intellectually thought that she was superior.
I do not think that can be purely chauvinism, because in the NHS there are a large number of female consultants, who are treated as being in a position of equality. The right hon. Lady must be extremely lonely having alienated so many of her associates. She must be about to fall for the greatest indignity in present political life—namely, that of accepting an invitation to lunch with Mr. Cecil King.
I now turn to the position of junior hospital doctors. The White Paper on pay is ambiguous as between its text and the appendix. There must be some way in which staff who work over 100 hours a week, and whose average working week is 86 hours, can be treated separately. Is there any other group of workers who have been asked by the Government to take a real reduction in wages?
I wonder why this kind of action is called industrial action. Surely this is either professional action or collective action. I object to the words "industrial action" being used when doctors take collective action.
I turn to the question of agency nurses and self-employed nurses in general. I gather that agency nurses comprise 20 per cent. of hospital nursing staff. I should think that that is a reasonable figure. I do not understand why the right hon. Lady wishes to reduce the sum payable to them, bearing in mind an answer which I received from her Department about six months ago to the effect that within a matter of a few pence the remuneration of agency nurses was identical with that of NHS-employed nurses. When we bear in mind that there is no holiday pay or redundancy pay, and the fact that such nurses are self-employed, must clothe themselves and all the rest of it, surely different considerations apply. The whole nursing profession resents the fact that there is this battle against agency nurses, because many nurses know that at one time or another they themselves may not wish to be fully employed in the NHS.
Finally, I come to a letter sent to the right hon. Lady by the consultants and others at Northwick Park Hospital containing a petition asking that the phasing out of private practice as discussed in the consultative document should be considered by the Royal Commission. The right hon. Lady told the House that this subject need not be included in the terms of reference because the Select Committee had already reported and, therefore, such a move was unnecessary. The hon. Member for Loughborough (Mr. Cronin) calmly said that it would be an affront to Parliament if it were included because all the evidence had been taken.
What surprises me is that the hon. Gentleman should not consider it an affront to Parliament that those recommendations by the Select Committee have
been ignored by the Government of the day. [HON. MEMBERS: "Read them."] I have them here and I am grateful for the suggestion that I should read them, because I think that they are important. The report says:
…we have carefully weighed all the evidence presented to us and we are of the opinion that private practice operates to the overall benefit of the National Health Service.
I am quoting the conclusions of the Select Committee, of which, I understand, the hon. Lady was a member, but I may be wrong. The report continues:
We are bound to observe that the criticism of the private sector of the National Health Service was not substantial either in volume or depth and certainly not convincing enough to show that National Health patients suffer materially in consequence.
I hope that hon. Members will not keep interrupting the hon. Gentleman. He has already been speaking for 19 minutes, and interventions will only make his speech longer.
I take your reproof, Mr. Deputy Speaker. As a result of interruptions, I have spoken for five minutes longer than I intended. I am coming to my penultimate words.
The existence of private practice may sometimes have a marginal effect on the length of waiting lists, but essentially the problem is due to the overall shortage of qualified staff and facilities. I have quoted the conclusions of the Select Committee which the Government, although they have accepted the evidence as a whole, have refused to accept. I agree with my hon. Friend the Member for St. Marylebone that the time has come for some kind of hotel payment to be made by patients who go to NHS hospitals. I hope that the Royal Commission will consider that suggestion. If, by making these charges to those who can afford them, one could raise, say, £400 million a year, which is a proper estimate, this would be an opportunity for a quick injection of further funds into the National Health Service.
I wish to speak with particular reference to the geriatric services. We have not seen a demand for pay beds in the geriatric services, possibly because they would not provide the most lucrative sector of medicine and also probably because they are not exactly housed in our best hospital buildings.
We have over the past two years done something towards correcting the imbalance between retired members of the community and the vast majority of people in general living standards. We still have to go a considerable way in order to bring the services in the geriatric sector anywhere near the provision that we are making in our district general hospital services.
Progress has been made in geriatrics in recent years, but, despite the dedication and devotion of many of those in nursing and in the medical field in this very difficult sector of medicine, geriatrics remains the Cinderella of the health service. While we may all feel that the service needs a larger share of the nation's resources, even a cursory examination of national expenditure on health would indicate that geriatrics is getting a quite inadequate share of the total health service expenditure.
But attitudes are more important than finance in this field. Geriatrics still does not seem to function in the mainstream of medicine. Although plenty of good work is going on all over the country in geriatric hospitals and units, there is still, in the eyes of the public, much of the old stigma of the workhouse and the old infirmary about anything which is labelled geriatrics. There remains a need to identify the geriatric section of a hospital with the main hospital of which it forms a part.
I was for many years a member of the board of governors of a large teaching hospital which took over a geriatric hospital from the local management com- mittee. As chairman of the geriatric hospital within the group, I was aware that benefits were obtained by the geriatric unit from that association. I was also aware that geriatrics remained very much outside the main life of the hospital. It was necessary to continue to use the old geriatric hospital beds, but this made it all the more necessary to link geriatrics positively with the main teaching hospital.
Agreement was secured some six years ago to provide six geriatric assessment beds in the main teaching hospital. Those beds would have linked the geriatric unit positively with the teaching hospital and would have done much to boost morale. They have still not been provided today. Those with what they consider to be more important specialities within the hospital still seek to confine geriatrics within the walls of the old infirmary.
We must overcome these objections. Geriatrics must be developed as a most important section of medicine in its own right, and the Royal Commission could usefully look at this matter. It could also look at the provision of care for the elderly. Such an inquiry would clearly indicate that we are not making the most sector.
The geriatric hospital must increasingly become the unit to which elderly people are brought for short-term care, enabling them to return invigorated to the community. This probably means that they should enter hospital very much earlier than they do today. The geriatric hospital should be recognised more and more as the place to which old folk go not for long-term care but to be made fit enough to return to their own homes. In my experience, the vast majority of them would prefer to spend their lives in their own homes.
We cannot continue to use an ever-increasing number of long-term beds in hospitals and welfare homes merely to provide long-term stay facilities. The alternative is to provide early positive treatment in our geriatric units. The community should be able to receive and to keep those who are not in need of expensive long-term residential care. This can be achieved only by an extension of domiciliary care and day hospital and day care facilities, with a real and meaningful link between the geriatrician, the general practitioner and the Department of Health and Social Security.
I know that in making a plea for improved geriatric services I am echoing one that has been made many times before, but this is a plea that need not be made in vain, because a far better adaptation of our resources in the geriatric field, with the provision of good domiciliary care and preventive medicine, could do very much to prevent hospitalisation and to prevent the much earlier need for welfare beds.
I have been attached to what was a pioneer venture, when it started 17 years ago, in demonstrating that the infirm elderly could benefit from daycare facilities. During that period, many infirm elderly who could not have reached the normal old folk's club were brought to the centre once a week. For many it was the only occasion when they got away from their own four walls and the loneliness and solitariness involved. I am certain that over the 17 years that sort of action in itself prevented many of those people having to spend their latter years in hospital or in residential welfare accommodation.
If the Royal Commission could examine in depth the best utilisation of our geriatric services, I am sure that much could be done to improve the lot of many of our old folk and to provide a better service to them without in any way adding to the cost of our rising health bill. It is a sector where I am certain, as I said earlier, that by the intelligent use of preventive medicine and by providing the necessary domiciliary and daycare facilities we can do much to prolong the life of old folk within their own homes and at the same time enable valuable National Health Service facilities in the long term to be devoted to other sectors of medicine.
I am grateful to the hon. Member for Peckham (Mr. Lamborn) for speaking for only 10 minutes. I must appeal to hon. Members. I understand that at least three speeches from back benchers each lasted about 20 minutes during the time that I was out of the Chamber. This is most unfair.
May I begin by saying how much I agree with the wise observations of the hon. Member for Peckham (Mr. Lamborn), who obviously speaks with a great deal of experience in geriatric care.
May I also say at the outset, in answer to some of the strictures which we have heard from Government supporters, that as a Conservative I have been from the very beginning a firm supporter of the concept of a National Health Service providing comprehensive care for all. Indeed, I confess that the happiest years that I have spent in Parliament were when I served as Parliamentary Secretary to the Ministry of Health in the early 1960s under an outstanding Minister, the right hon. Member for Down, South (Mr. Powell). It was an exciting time, partly because of the right hon. Gentleman's remarkable administrative abilities but also because we were hopefully embarking upon a large programme of expansion in the National Health Service. Yet even then it was clear that there would always have to be tight administrative control, imaginative thinking about finance and a careful watching of priorities if the National Health Service was not to run into difficulties.
The reasons were, first, that we had to recognise that we lived in an age of rising expectations, that the demand for better health care would grow and that a shift to preventive medicine would probably lead, as experience in America has since shown, not to a lesser but to a greater demand for health care since it would reveal hitherto undetected conditions which required treatment.
The second reason was that we could expect, inevitably, not only improvements in existing treatments but the introduction of new techniques which would require ever more expensive equipment.
The third reason was that, although much disease would be eliminated, or at least brought under control, and periods of illness for younger people would be shortened, older people, as the hon. Member for Fife, Central (Mr. Hamilton) reminded us, would live longer, with the result that the total volume of illness in the community would probably grow rather than diminish.
I thought that the Secretary of State made a very valid point when she said that the troubles of the National Health Service did not begin with her. That is quite right, partly for the reasons that I have just given and partly because the reorganisation of the service was bound to cause initial difficulty. Nevertheless it is true to say that until about a year ago the NHS seemed to be coping reasonably well. It is true that it had its problems, but it had been getting an increasing share of national resources. Indeed, over the last decade its share of the gross national product rose from 3·8 per cent. to 5·4 per cent. What is more, it had been getting more staff.
I concede that it would be a great mistake, therefore, to believe that the National Health Service has been suddenly plunged into a crisis because of a dispute between junior hospital doctors and the Secretary of State or even because of the political row over pay beds. These mask a deeper crisis over the whole structure of the service and the way in which it is being run and financed.
In any event, the row over the junior hospital doctors should never have been allowed to develop since it is contrary to reason, common sense and human nature to expect some exceptionally hard-working doctors to take a cut in their remuneration at a time when everyone else is allowed a modest increase.
As for the pay beds dispute, with respect to the right hon. Lady, this is not merely irrelevant to what needs to be done to rescue the National Health Service but in the long run it will be highly damaging to standards of health care generally.
It is not just the doctors who object. The leaders of the nursing and midwifery professions have told the Secretary of State that her plans for curbing private medicine would be disastrous if pursued in the present climate of breakdown and distrust. Speaking for myself, I would not go to the stake for pay beds. To me, the far more crucial question is whether it is in the interests of the future of medicine and the health care of our people to restrict the private sector as the right hon. Lady proposes. The pay beds issue is not all that important if private medicine in this country is to be cribbed and confined, because that will mean the mass flight of good doctors and consultants.
No. I want to try to keep to the injunction which Mr. Speaker laid upon us. I have quite a lot to say, and I wish to complete my remarks as quickly as possible.
This is not a sudden crisis but one which the Government have failed to see coming for far too long.
Let me speak about the area which I know. It is better for hon. Members to speak about their own areas because here they are in receipt of the views of patients, doctors and professional organisations all the time. Up to about a year ago, complaints about the National Health Service in Essex were minimal. Standards in our local hospitals were high, as the hon. Member for Basildon (Mr. Moonman) will confirm. Now, however, not a week passes without local doctors or their patients appealing to me to draw the attention of the Government to the deterioration of our local services.
Over the last year we have had wards closed for lack of nurses to staff them, and the community health council is now warning that more wards are likely to close. Operating theatres are shut because of the lack of supporting staff. The ambulance service is not operating properly because of a dispute over the London weighting allowance, so that men who do not get the allowance are refusing to take patients to hospitals in areas where their colleagues receive it. Because South-East Essex and Southend are excluded from London weighting, our hospitals are losing technicians, to the detriment of patients.
The Government have known about this for months. In July the situation had become so serious that the Essex Medical Committee felt obliged to draw the attention of the North-East Thames Regional Health Authority to the growing waiting lists of so-called non-urgent cases. I say "so-called" because with some conditions failure to treat in good time will cause more serious problems in future.
In some Essex health districts the waiting time for non-urgent appointments has become as long as 32 weeks for general surgery, 37 weeks for orthopaedics and 31 weeks for gynaecology. In one district general hospital patients have to wait as long as 12 or 13 weeks for an urgent outpatient appointment, and routine new patient appointments are not available at
all in the general surgery, ENT and orthopaedic departments. The Essex doctors claimed that
the backlog is so vast that many of the outstanding cases will never be seen.
What has happened to the National Health Service when doctors know that vast numbers of their patients on waiting lists for treatment will never be seen? That is a matter which should concern the Secretary of State, and it is a charge which should be answered today.
As a result an increasing burden is being put on general practitioners, who are forced to act as specialists in order to determine which of their patients merit urgent or non-urgent appointments, although they know in advance the difficulty in securing even urgent appointments. The Minister of State should know this to be the case since he is a doctor himself.
Not surprisingly, the Essex doctors have concluded that the situation amounts to a breakdown in the National Health Service. [Interruption.] I am speaking purely about my own area; other hon. Members can speak for theirs. It is even more than that: it is an enforced lowering of the standards of health care which made the National Health Service unique in former years. The Secretary of State said—I was glad to hear her say it—that the Government have decided to concentrate on people rather than buildings. This debate should do one thing: remind the Government that the National Health Service is not about doctors or nurses but about sick people.
Let me illustrate what the statistics mean for ordinary human beings. The Minister of State knows of this case because I have put it to him and have not yet had an answer. It is the case of a 10-year-old boy, who might be anyone's son, who has needed restorative ear surgery on his right ear for a number of years. The child appears as a statistic on the non-urgent list and his mother has been told that he will not get an operation for two years. Yet I am advised that the child's general practitioner has treated him periodically for pain and discomfort. One can imagine what the effect of a delay of two years will be on this child's schooling and general health.
I have checked the facts and found that failure to tackle the condition is not the fault of the hospital concerned. The ENT surgeon is overworked. His operating time is limited because, despite continued requests for an anaesthetist, the hospital still lacks one. He is the only ENT surgeon available for restorative surgery and of the two operating theatres allotted to him only one has ever been available because of shortage of staff.
I could give a dozen more illustrations, some of them far worse and more tragic in their implications, but I shall not presume on the time of the House since every hon. Member knows in his heart that such cases exist in his own constituency and is equally worried about them.
What should be done? I hope that the utmost attention will be paid to the remarks of my hon. Friend the Member for St. Marylebone (Mr. Baker). Are the difficulties due merely to lack of money? If so, why in Heaven's name precipitate a crisis over pay beds, which bring in between £25 million and £30 million? There are many ways of finding extra money. We could run a national lottery. We could charge for meals in hospitals or for visits to the doctor or by the doctor to the patient's home, as is done in many civilised nations.
If it be objected, as I would expect it to be, that this must be to tax ill health, we could introduce a realistic health insurance scheme so that the nation pays a fair price for health care. What is absolutely wrong, misguided, stupid and in the long run perhaps even criminal is for the Government to say in advance that they will block any extension of private medicine, especially as that might ensure bringing back home many more of the doctors and nurses who have emigrated. At least there would be a chance of remobilising scarce resources. It is right, of course, for the Royal Commission to examine all these and other ideas for attracting fresh resources into the National Health Service and to do so with the closest scrutiny. But there are three decisions which cannot wait upon a Royal Commission moving with customary and majestic grandeur slowly through the years until it finally reports. The situation will not wait upon the report of a Royal Commission. I remember the present Prime Minister, as Leader of the Opposition years ago, pouring scorn on Royal Commissions because they were a means of pushing something out of the way, allowing it to be forgotten.
Three things require to be done now. First, the pay bed proposals must be dropped. Certainly these should not be implemented until after the Royal Commission has reported. Second, the Royal Commission's terms of reference should be widened so that it can offer a truly independent judgment about all the matters which are relevant to the operation of an efficient service. Third, it should be asked to make interim recommendations on any matter which it considers merits priority.
I end as I began. I believe in the concept of a National Health Service giving comprehensive care to all. I react with anger to the spectacle of a splendid organisation dedicated to helping the sick and the suffering being driven into the ground by stupidity and political spite—and so will the nation, unless the Government act.
I shall begin by paying a tribute to the National Health Service. I am glad that no one in this country today need fear sickness or injury as people used to do. I am therefore sorry that the debate is taking place against a background of unrest in the NHS.
I could not agree more with the hon. Member for Essex, South-East (Sir G. Braine) that the health service belongs to the people, not to the doctors or the nurses, not even to the porters and not to the politicians. It belongs to the people because it is a national service. It is time we all took that to heart.
I do not believe that the NHS is crumbling. Just the other day I had the pleasure of meeting the people involved in the West Galloway accident service in my constituency, where I could see how the local doctors, fire officers and police and the local community as a whole were engaged in this most useful service for the benefit of those who suffer accidents on the congested A75.
There are several questions which the Secretary of State and the Royal Commission should ask themselves. A principal one is why the extreme discontent concentrated in one part of the United Kingdom rather than another? Why is it in England rather than in Scotland? I dare say that English Members would wish to inquire why it happens in one area of England rather than another.
The reasons are not far to seek. In Scotland, pay beds are far fewer and their number is decreasing. Private practice is much less common; we have no Harley Street. Agency nurses are a minor issue and the junior hospital doctors are less militant, probably because they find vocational satisfaction in their conditions in Scotland. In Scotland, therefore, it would be possible to allow these minor irritants to fade away with a little gentle help from the Secretary of State.
It follows that morale in the Scottish Health Service is higher than it is in England. The problems which are provoking unrest are generated outside Scotland, although occasionally the unrest spills over into Scotland.
If the Secretary of State and the Royal Commission seek to understand the deeper reasons for these differences, I would direct their attention to the general ethos of Scottish life and thought. I believe that the Scottish people have a more egalitarian turn of mind. After all, it is we who say "We're a' Jock Tamson's bairns." I have never heard that translated as "We are all John Thompson's children," although there was a day when the shires of England resounded to the cry
When Adam delved and Eve span,
Who was then the gentleman?".
Because of this, we have a greater sense of social cohesion and the NHS personnel have a greater personal commitment to the common folk of Scotland whom they serve so ably. This is reinforced by the fact that our great teaching hospitals have always been general hospitals serving a particular area, so that all our doctors have had their feet firmly on the ground during training.
Because of all these differences, there should have been two separate Royal Commissions. It is still not too late for the two Secretaries of State to change their minds on this. Alternatively, it would be possible to ask the one Commission to provide two reports. This could be of great importance, because as the Scottish Assembly comes closer it becomes clear that the Scottish Health Service will be the responsibility of the Scottish Assembly and therefore the Royal Commission, moving in the majestic way that was propounded, may end up by reporting to this House and also to the Scottish Assembly.
There are one or two aspects with which I should like the Royal Commission to deal. I should want it to inquire into the rôle of social conditions as a factor of bad health. There is a link between deprivation and ill health. We know all about that in West Central Scotland, so there is an area into which the Royal Commission might well inquire It seems to me that a many-pronged attack on social deprivation, through an improvement in general housing and amenities, through the creation of more jobs—by means of the Scottish Development Agency, for instance—and through a broad educational programme would have an effect on our general standard of health.
After all, certain aspects of health care are social as much as medical problems. I think particularly of alcoholism. In Scotland we have a need for specialised units that would provide counselling services so that the descent of the alcoholic could be stopped at a much earlier stage. It is one thing to provide drying-out facilities. It would be far better to interrupt the course of the disease at a much earlier stage. This could be done in such a way that less money would be spent on that than has to be spent on providing beds in mental hospitals in order to deal with the alcoholic.
Some people laughed at the idea that a special portion of the tax on alcohol should be devoted to research into the problem and into action that would help to improve matters, but I think that it is a highly commendable idea and one that should be considered carefully.
I suggest that the Royal Commission should inquire into the link between the health service and the social services, because there is an important overlap. Reference was made earlier to geriatric care. I do not want to labour the matter, but I think that the provision of suitable accommodation outside hospitals would help not only geriatric patients but also many mentally handicapped and mentally ill persons.
I have said that we are looking forward to the coming of the Scottish Assembly. [Interruption.] This is important, because I trust that the Scottish Health Service will come under the Scottish Assembly. It is important to us in Scotland that that should be so. There are exciting prospects ahead for the National Health Service, and I am sure that the personnel of the health service in Scotland will rise to the challenge that these circumstances will bring and will help to make better what is even now a very good service indeed.
I have great sympathy with what the Secretary of State is trying to achieve, but as to the manner in which she has sought to achieve it I believe that her lack of tact and her pugnacity have done great damage. A Minister with a less pugnacious manner would have achieved by tact and persuasion exactly what the right hon. Lady has tried to achieve in her way.
The medical profession last year asked for £500 million for the National Health Service. It so happens that the Government have spent £750 million on the service, or £250 million more than was asked for.
My right hon. Friend the Secretary of State will not be surprised to hear me say that that extra is not enough, but the hon. Member for Canterbury (Mr. Crouch) was a member of the Government who, at a time of inflation, cut by £500 million the money provided to the health service. That is a matter of fact, and I make no apology for this attack.
I shall make my speech in my own way. I repeat what I said a few moments ago: the medical profession asked for £500 million, and the Government provided £750 million. The hon. Member for Canterbury complained that that was to cope with inflation, but when his Government were in office he voted, at a time of inflation, for a cut of £500 million.
When we came to office we found that those who could make the greatest contribution to rehabilitation—namely, the nurses and the paramedical professions—were receiving abysmally low salaries which had been held down by the Conservative Government. The pay for these groups of people has been increased by 80 per cent. That is a lot, but it is not enough. Conservative Members cannot belabour me for giving these figures.
If one looks at the 1974 report on the National Health Service one finds plenty of reasons for being critical, and that is what I intend to be tonight. I believe that it is possible for certain facilities and resources to be reallocated in the health service to the benefit of a substantial number of people, but this will require a lot of courage on the part of hon. Members on both sides of the House. We know that we can keep people out of hospital, and that is our job, but how can we do it? It can be done by providing good domiciliary services and by allowing people to live in their own homes with adequate support.
There are three or four points in the annual report that I propose to consider. The first of these involves health centres. If one considers the way in which resources are spent in the health service, one sees that far too high a proportion is spent in hospitals. If help was given to outside services, it would be possible to keep many people out of hospital.
The report shows that there has been some improvement with regard to health centres, but the rate of development has not been fast enough. Nevertheless, in some ways the health service is moving in the right direction. Any doctor who mans a health centre, will realise that these centres do not have the necessary supporting facilities. This is the result of the low rate of pay for the paramedical professions over many years. Their pay has been increased by 80 per cent. It is not enough. We shall end up with a better service, although perhaps a slightly less costly service, if we apply resources in this way.
Great pride is taken in the work of the Family Fund to which reference has been made. Hon. Members will remember that the Family Fund was set up by the right hon. Member for Leeds, North-East (Sir K. Joseph) at a time when there were difficulties over the thalidomide fund. We were told that we were spending time on the problems of thalidomide children and not on those of children who were born congenitally disabled, the reason for which we do not know.
At that time the Secretary of State awarded £3 million. Since then there has been a further £3 million and recently another £2 million. We now find that the working of the Family Fund is very much bedevilled by the reorganisations in local government and in the health service, which have caused not harmony but often conflict. I regret that, because of local government shortage of money and limitations placed on the health service, the Family Fund is being inundated with requests for equipment which should have come either from the health service or local government. All we are getting at present is quarrels. I hope that my right hon. Friend the Secretary of State will intervene over the Family Fund and help to resolve some of the grave problems that it faces.
The hon. Member for Essex, South-East (Sir B. Braine) mentioned the regrettable delays for certain people, particularly the young, in getting treatment. It is rather unfortunate that there are four or five children throughout the country—and this is not a constituency matter—who are being denied the use of equipment because of the conflict between local government and the health service, with the poor old Family Fund in the middle.
There is one matter that causes me a great deal of anxiety. The 1974 annual report of the Department of Health and Social Security recognises the problem of housing people after they have left hospital. It also recognises a consultant's concern about whether to release a patient because of the home circumstances into which he or she has to go. We are all aware of this from our constituency mail. The Department is also aware of it.
Paragraph 6.71 of the report says:
On the initiative of the two Departments"—
the Department of Health and Social Security and the Department of the Environment—
a number of local authorities are planning special housing developments to see whether very severely disabled people can lead an independent life with the necessary community support outside hospitals or residential homes. It will be some years before these experimental schemes can be evaluated, but the initial response from local authorities has been very encouraging.
Enough evidence is already in existence to show that good housing facilities for seriously handicapped people who come out of hospital are a means of saving money.
In this country we have units of excellence, especially in the sphere of rehabilitation. It would be unfair to name them, but it is appropriate on this occasion to name two—the Mary Marlborough Lodge and, for children, Chailey Heritage. I should like existing knowledge to be applied with far more sense of priority so that many of those who are lingering in hospitals, or sometimes in grubby accommodation, can return to the community, because it is economically possible, technically feasible and morally sound.
If the Royal Commission could look at these aspects I am certain that many of those suffering would be extremely grateful.
Of course, not all the faults of the National Health Service can be laid at the door of the Secretary of State but let it be said quite clearly that no one else has ever succeeded as she has done in uniting the whole of the medical profession to a white-hot boiling point of anger. If she is genuinely interested in the National Health Service, the best way she could help it is to resign tomorrow. The way in which repeatedly this afternoon she accused those in the NHS of contemplating industrial action because of their politics will not be forgotten easily outside this House. It is not true to say that either the doctors or the nurses are interested in politics. They are interested in the National Health Service and want the service to function in the best possible way for the patients. The Secretary of State offends more as Fagin than as Scrooge.
We understand about the shortage of money. However, what cannot be forgiven is that she is dipping her hands into pockets and pulling money out. It is no wonder that the junior hospital doctors are behaving like Oliver Twist. How can it be fair or reasonable to expect one-third of their number to take a salary cut at this time? I should not like to be the wife of a junior hospital doctor, because, due to the long hours he works, he would be almost a stranger to me. On top of that, to be told that at a time of raging inflation he must take a cut in his salary is grossly unfair.
It is also unfair that although the hours of the working week have been set at 40, overtime does not start until 44 hours. Is it to be supposed that the junior hospital doctors are expected to donate to the National Health Service an extra four hours after their working week is finished and before overtime starts?
There is also the matter of the "no detriment" clause, which is a complete contradiction in terms. How on earth can we have a "no detriment" clause when, under the new scheme, a new appointee will receive less than he would have done had there been no new scheme?
There is the question of being on call and working nights. Many junior hospital doctors are astounded to learn that the new agreement means not two nights off in three but that they are contractually obliged to work alternate nights. If they are on call, they will be paid what I would describe as an insulting amount—28p an hour. I could not even get a baby sitter for 28p an hour, never mind a highly qualified doctor.
When the doctors are working in the hospital their overtime pay is derisory. For example, there is the case of a 35-year-old neuro-surgeon in Birmingham who has been qualified for 13 years and has eight years of specialisation behind him. If he is called upon to perform an urgent brain operation at night, he is paid at best £1 an hour for that operation. At one time doctors would carry out operations for a small fee or for no fee at all.
This is where the Government and the Labour Party ought to learn a little lesson about the dangers of imposing egalitarian ism on this country. I want there to be pedestals on to which and towards which people can climb, because if they are allowed so to do they behave in a certain manner. The trouble is that if one goes hell-bent after egalitarianism to such an extent that the doctors are down to the level of the dockers, the doctors will behave like dockers, and when they have genuine grievances they will take industrial action. The Government cannot be surprised that that is so.
The junior hospital doctors look at their future and see the grievances of the consultants, the senior men into whose shoes they will step at some time. They see the grievances which those men are experiencing. That is one of the reasons why junior hospital doctors are not happy today. The consultants' contract on incremental pay has been broken. They are constantly harassed by a load of administration, too much of which is very poor administration indeed.
I was sorry to hear from the Secretary of State today that she does not envisage changing any of the reorganisation plans. I hope that she will think again about that, because many consultants find today that it is unbelievably difficult to get even the most simple pieces of equipment because the administration is so difficult. This is one of the things that was done by the Opposition when we were in Government, and it ought not to have been done in the way that it was. Many Opposition Members are concerned about the whole question of what has happened since reorganisation.
Again, the Salmon Report has taken too many first-class nurses off the wards and put them into administration. This, too, has added to the difficulty.
The morale of the service today is either destroyed completely or is heading straight for destruction. This is much more serious than merely a question of pay. It would not be settled if all the junior hospital doctors, all the consultants and all the nurses suddenly, tomorrow, got all the money for which they were asking, because what concerns them most is the disastrously falling standards of care for the patient.
As regards cuts in nursing staff, one health district is reported to have axed 50 of its staff, and 43 of those were nurses and only two were office staff. If anyone had to be sacked, I should have liked to see only two nurses sacked and 43 office staff sacked. That health district got it completely the wrong way around.
I am sorry that the Secretary of State was caught a little on the hop today and was not able to say how many wards have been closed, but it is true that many wards, and even maternity hospitals, are closing. All of us know that this is true from knowledge of our constituencies.
Earlier this year I raised in the House the question of the accident hospital and the eye hospital in Birmingham and the radiotherapy unit at the Queen Elizabeth Hospital. I begged then that standards should be improved for the patients. In fact, very little has been done, if anything. A corridor has been sanctioned and may be built, but there are 10 radiotherapy consultant vacancies in the Queen Elizabeth Hospital at present and there is no one to fill them. In the children's hospital in Birmingham, which serves a population of 5½ million, there is no neurologist, no chest specialist and no skin specialist, and there are no plans to get any of them either.
Last Friday a young doctor came to see me. I assure the House that he was not motivated by any considerations of politics, but he worked at the children's hospital and he was appalled at the falling standards of care for children there.
I am worried, too, about the question of anaesthetists and about operating theatres. I should like to know for how many hours certain operating theatres are supposed to be open and for how many hours they are actually open. The anaesthetist is a vital part of the operating team. While one can have simple operations, one cannot have a simple anaesthetist. He must be a highly qualified man. Some 30 per cent. of anaesthetists' posts in senior registrar grades are vacant. That means that the supply of consultant anaesthetists for the future is likely to be very severely below the required strength.
The worry of this matter is that, faced as we are with these shortages, there are apparently pressures being applied by the Department of Health and Social Security to lower the standards of the examination. I hope that the Secretary of State will note that if we accept that falling standards will henceforward be the way we proceed, many more people will die of anaesthesia in operations. A locum anaesthetist was a relatively rare bird in days gone by but he is extremely common today. A large number of these locums are not properly qualified.
These are the reasons why morale is low and why so many people in the medical profession today are voting with their feet. It is all very well to ask them to give one year for Britain. Many of them think that they have already given one year or two or three years for Britain. The junior hospital doctors would be a great deal happier in accepting the pay cuts which they have to take now if there was a bright day ahead, if somehow a little way ahead they could see that standards would stop falling and start rising. But there is no bright day, and that is one of the things which is so troubling the junior hospital doctors.
I come finally to the question of pay beds. The Secretary of State has issued a consultative document. I earnestly hope that that is what it is meant to be, because from the way that she and her hon. Friends talk it seems that there is no question of any consultation about the matter at all and that it is all settled. However, let us once and for all get rid of the lie that somehow, because of pay beds, desperately sick or dying people have been prevented from entering hospitals because rich people have taken the vacant beds. That is not true. There has never been a case of a desperately sick person needing hospital care and failing to get it because someone paid, went into hospital ahead of him and took the bed.
If the Secretary of State takes note of the views expressed about the consultative document, she may even change her mind. Certainly, if she is interested in the future of the National Health Service, she must do so. She now knows the nurses' views on the consultative document, and the hospital administrators' views. Those views may not be the same as the views of the Minister of State, but at least he ought to listen to them. From Birmingham the
voice comes loud and clear—and not on a political basis. I have in my hand communications from three sources in Birmingham. I shall not quote them all for lack of time. However, one doctor says:
I think it is fair to say that all of us, whether part-time, whole-time, NHS or University Clinical Staffs feel that the legislation proposed must somehow be prevented from reaching the statute book.
That is from the Queen Elizabeth Hospital, which is an important part of the University of Birmingham and a teaching hospital. The local medical committee says the same thing.
I beg the Secretary of State to read the document drawn up by lord Goodman for organisations representing the medical and dental professions and the Independent Hospital Group, which says:
We do not accept as sound or desirable either of the two chief proposals of the document. Indeed, both proposals, if ever put into effect, would be profoundly damaging—to the community, to the NHS, and to the medical and dental professions. Of this there is no shadow of a doubt.
I beg the Secretary of State to let the consultative document be what she says it is.
The House will be familiar with the quotation from Gaius Petronius in the first century A. D. regarding reorganisation in which he said:
We tend to meet every new situation by reorganising, and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.
That is a description of what has happened to the National Health Service. It is not merely the reorganisations that have taken place in recent years, because the reorganisation goes back to the day in 1957 when the then Conservative Government set up the Willink Committee to look at the entrance into the medical profession.
The effect of that was to reduce the number of doctors qualifying in 1964 from 2,100 a year to 1,500. We are still suffering today from the effects of that reorganisation. The Willink Report—it had some sensible comments in it, but not many—said that not all doctors trained in Great Britain remained here in practice and, conversely, that not all doctors practising in Great Britain had been trained here. That is borne out by what is happening today.
The Willink Report said that in 1957 the export of doctors from Great Britain was approximately 200 a year. Earlier on, the hon. Member for Sutton Coldfield (Mr. Fowler) mentioned the scare figure of 300 doctors a year leaving. This was a small increase over the intervening period of nearly 20 years. The hon. Member did not see fit to mention the net figure—that is, after taking into account the number entering Great Britain.
The next reorganisation occurred as a result of the Todd Committee which had to undo the harm done by its predecessor. It tried to build up all over again the number of doctors entering the medical profession. It recommended a substantial expansion in medical training, starting in 1970. Unfortunately, despite what the Secretary of State said today, the number entering the profession is far too few and, what is more, not all those who are medically qualified are yet being properly used in the National Health Service.
For example, few women doctors ever get the opportunity to enter a consultancy in their specialty. As for opportunities that arise for the retraining of married women after they have brought up their families, many hospitals and institutions will not be bothered with making the flexible arrangement necessary to enable women doctors to undertake the training. I am proud to say that in my constituency the Goodmayes Hospital, which deals mostly with psychiatric cases, has been able to adjust its timetable of training so that no fewer than 12 women doctors have gone through a training course there.
Many more women doctors would be available if other hospitals followed the example of the Goodmayes hospital. Talents are being wasted because hospitals that say that they can get staff easily and therefore do not need to adapt their training arrangements are taking the easy way out and the service as a whole is losing.
A recent article in The Times talked about the difficulties that women have in obtaining training in the service and stated:
The medical profession, like many others, tends to view marriage on the part of its women members as evidence of a faulty sense of values.
We appreciate that it is not easy to have "flexi-hours" in medical training, but we cannot afford the luxury of training women doctors not to practise; neither can we afford the luxury of training male doctors to go overseas and give the benefit of training obtained in this country to other countries, unless there are some reciprocal arrangements. Fortunately, there are.
Another aspect of reorganisation in the service was the famous one initiated by the right hon. Member for Leeds, North-East (Sir K. Joseph). As a member of the National Joint Committee of Women's Organisations I was one of those who responded to the Green Paper that the right hon. Gentleman published. We commented that the new authorities to be established would be appointed by and accountable to the Minister, either directly or indirectly, in which case it would be to the next tier of the structure, with little accountability to local people. We commented, too, that there had been a tremendous emphasis on the managerial abilities of appointees to the National Health Service committees, contrary to the accepted principle of appointments in the public sector where management had until then been the function of paid officials, not of the lay appointees.
The change that has taken place in the National Health Service as a result of those proposals has been devastating not only to people in the ancillary services and to the nurses, but even to the consultants, who a few months ago were doing battle with the Secretary of State and complaining bitterly of the time they had to waste in committees and the amount of time they spent on paperwork because of the way that this reorganisation had taken place.
I beg the Secretary of State—this is one of the few matters on which I agree with the hon. Lady the Member for Birmingham, Edgbaston (Mrs. Knight)—to re-examine the question of reorganisation. I know the inconvenience that reorganisation causes. I am not sure whether the quotation that I used at the outset of my speech applies to un-reorganising. The National Health Service is in desperate need of help. Many of the medical services call out for help in ridding them of the burden being placed upon them by the extra administrative work that the service now has to bear.
I ask my right hon. Friend the Secretary of State to do as I suggested and to look again at reorganisation. Its cost to the nation and to the service is far in excess of anything that was promised in the original Green Paper. It has done tremendous harm in every aspect that it has covered and I hope that long before the Royal Commission gets down to its job, my right hon. Friend will take the opportunity of following my suggestion.
We have heard about the views of the doctors and other members of the profession—the nurses and the midwives—on the ending of pay beds. The National Union of Public Employees, which has vast numbers of its members employed in the National Health Service, is endorsing the Secretary of State's aim to end pay beds. The union is begging my right hon. Friend to terminate the phasing out at the earliest possible moment and not to let this matter drag on for an unconscionable time. I hope that all these considerations will be borne in mind, because everybody on this side of the House—and, I discover to my surprise, even a number of hon. Members opposite—wants the National Health Service to survive.
One thing which has impressed me about the debate is the general awareness throughout the House of many of the problems that exist in the National Health Service. There is general disagreement about what has caused the problems, but there is fairly wide agreement about what the problems are.
The problem that strikes me as proably the most long term to the detriment of the people is the length of waiting lists. One cannot but be concerned about the fact that waiting lists seem to be ever lengthening. Certain recent actions will not shorten waiting lists. Throughout the service there is an amazing dependence on people from overseas who have decided to come as doctors to practise in Britain. I have been struck from inquiries I have made and from talking to various people in the service by the tremendous atmosphere of distrust of Government intentions that now prevails about pay beds, the conditions of junior doctors, and the matter of agency nurses.
For years the National Health Service relied on good will. Only too often the words "good will" could be replaced by "exploitation". The nurses exploded that tendency by their militant action some years ago. However, I have learned from my inquiries that the underlying good will that was there is there for the asking still, but the House must make one or two decisions in order to encourage it.
I am particularly pleased that a Royal Commission is to inquire into the service. It is welcomed throughout the House. It is generally agreed that it is time that we had a reassessment of where the service is going. I have said in the House previously that Liberals are in favour of the phasing out of pay beds. I reiterate that my party supports the Government in that respect. However, I beg the Secretary of State to reconsider the decision not to include this question with the remit of the Royal Commission. I cannot see what harm that would do. It is only a question of seven beds per constituency, and I understand that normally as few as three and a half of them are occupied. In any case, it is a matter that affects mainly London and the South-East. The House is far too concerned with problems in London and the South-East.
I refuse to believe that the question of pay beds is the root cause of the problem. Virtually no pay beds exist for many specialities, but the problems of the service exist in those areas just as they do anywhere else. We support the eventual abolition of the system, but I think that I could guide the Liberal Party into saving the Secretary of State's salary if only she would include this matter within the remit of the Royal Commission even if there were a proviso that a report must be made within, say, three months. The question of pay beds affects the finances of the service, and it is foolish to ignore that fact.
Another matter of which a great deal of notice is taken in the House is the junior doctors' dispute. I should like the Royal Commission to do far more than simply consider the peripheral problems. It is time for us to examine our medical priorities. I am not prepared to support a system in which we allocate resources, in a sort of auction, on the basis of those who can find the money to pay for operations, and so on. I accuse the House of not facing squarely the alternative of working out how we should allocate the priorities and the facilities at our disposal. Technology within the service has outstripped the money supply, and it is time that the House recognised that. I hope that the Royal Commission will spend some time on looking into that aspect.
I do not want the House or the Department of Health and Social Security to lay down criteria for the way in which doctors should behave, but I wish that the doctors would come together far more to try to improve their cost-effectiveness. We read of substantial differences in time for after-care, in various parts of the country and this must cost a great deal of money. An hon. Member spoke in detail and with substantial accuracy about different treatments given by different doctors for similar illnesses, which must be very expensive. I am sure that substantial sums of money could be saved in many respects if the doctors came together on them.
The whole subject of cost must be investigated. As I have done the rounds of the medical profession—it does not matter which grade I talk to, whether it be doctors, porters, or nurses—all have said that a great deal of money could be saved. When one pursues the matter and asks where money could be saved other than in administration, they are not as specific in their complaints. There is, however, a fairly united view that the reorganisation instituted by the Conservative Government is one of the causes of the problem. One cannot help but notice—and this is a reflection of the change—that, whereas the service apparently has considerable undermanning problems among nurses and doctors, there is no shortage of people who wish to fill the administrative vacancies. I ask the House not to plunge quickly into another reorganisation but to avoid adding to the present confusion.
The dispute among the junior doctors is very dangerous. At present it is a rather gentlemanly affair, with people sending notes to patients saying that they will not be treated, junior doctors waiting in corridors so that if an emergency arises they will be able to take over, and consultants covering hospital work. But without doubt the backlog is increasing and we are playing a game in which the stakes are very high.
The basic problem of the junior doctors is simply the number of hours worked. We can understand why it is necessary for many doctors to be on stand-by—one never knows what tragedy may hit an area—but I do not understand why it is necessary for doctors to work on average as many hours as they do. Plainly, we are very short of doctors, and that is the basic problem to which the House should pay attention.
I wish that the recent pay negotiations with the doctors had included a "no detriment" clause. I came to the House today with the intention of saying that the Government should immediately embark on discussions with the junior doctors and promise them that when next April came there would be an immediate swop round of the money available so that the junior doctors could be given a guarantee that from that date their position would not be eroded. I gather that that is precisely what the Secretary of State said she would do.
Although the pay policy was introduced at a time of panic and a mistake was made in allowing anomalies such as this to be created, the pay policy must be supported for the preservation of this country's economy and we must ask the doctors to accept the offer until April. I cannot be too critical of the Government on that score.
I have already told the Minister that we shall support the Government if they will include within the remit of the Royal Commission an investigation into the question of pay beds, with a three-month report. One may criticise hon. Members' reasons for voting, but at least that is an honest observation. I like to think that the Liberal Party has been more constructive in this debate than other hon. Members.
The argument about the patriotism of doctors nauseates me. I have heard it said from all quarters that doctors are disloyal if they go abroad. I can think of no way in a free country by which one could stop them from going abroad, but I am not concerned about the emigrating doctors because I have little time for them. However, the cry about a lack of patriotism is a slur on thousands of immigrant doctors in this country who keep the service going but who did exactly the same as our doctors are doing by leaving their own countries. Do hon. Members extend the argument about lack of patriotism to them? It may be argued that the needs of their countries are greater than ours.
I do not believe that the House has done much today about overcoming the basic problem. The debate has been full of anger and party politics, which rarely solve anything. I listened to the speeches of both Front Bench spokesmen. I believe that the temperature of this issue could be lowered if those responsible for appointing the spokesmen on both Front Benches considered those who are second in command and promoted them in the near future.
So far the debate has been eccentric and almost embarrassing. The Opposition wish to extract the maximum publicity from this occasion. They tried to embarrass the Secretary of State. They called for her resignation. A great deal of time has been taken up with constituency cases. The hon. Member for Essex, South-East (Sir B. Braine) raised a series of NHS problems. It would be more appropriate for Members of Parliament to deal with such cases in their advice centres, if they run them that is. Members of the Opposition have simply failed to make an impact on the Minister. In that respect the debate has not been worthy of the occasion.
The problems of the NHS did not suddenly emerge in February 1974. The hon. Member for Truro (Mr. Penhaligon), with good sense, indicated a lack of integrity on the Conservative Benches. I do not wish to engage in a political knock about. It is less than honest for members of the Conservative Party to enjoy themselves at the expense of the Secretary of State, despite what the Press may say tomorrow, as they are not prepared to accept the consequences of the actions of the Tory Government over the previous few years. As there has not been a continuous Labour administration since 1945, it would be far more reasonable and honest if the Opposition shared the responsibilities, the errors of judgment and the failures of planning that have occurred since 1945.
In the mental health service, the Government face a serious problem about the use of resources. In the recently published White Paper on mental health the Minister of State indicated that if we were to spend more on the mental health service, the funds must come from other parts of the NHS. That is an unfair way of stating the matter to parliamentarians, as a decision of the Government is involved. I am not sure that that is the responsibility of Members of Parliament. We are not required to create a ledger account of services for the mentally sick and handicapped, as if there were no way in which we could make use of our resources. In the past year, 24 million working days were lost as a result of mental ill health. It is dubious for Members of Parliament to describe the problems of the NHS only in terms of its finances. We must look at the qualitative aspects of the service and see whether the administration is as effective as it should be.
I wish to refer to the prevention of mental ill health. Many of the factors leading to mental illness are outside the control of society. Those factors cannot be seen in terms of the ledger or financial account mentality. However, we can reduce stress in many areas such as employment, housing and town planning. The health and safety executive is equipped to offer advice to industry and unions on the stress of modern industrial conditions. We may not always be able to alleviate stress, but we do not have to add to it.
Secondly, there is the problem of recognition. The White Paper on Mental Health makes the point that the general practitioners already undertake 90 per cent. of the treatment of diagnosed mental illness. Their rôle is expanding. In my view, general practitioners need training in the recognition of mental illness. Therefore, a training programme is a priority to enable the general practitioners to treat mental illness and to recognise those cases that require specialist psychiatric help.
There is another important group of key workers in the recognition of mental illness, especially in families with problems. I refer to the social workers. They are also responsible for the valuable work of rehabilitation after treatment. This is not a question which is dependent on obtaining more resources. The White Paper, in outlining ways to help the mentally sick, implies that the facilities that already exist in the community can be better utilised. One of the most important developments in the mental health service is after-care and community work. That work does not require new functional buildings. There are many facilities, such as church halls, otherwise used infrequently, that can be used. In this way we can use existing premises without incurring further capital expenditure. We seek to embrace the recommendations of the White Paper on mental illness and to ensure that we use existing services without further capital outlay.
I would like to draw attention to the importance of volunteers to the mental health service. This is not just because the service does not have the resources for all the staff it needs. Volunteers can help. Even if we had every resource we needed, we should still have room for volunteers. There is always room for the acts of individual kindness that are a spontaneous expression of the community's concern and a continuing link with the world outside the hospital. I welcome the new steps being taken to introduce and integrate voluntary work into the official service.
I regret that the White Paper did not address itself to the revision of the Mental Health Act 1959. I hope that this does not indicate a battle or debate between the resources and the operational and managerial side. The question of how much we can spend on the NHS has bedevilled all Governments for a long time. I have no doubt that in terms of the national economy this sector must be given priority. Yet at the same time we must make the most of the NHS facilities we have. I refer not only to the mental health service, but the service in general. We have had additional problems with the reorganisation of the service and the failure to understand the use of complex managerial skills.
We may bring emotion to this discussion. Indeed, more emotion has been expressed in the past few hours than is necessary. The NHS and the public expect the Government to show an intelligent appreciation of the work of the doctors, nurses and other staff of the NHS. The Secretary of State has indicated an approach to their need. I do not believe that she has created the impression that her actions are evil or muddled, as suggested today. The Secretary of State is doing a difficult job, with little support and co-operation. Because of the debate on resources we now have a chance of effectively rationalising the NHS. It is a pity that such a stimulus did not occur five or 10 years ago.
I have an uneasy feeling that the debate has already done more harm than good. What people outside the House will notice is not what has been said by any hon. Member in the last two or three hours, but what the Secretary of State said at the outset of the debate and what the Minister of State may say at the end. In my view the Secretary of State might just as well have asked "Why are we having this debate? What is all the fuss about?" That is exactly what is wrong. Everyone in the medical profession outside the House, many patients, health service administrators and others, have the overwhelming feeling that the Government are living in cloud cuckoo land and trying to wish the problem away. If that is the message of the debate, clearly a good deal more harm will have been done.
I do not wish to spend a great deal of time picking on points made by the Secretary of State or other hon. Members. However, I should like to comment on the farcical figures bandied about concerning the percentage of GNP spent on the National Health Service last year. We heard an emotional statement from the Secretary of State that she had put people before buildings. But when we analyse what she said and the figures, it boils down to the fact that the Government paid for the wage inflation that they had created in the service. No better buildings were provided and no better services. They footed the bill for the wage round let loose by their policies after the election of February 1974. Last year they bailed the service out of the disastrous consequences of their own economic policies. The fact that the proportion of GNP spent on health had to increase is merely an indication that wages grew so much faster in the public sector than elsewhere in the economy. If the Government want to be proud of that, they are welcome.
We have heard the suggestion that the supply of nurses has miraculously eased. That is not the experience of many who have spoken in this debate. But even if it is true, it would be no more than the mirror image of the fact that we have the highest unemployment since the war. No one is sure that if he leaves his job he will get another. If the Secretary of State wants to make a proud claim about that, she is welcome to do so.
I do not particularly want to spend too much time on this theme or to enter into the delicate question of whether the Secretary of State should resign, which has already split the Liberal Party in half. It is clear that whether the Secretary of State stays or goes, whether she is to blame, whether the present Government are to blame, or whether the previous Government are to blame, there is an element of bitterness and mistrust about the Secretary of State's relations with the profession that demands that something is done—whether it be a change in her approach to the people in the health service or some other change—before we make any progress.
Above all, there are two requirements. First, there has to be some recognition of the scale, size, or nature of the problem, which we have not received today. From the letters I have received from consultants it does not appear that they are just money-grubbing people after the best money they can get, and who, if they do not get it, will go to America. The letters that I have received are in terms of despair about whether they can continue to do a decent job within the structure that is provided.
Their morale is constantly attacked. They have fears about the future and the inadequacy of the service. They are concerned about whether they will be able to do a worth while job as consultants if they remain within the British health service in its present state of morale and conduct by the Secretary of State. That aspect has not been recognised by Ministers. They feel, too, that they are being played with by politicians.
As the hon. Member for Basildon (Mr. Moonman) has said, criticisms can be made on both sides of the House about how we deal with the matter politically. The Secretary of State has said that the pay bed issue, which has caused tremendous upheaval and anxiety in the profession, is an explicitly political issue. That is why she does not want the Royal Commission to look at the matter. If that is so—it cannot be denied that it has caused a good deal of the present collapse in morale among doctors in the health service—surely it is merely playing politics not to be prepared to reconsider that decision and not to allow the Royal Commission to take an objective look at all the factors that are now involved in the running of the health service. I strongly support what my hon. Friend the Member for Essex, South-East (Sir B. Braine) said about the Royal Commission and the general widening of its terms of reference.
We must be satisfied that Ministers understand the anxieties and are prepared to be realistic in going some distance to meet the feelings of those who express them. There must be at least a constructive approach to the problem now, and not just a Royal Commission that will report in two years' time. It must be clear that Ministers are genuinely trying to tackle the problem and not just trying to argue that all is for the best in the best of all possible worlds.
I wish to concentrate on what is unashamedly a local point. I do not pretend to know whether the National Health Service is crumbling in a great national way. I do not spend my time travelling around the nation looking at what is happening in the hospitals and health services in the far North, Wales and the Midlands. However, I do know what is happening in my area, about which I have been in correspondence with one or other of the Ministers for a considerable time. The two areas with which I am concerned are the Colchester and Chelmsford districts of the Essex Area Health Authority.
I shall choose my words carefully. I do not want to say that the services in those areas are crumbling, but there is growing anxiety amounting almost to desperation amongst the consultants, doctors, administrators and, indeed, amongst almost anyone one talks to. I recently received a copy of a telegram—it was sent to the Secretary of State—from the Chelmsford District Community Health Council asking for a meeting with her. It says:
Health services in Chelmsford district running on luck and good will. Hospital situation deplorable. Some specialties emergency only basis at best".
Lest it be thought that this is some politically motivated Conservative dominated body, I point out that the local branch of the National Association of Local Government Officers sent at about the same time a resolution in not dissimilar terms. This is a widespread view. It is not politically motivated.
These are the feelings that exist in this part of Essex. They have been building up for years with the diminution of the hospital services in Braintree, which is the town that gives its name to my constituency, and then there has been the closure of the casualty department at Black Notley Hospital which has pushed an even bigger load onto the already inadequate casualty facilities in Colchester and Chelmsford. In recent months I have received an endless flow of letters about these matters. Only last week there were 2,000 signatures demanding the re-opening of the casualty department. Until someone can provide a satisfactory alternative, I am with those people all the way.
I do not believe that it is wrong. I come to a general point about the health service and what I believe Ministers should now be doing. My concern is widely shared. The rundown of existing hospital services in this area has happened over the past few years on the understanding that there would be new district general hospitals for Chelmsford, or for Colchester, or for both. What has happened is that each year we have lost something and each year absolutely nothing has come to provide us with a service in its place.
I have got the point now. My speech will be extended further if the hon. Member persists with his interruption. I make it clear to the hon. Gentleman that my argument leans towards the suggestion that there is a maldistribution of resources within the health service. It is particularly striking in my constituency. Its rectification could be a major contribution by the Minister to increasing confidence in the National Health Service, certainly in my area, and, I suspect, in a number of others.
The point is that these areas have had a rapidly growing population since the war. Where is the money being spent—at least in the North-East Thames area? It is being spent on new hospitals that are being built in the declining population areas of north and east London, and it is still going on.
This year there is talk of building a major hospital in Newham. I have nothing against Newham, but I would guess that a substantial part of Newham's population has already been decanted into my constituency and other parts of Essex. Yet new hospitals are being built in areas of declining population, whereas areas such as mine, with a rapidly expanding and still growing population, are getting nothing at all.
Last year I asked the Minister of State for some statistics on this matter. I shall not weary the House with all of them. However, I observe that the Chelmsford and Colchester districts have had no new hospitals or major improvements since the war. When my hon. and learned Friend the Member for Colchester (Mr. Buck)
raised some of these problems with the Minister a few months ago, he was told:
I must tell the House that we shall have to toe thinking in less ambitious terms as far as new building is concerned."—[Official Report, 1st May 1975; Vol. 891, c. 799.]
As far as my area is concerned, one cannot be less ambitious than nothing.
Following the working party on the distribution of resources between regions, which I understand has reported, I want an acknowledgement by the Minister that there should be a careful look at the allocation of resources between areas within regions. I am sure that the hon. Member for Basildon will agree that areas of expanding population should have proper account taken of their health needs, because the population is young and is continuing to grow.
Confidence in the National Health Service in my area, stripped of all the grander issues that we have been debating, will not recover until something is done about this specific practical aspect of the problem.
While I understand and appreciate, Mr. Deputy Speaker, that you cannot in any way rule on or control the content of speeches by hon. Members, I hope you are taking note that a number of speeches by Opposition Members have been almost entirely confined to constituency points which, I suggest, should be raised with the Minister concerned either by letter or in discussion with him. I deprecate the use of parliamentary time on matters of that kind. I do not say that hon. Members should not be concerned about their constituencies, but this is not the time for these points to be made.
I take the hon. and gallant Gentleman's point, but this is not the time for matters which can be pursued in other ways.
It is interesting to note that the junior hospital doctors' dispute seems to have sparked off this argument. To my mind it is tragic that these unfortunate young men and women should be involved in a situation for which my right hon. Friend is being attacked.
I do not agree with the hon. Member for Braintree (Mr. Newton) that the whole of the medical profession and the public are up in arms about the pay bed issue. That is not the situation. As was pointed out by my hon. Friend the Member for Loughborough (Mr. Cronin), the numbers of consultants who use pay beds are very small. Therefore, this matter does not affect a large proportion of the medical profession and it is not supported by the vast majority of the population.
I do not think that anything is achieved by the panicky accusations and shrill cries about the imminent collapse of the National Health Service. It is easy to be in favour of a greater allocation of finance for the health service, but it is a colossal cheek for the Opposition to criticise my right hon. Friend in terms in which they do.
What did the previous Government do when they were responsible for the health service? They made savage cuts in the capital alloted to it and they introduced a pay policy which led to near revolt on the part of the nurses. There was not a whisper of condemnation from the medical profession at that time. It was left to my right hon. Friend and to this Government to sort out that matter, and not only to restore the position of the nurses but to increase the resources for the health service.
It is all very well for Opposition Members to be mealy-mouthed about the 5·4 per cent. of our gross national product which is being spent on the NHS—a mere £4,500 million this year. I know that some other countries spend more. However, no other democratic country uses 5·4 per cent. of its GNP to implement a National Health Service which is State financed to the extent of 92 per cent. In most countries the State's allocation is much smaller. In some instances it is tiny. For example, in America it is minute. No one can laud the Americans for their health system. I have had many contacts with American doctors and patients who have had the good sense, if visiting this country, to use our health service and to compare it with the health service in America. I know which of the two services they prefer.
It is all very well for Opposition Members to refer to the situation in the United States. It is not the United States Government or legislators who do not want to institute, implement and inaugurate a health service; it is a very tightly-bound medical profession which has a lot of influence and power, which it uses to prevent the implementation of a national health service. One might imagine that it was virtuous to do what they do. I do not think that it is.
One must not be complacent about this matter. There is no doubt that improvements could and should be made in the health service. I should love to see more impetus given to and greater stress put upon the prevention of disease rather than the treatment of illness. I should like to see the development of an occupational health service and the day when every aspect of our health service is completely free at the time of use.
My hon. Friend the Member for Loughborough, in a thoughtful speech, referred to consultants, nurses, junior hospital doctors and GPs. In addition to those very valuable people, there are many ancillary workers whose contribution to the health service is equally valuable and without which it would indeed collapse.
My hon. Friend talked about disgruntlement in the medical profession. There has always been disgruntlement between the medical profession and a Labour Government. Dr. Donald Gould, writing in the New Statesman last week, put it very well:
Doctors are born malcontents.
He is right. They are born malcontents. But he gets to the point very well when he goes on to state that
doctors, as a professional group, are far too isolated from the rest of society and from some of the harsh realities—particularly the economic realities—of daily life.
Do not talk nonsense. They do not work 80 hours a week. They are on call for a proportion of that time—about half. When I was a general practitioner, on that basis I worked 168 hours a week. But I did not work those hours. I was on call. There is a big difference.
There has always been conflict between the medical profession and a Labour Government. The medical profession in England in particular—I say this to the Welsh and Scottish National Parties—thinks that it is a cut above the rest of us. It thinks that it is God's gift to humanity. That is not the situation in Scotland, because, if I may put in a plug of this kind in the same way as did the hon. Member for Galloway (Mr. Thompson), the medical profession there is drawn from a much wider cross-section of the community. Our medical training is different. We take medical training in a university or in college and mix with all the other students. A medical student in England goes to a specific school and mixes with no one except medical students. He gets a completely wrong idea about what is going on in the world.
Let us not make too much of a conflict between the medical profession and the Labour Government. What are the consultants grumbling about? Does the House know the salaries earned by consultants about which they are supposed to be so disgruntled? The salary scale ranges from £7,536 to £10,689. Roughly 40 per cent. get merit awards, which range from over £2,000 a year to over £10,000 a year in addition to their salary. That means that during the course of their careers 50 per cent. of the consultants can be sure of getting a merit award. That is not a terribly bad livelihood.
I do not know whether I am bringing this information to an unsuspecting public, but do they know that the average income for general practitioners is £11,860 gross? Nowadays the life of a general practitioner is much better than I had during my years in general practice. I do not complain about that; good luck to them. Some of my GP friends manage to play golf two or three times a week. I do not object to that, but it is not a cause for discontent.
Junior hospital doctors have always been a badly exploited section of the medical profession. There is no doubt of that. I remember my days as a junior hospital doctor when I worked 104 or 105 hours per week, not a 40-hour doctor, when I earned £104 or £105 per year, not for a 40-hour or 80-hour week but for a 168-hour week. I was on duty all the time. There was no one else there to help me out. I do not claim that it is a good situation; it is very bad, but it is not new, One might think that junior hospital doctors have had no rise, but they had a 30 per cent. increase in April. Even the youngest junior hospital doctor, wet behind the ears from medical college, receives a minimum of £2,869. That is not a tremendous amount of money but it is much more than in my day, even taking into account the devaluation of money. A senior registrar receives £6,279. These are regular grades that the doctors will achieve without promotion. The registrar would be of about seven or eight years' standing as a doctor and about 30 years of age. I am not suggesting that that it is a fortune, but it is not too bad. I did not become a member of the medical profession to grub for money. Our duty is to our patients and not to our pockets.
I had two years in general practice before the establishment of the National Health Service. If I had any doubts about my Socialist convictions, they were completely dispelled by my experiences then. People who needed my help as a doctor were reluctant or unable to seek my assistance because they could not afford to pay. Opposition Members should reflect on that situation before they attack the NHS.
I welcome the Royal Commission. I hope that it will turn its attention to many aspects of the medical scene. I hope that it will take into account the climate and the kind of society in which we live, which often causes the diseases from which we suffer. I hope that the Royal Commission will consider the possibility of an attack on the two main diseases of our day, cancer and heart disease, because I believe that these conditions are part of the climate of the country in the same way as tuberculosis was in the nineteenth century and the plague in the seventeenth century.
In its deliberations, which must be fairly long and of a varied character, the Royal Commission must not tamper with the cardinal principle of our British National Health Service, which is the right of our people to receive medical advice and treatment without payment at the time of use. The financial barrier which was previously imposed must never be allowed to return.
I am grateful for the opportunity to give vent to my anger, which has been simmering for more than six months, about the way in which school nurses and tuberculosis visitors have been treated by the Secretary of State.
The school health service has been looking after our nation's children for 60 years. It came into existence following the War Office findings that 50 per cent. of the men enlisted for the Boer War were physically unfit for military service. The service became a statutory service under the Education Act 1944. Its future is now in doubt.
The TB visitors, who work with TB and cancer patients from chest clinics, are depressed and resentful and are carrying on their work only from a deep sense of duty and loyalty to their patients. Is it possible that the Secretary of State is blissfully unaware of the situation, or is she deliberately trying to destroy morale among school nurses and TB visitors, as she has done in other sectors of the health service? Alternatively, perhaps she is so blinded by dogma that she cannot see further than the foot of the nearest private bed.
The reorganisation of the school health service in 1974 resulted in school nurses being taken over by area health authorities which provide an agency service for the education authority—the choice of expression is not mine. Each school nurse's case load is between 2,000 and 3,000 children. She usually works in three or four schools until the birth of a vast comprehensive school when she may work in one.
The typical school nurse's day starts at 8.30 a.m. at the family health clinic. In urban areas she is at school by 9 o'clock. She sees all children once a year while they are at nursery school, at five years old when they enter the infants' school and at nine years old before going to junior school. The school nurse is a practitioner and a professional in her own right. She plays the part of detective in spotting defects in children's health and recommends appropriate corrective action. As well as visiting schools, she spends half her time in home visits and is expected to collect reliable information for Government research purposes and to participate in health education programmes at school. As will be seen, the future health of our nation's children is in her hands.
On the other hand, the TB visitors are chest clinic and visiting sisters. Each serves a population of about 250,000. TB visitors were formerly nominated from ward sisters. Their main work is domiciliary visits to patients who have chest conditions—chronic bronchitis, cardiac complaints, and tuberculosis. In England and Wales there are, yearly, new notifications of 11,000 tuberculosis sufferers. The 1973 figures showed that tuberculosis was still causing more deaths each year than any other notifiable infectious disease.
In the large cities the qualified and experienced TB visitors are still much needed. Members would have thought that the Secretary of State would recognise the crucial work of the school nurses and TB nurses and would have championed their cause against any attempt to discriminate against them, but she has not done so. Perhaps it is because the right hon. Lady is influenced only by the large battalions. As there are only 4,000 school nurses and 200 TB nurses, she is none too concerned.
There are now two classes of school nurses. Mrs. Graham, of Knowsley, is one kind. She is a State Registered Nurse with three years' training, a registered fever nurse, one years' training, and a State Certified Midwife, one year's training. She has a certificate for tropical diseases and another from the Royal Institute of Public Health and Hygiene. But Mrs. Graham does not have a health visitor's certificate. To gain such a certificate there is an eight months' course, a course, which has been in existence for only the past 13 years. Mrs. Graham has been in the service for 34 years.
Then there is Mrs. Sanson, from Cumbria. She is a State Registered Nurse and a State Certified Midwife with 35 years' experience. She was a maternity ward sister for many years and then a district nurse-midwife. In 1967 she accepted the post of school nurse full-time because of a shortage of health visitors. She does not have a health visitor's certificate.
Mrs. Tuttle, of London, does not have a health visitor's certificate either. She was a ward sister and a State Registered Nurse. She is a registered sick children's nurse with 20 years' experience. These women have experience and qualifications but not a health visitor's certificate. Instead of having the status and pay of a ward sister (1), they are paid on the basic grade of staff nurse. That is the rate for new entrants to nursing.
I shall make it plain that the work of the school nurse, whether she is certificated or not, is identical to that of a hospital nurse. She has identical responsibilities and the task required of her is exactly the same. However, there is discrimination. There are two classes of nurses within the same service. There is the one with a health visitor certificate and the one without, such as Mrs. Graham, who has 34 years' experience and a host of other qualifications. She is on the same grade as a young nurse of 22 or 23 who comes straight from the eight months' course.
The Whitley Council, which deals with the terms and conditions of nurses' pay, recognised years ago that a school nurse fulfilled a unique and vital rôle even without the health visitor certificate and that that should be reflected in her status and pay. For this reason she was paid on an interim scale above staff nurse but below ward sister. When the staff nurses' starting pay was £1,191, rising to £1,454 the school nurse and TB visitor without a certificate started at £1,299, rising to £1,728. Halsbury, in an attempt to simplify the pay structures, exacerbated the odious class differential by downgrading the pay and conditions of school nurses without certificates to a common grade, title and common pay scale, as Halsbury called it. At the same time the school nurses with certificates had their pay and status upgraded. It is the Minister's indifference to this situation that has caused a crisis of confidence.
In 1954 the salary differential between the TB visitor with or without the certificate was £20. In 1960 the differential was £110. In 1967 the differential was £150 and in 1970 it was £180. Following Halsbury, the differential was increased to £1,248 at the top end of the scale. As nearly all TB visitors are at the top end of the scale, it means that they are all earning £1,248 a year less because they do not have the certificate. Whereas in 1954 the differential represented 5 per cent., in 1975 it represents no less than 50 per cent.
Halsbury established the following arrangements for nurses. There is a ward sister (1), including school nurses with certificates, and there is the ward sister (2), which includes community nurses and district midwives. Then there are staff nurses, which include school nurses and TB nurses without certificates. What Halsbury has done is to ensnare many senior ward sisters who, to gain wider experience, entered the school nursing profession some years ago and now find themselves at the bottom of the grade with no hope of getting back to their rightful position.
Since Halsbury was implemented last year, the Whitley Council has been asked to examine the matter, but nothing has happened. I have appealed to the Secretary of State and to her Ministers. I have tabled Question and Early-Day Motions. The right hon. Lady's reply can best be summed up by reading an extract from her letter of 7th August to the staff side of the Whitley Council, in which she wrote:
I have taken longer to reply than I would normally wish but that is a reflection of my concern to examine very carefully whether I could respond positively to your request at least on school nurses and TB visitors. Let me say at the start that I appreciate the keen disappointment of some nurses on discovering that despite substantial increases in their salaries—".
That is a reference to an increase of 5 per cent. Is that what the right hon. Lady claims to be the biggest increase in the history of the National Health Service for school nurses without the health visitor's certificate? The letter continues:
the simplified grading structure, which was generally welcomed by both sides of the Council, resulted in changes which so adversely
affected their previous relativity with their colleagues. This is, of course, a potential hazard in any such exercise.
From that extract it will be seen that the nurses were given a sharp slap in the face by the lady with an iron hand. Since my appeal to the right hon. Lady, the staff side of the Whitley Council and NALGO have asked that the matter should go to arbitration. However, the management side of the Whitley Council has refused.
I quote a further extract from the right hon. Lady's nauseating letter, in which she writes:
I am confident that the management side did not take lightly their decision not to agree to join the staff side in conciliation—as you rightly say, for the first time in many years—and after most careful consideration I have concluded that I cannot reasonably take exception to their view that it is undesirable to take to arbitration the findings of an independent review body.
What is this independent review body which the Minister talks about? The Whitley Council is made up of two halves—namely, the staff side, representing the professional bodies, and the management side, representing her Department and the regional and health authorities who are beholden to her. Independent indeed!
What effect has this all had? Nurses are drifting away, and it may well reach the point soon where the right hon. Lady will be unable to carry out her statutory responsibilities laid down in the 1944 Act because of her inability to staff the service. Let us take Liverpool, for example. There is a nursing establishment of 84 but there is a 13 per cent. shortage. Of the remaining 74, only 19 of the school nurses have the health visitor certificate. In Sunderland, for example, out of 28 school nurses only one has the certificate. It would not be possible to run the Liverpool school nursing service with 19 nurses doing the work of 84. When we see that an aide to a social worker, as advertised in London, can receive a salary of about £3,000, we can understand the deep personal resentment of these nurses.
So severe has been the downgrading that some school nurses have to retire early to protect their pension rights. Mrs. Kerr, of Birmingham, is an example. She is a former ward sister and would have been earning a salary of £3,894 but is now earning £2,646. She is having to stop work as a school nurse since her pension rights are calculated on the best of the last three years she has worked.
The service is in decline, morale is getting low and school nurses are depressed and are drifting away. Few school nurses with health visitor certificates are coming forward to fill the gaps. Perhaps the right hon. Lady will explain how she will run her statutory service when the staff falls below the minimum requirement. Has she considered any steps to halt the drift, and, if so, what are they? Systematically, the right hon. Lady has neglected school nurses and health visitors. Equally reprehensible has been her behaviour towards the small but concerned group of nurses who look after TB victims and who often contract the illness themselves.
School nurses are a very important part of the Welfare State and they have given nearly four generations of service to the nation. What have they done to deserve such treatment at the hands of the Secretary of State? The right hon. Lady was once shattered to learn that nurses were against her plans for the National Health Service. One wonders what further catastrophe has to occur before she desists in her petulant and obstinate disregard of the plight of school nurses and TB visitors. The Secretary of State should have not only her salary reduced by half but her status as well.
The Chair must intervene because many hon. Members still desire to speak in the debate. We have only 30 minutes left for back-bench speeches. Therefore, I hope that speeches will be confined to a duration of 10 minutes.
I am deeply conscious of the unenviable position in which my right hon. Friend the Secretary of State for Social Services find herself in face of the economic situation but, in deference to my hon. Friend the Member for East Kilbride (Dr. Miller), I must draw her attention to the plight of the hospitals in my constituency in Watford. I do not know whether my right hon. Friend knows that, because of staff shortages and defunct equipment, the casualty department of Watford General Hospital was closed over the weekend a short time ago. This is absolutely deplorable.
I appreciate the hon. Gentleman's dilemma. I should like to turn to phase three of the Watford General Hospital, which has now been delayed for two years and which does not look like going ahead at all. One of the provisions of phase three was the building of a suite of four operating theatres and a theatre sterile supply unit. The whole project was shelved, with the result that we have operating waiting lists sometimes for months; there are even waiting lists for X-rays. We are being provided with one operating theatre at Shrodells Wing, but that is not enough.
The Watford Memorial Wing was built 50 years ago and needs an extra operating theatre, improved outpatient facilities, additional medical beds and additional pathology laboratory provision. At Shrodells we need 29 acute beds, as well as medical, orthopaedic, gynaecological and geriatric provision. We also need 54 children's beds and 19 communicable disease beds, an accident and emergency department and a minor theatre.
I do not know whether my hon. Friend the Minister of State knows it but, because phase three was expected at Watford, nothing at all was spent on facilities that would have become obsolete once the new building was available. As a result—and here I quote from Mr. Treharne, the South-West Herts District Health Administrator—bathrooms and toilets are in a shocking condition, 50 years out of date, most unsatisfactory and not adequate for the patients they serve in number of facilities. Phase three was supposed to be brought in many years ago, so that it is not as though it was a new idea.
I appreciate that certain cuts have to be made. My right hon. Friend said that cuts must be made in capital expenditure rather than in services. However, if we go too far in cutting capital expenditure, we shall cut the vital services, and I ask my right hon. Friend and the Minister of State to ponder on the situation and to act accordingly.
I shall concentrate on what I consider to be the central issue, which I hope the Royal Commission will face. I welcome the formation of the Royal Commission and I hope that it will be able to take account of the structure of the National Health Service not only in England and the South-East, but in the English regions and in South Wales.
I dismiss the pay bed issue very quickly as being totally peripheral. There are only 68 pay beds in the health service in Wales. The whole argument has been highlighted out of all proportion to reality. We should be talking about the allocation of resources within the health service.
I am extremely concerned about the way in which the allocation of resources has been centralised. The district general hospitals and teaching hospitals have been eating up resources at the expense of other sectors of the hospital service and the community health services generally. These centres have been sucking in the resources, and as a result there are severe problems facing the peripheral hospitals and the community health services generally. When the great clinical and research complex was constructed, it was not in Gateshead, Glasgow, Barrow in Furness or Merthyr Tydfil, but in the outer part of London, at Northwick Park, to serve the convenience of the South East of England.
We have a similar problem in Wales with the construction of the Heath Hospital in Cardiff. The building of the Heath Hospital and the far higher level of costs incurred in the building of such a massive district general hospital have resulted in the revenue position of the peripheral hospitals in Cardiff to date being severely reduced. As a result of the building of this massive centralised teaching hospital, the speciality of cardiac surgery and thoracic surgery, which used to be a leading speciality in the Cardiff area, has now been severely run down, with the result that patients have to go to London for cardiac surgery, which used to be done at Sully in Cardiff.
Not only have we to look at the structure and the building of district general hospitals. There are also problems of the bed costing in those hospitals and the different ways in which these can be reduced by increasing the occupancy rates. A more effective programme of investigation—possibly a computerised programme—in all the major hospitals could ensure that the bed occupancy rates in district general hospitals were increased.
In addition to the problem of bed occupancy and the standardised costs of district general hospitals, which are so much greater than those of the peripheral hospitals, their very existence has effected the revenue account position of the peripheral hospitals. We now see proposals to close down more of the community hospitals and some of the old cottage hospitals. In Clwyd, for example, there is a proposal to close down the hospital at Llangwyban, which was a long-stay hospital, in order to fund the new district general hospital at Bodelwyddan.
The Royal Commission—and, indeed, the Department—should be looking now at ways of pruning the overspending of the district general hospitals, and not running down the peripheral hospitals, which are mainly our long-stay hospitals. I highlight particularly the position of Ely Hospital in Cardiff. Despite all that happened there, the revenue of that hospital this year has been cut back in order to transfer that revenue to maintain Heath Hospital. What is happening in Cardiff is typical of what is happening throughout the health service.
I have discussed with the Minister the need for joint allocation and joint financing of services as between the hospital sector, community health services, and the personal social services and I shall not detain the House. It is important that we should look at joint allocation of projects as between area health authorities and the personal social services, so that we can flexibly direct resources out of the area of historic overspending, such as the district general hospitals, into community provision.
The Royal Commission has an excellent opportunity to look at this basic question of resources, linking resources to the demographic factors and the morbidity factors. Gwynedd Area Health Authority has been under-funded in the past, and that under-funding has been transferred into the new reorganised system.
I shall support the Government tonight, not because I am satisfied with the direction in which they are leading the health service, but because I am even more appalled by the direction proposed by the official Opposition.
When they were not concerned with constituency matters, most of the speeches from the Opposition benches to which we have listened have been squalid little exercises abusing the Secretary of State. Led by the pirouetting figure of the hon. Member for Sutton Coldfield (Mr. Fowler), all of them have spent a great deal of time talking about pay beds and the need to retain them in the National Health Service. However, none of them have analysed the principle and the ideals of the NHS.
Government supporters believe the principle of the National Health Service to be based upon the maxim, from each according to his ability, to each according to his need. It is founded on the ideal that medical care should be available to all, that it should be free at the point of use and that access should be on the grounds of strict medical priority alone and not upon the basis of ability to pay. In view of that principle and ideal, we find the existence of pay beds an affront to the very concept of the NHS.
No one denies that there is queue-jumping because of pay beds. Indeed, it is their raison dêtre. It is outrageous that the wealthy should be able to move to the front of the queue by greasing the palms of consultants. The Opposition say that it is necessary for busy business men to take advantage of pay beds because they need to time their operations. It is argued that the system is necessary for their convenience. But their convenience is no more important than the convenient timing of an operation for a working woman in Kirkby or Ormskirk who has the same problem of making crucial and necessary arrangements for her family and household. Why is the business man so much more important than other members of the community? That we tolerate, let alone defend, the existence of pay beds is a blemish on our society.
The all-party Expenditure Committee of this House pointed clearly to the abuses of the National Health Service practised by private medicine, with consultants taking out equipment from the NHS and using it in Harley Street. If nothing else, the private abortion clinics are a graphic enough illustration of the exploitation capability of doctors.
Pay beds have only a 52 per cent. occupancy rate. It means that beds wait for the whims of the wealthy while the poor sick wait for beds. At a time of extreme pressure on our resources, the greater is the need for rationing by strict medical priority, and the abolition of pay beds from the National Health Service will release facilities and funds for the really medically needy.
What are the arguments for retention? What arguments are proffered by the Opposition? The Opposition adopt their customary rôle of defenders of privilege and wealth. They wheel out a series of geriatric arguments which deserve a quick mercy killing. They want to turn health into a market commodity peddled to the highest bidder, often with the easiest, trivial and most expensive to deal with complaint.
The hon. Member for Sutton Coldfield said that this was only a small problem, that we should not bother with it, that pay beds were insignificant, that in terms of the number of beds in the NHS they represented only about one per cent. and that we should not make a fuss about them. In a way he is right, but he should not make a fuss because his argument cuts both ways, justice is on our side, and each will move to its inevitable conclusion.
The Opposition talk of the cost to the Exchequer of the abolition of pay beds. However, they do not set the revenue derived from pay beds against the expenditure incurred. Nor are Government supporters prepared to accept selling the principle of a free, generally available, accessible-to-all National Health Service for the sake of a few "bob", as the Opposition seem prepared to do.
The Opposition also put forward the scaremongering arguments about emigration. They advance the silly argument that if private practice is separated from the National Health Service, doctors, poor dears, will have to travel from one hospital to another, which will take them more time and make them more exhausted. These are indications of the level of argument to which the Opposition have been reduced.
They even say "We will lose private donations if you take away this privilege. Private benefactors will no longer come along in a magnanimous spirit and produce money for the health service." We do not want that kind of patronage.
Then they deal in the big argument, the freedom-of-choice argument, the "three cheers" kind of expression. Yet they do not say that there is no choice for the majority, for the 98 per cent. of the population who do not have the ability or the wherewithal to use pay beds. There is no choice for the poor: they are not free to see a consultant. Indeed, patients in my constituency are not even free to choose their doctor when struck off a GP's list. They have no redress against that action.
"Freedom of choice" is the phrase used by a vested privileged minority in defence of a vested interest. It is the cry of the reactionary through the ages against any move to progressive legislation. What it means in practice is the freedom of consultants—
No, I have no time and the House has no time to waste on non-interventions by the hon. Member.
"Freedom of choice", when used by Opposition Members, means the freedom only of consultants. Indeed, the hon. Member for Sutton Coldfield made this clear in the House on 5th May, when he said that pay beds enabled the specialists
to preserve for themselves"—
the freedom to practise outside the full-time salaried service."—[Official Report, 5th May 1975; Vol. 891, c. 1086.]
So the freedom is not that of the patient but, as the hon. Member made clear, freedom for the specialist. The choice which is linked with that freedom is the prerogative only of the rich. This is intolerable and cannot be accepted.
The hon. Member for Sutton Coldfield asked on 19th April whom the Government were trying to please by the aboli- tion of pay beds. We can turn the question around. Whom are he and his hon. Friends trying to please by their retention? The mass of the population have no opportunity to use pay beds. They will not be pleased by their retention. The hon. Member would please a vested interest.
The hon. Member also asked, in his childlike, pirouetting, inquisitive manner, who would lead the applause for the implementation of our policy. We know that if our policy is not implemented and if the doctors can take their hands out of their full pockets for long enough, they and they only are the people who will applaud his policy. They are the same people who applauded his conference speech when in the same breath he promised to fight for the retention of pay beds and—should the misfortune of a Conservative Government ever come about—to take away social security benefits from the families of strikers. For that, he received a cheap standing ovation from the blue rinse set of the Tory Conference.
But at least we have the hon. Member's pledge that he will fight the abolition—and we mean the abolition, not just the separation—of pay beds all the way. We can therefore look forward to the intervention once more of "Rossi's irregulars", straight from their success on the Community Land Bill—all 15 of them—who will no doubt come here late at night to fight our legislation. We shall be pleased to deal with them then as we did only last week.
Let us be clear: the doctors' strident defence of pay beds is a defence of themselves, of their own interests. They show a concern for money rather than a concern for the sick. Why do they not make the same fuss, why are they not so vociferous, about the long waiting lists? Why are they so more concerned to help others to jump the queue? Because they are paid, and paid handsomely, that is why.
They know that the private sector could not function without the National Health Service. Indeed, the hon. Member for Sutton Coldfield seems to have put his foot in it more than anyone else. He made clear again on 5th May, when he whined in the petulant manner that he so frequently adopts in this Chamber, the difficulties that would be faced by the private sector if it were to be cut off from the health service and particularly from the diagnostic facilities for the treatment of cancer. The doctors want to continue their lucrative and parasitic activity of feeding off the sick. The mantle of healer of the sick has slipped.
Doctors belong to a caring profession. The only trouble at the moment is that a minority care only about themselves. Things were different once, and I quote from "Medical Ethics" as set out in the British Medical Association Handbook under the heading "The Brotherhood of Medicine", it says:
The entrant to the profession of medicine"—
this is relevant today when junior doctors are on strike—
joins a fraternity dedicated to the service of humanity. He will be expected to subordinate his personal interests to the welfare of his patients, and, together with his brother practitioners, to seek to raise the standard of health in the community among which he practises.
The Declaration of Geneva—these are great and fine words—goes on to say:
The health of my patient will be my first consideration"—
today, when they are treating emergency emergencies only?
I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.
The last one is the best:
A doctor must practise his profession uninfluenced by motives of profit.
What a fuss we have heard from them about the general problem of pay beds.
Those fine words were reiterated in 1973 when, as hon. Members will recall, ancillary hospital workers were on strike. The doctors then were out in force displaying their righteous indignation—and I quote from The Times of 13th March 1973. Screaming banner headlines said:
Consultants say strike is threatening to cause death and permanent ill health.
A report following that headline said:
The hospital strike is threatening permanent ill health or disability for some patients and premature deaths for others, 300 consultants in Birmingham said yesterday.
The consultants said:
Unless we are able to admit patients to our hospitals and to call on the full diagnostic and investigatory services for cases other than emergencies"—
and it is only emergencies that we are talking about today—
some patients will inevitably suffer an irreversible deterioration in health.
They went on to say:
The consequences of this will be permanent ill-health or disability and, for some people, death at an earlier date than would have been the case had our normal hospital services been available.
The consultants were saying that during the hospital ancillary workers' strike, and they went on displaying all their indignations in the letter columns of The Times on the rights and duties of hospital workers.
Expressing sympathy for the ancillary workers, a Dr. Sampson wrote in The Times of 10th March 1973:
None the less I never thought the day would come when these workers would strike in support of a pay claim, however justified.
He went on:
In the case of a strike by hospital workers the harm is done entirely to those who are already in poor health"—
how appropriate those words are today—
or old or in mental distress, and such a strike is therefore especially cruel. What sort of leadership has so contaminated this admirable group of workers?
There are many more examples. On 30th March 1973 a Professor Goodwin said these words, which are most pertinent to the situation today:
While it may be true that no patient who is being treated as an in-patient in hospital is suffering as a result of the industrial dispute involving certain hospital workers, it is true also that many patients are suffering and are in danger of life and health because they cannot be admitted to hospital…When the necessary operations are delayed, the results can be catastrophic.
The Professor, who is a cardiac surgeon, pointed out:
Delay for even a short period causes a disastrous inflation of hospital waiting lists so that the problem becomes progressively more serious with the passage of time.
The public should understand fully the catastrophic hindrance to the treatment of one of the commonest and most serious group of diseases at the present time; nor should there be any illusion regarding the suffering caused.
Dr. R. W. D. Turner on 19th March 1973 attacked the ancillary workers. He said:
One of my particular concerns is the assessment and preparation of patients for operations on the heart. In many cases the individual is aware that surgical treatment may
give a new lease of life, or abruptly end their days. They have been prepared and are ready for the day. The psychological trauma of postponement is very considerable.
Operations are being postponed today by the self-same doctors who were so quick to condemn the hospitals and ancillary workers in 1973.
Dr. Turner continued:
In addition, postponement in many cases lessens their chances of survival; often arrangements have had to be made for the children to be looked after or the husband has had to leave his work for this purpose.
The medical profession has great sympathy for hospital and ancillary staff, but this is not the way to set matters right. Many are doubtless unaware of the effects of their actions, but their leaders should know and advise accordingly. Leadership should imply a sense of responsibility but this is sadly and disastrously missing".
If those words were true in 1973, they are even more true today when those self-same doctors, who were so quick off the mark to condemn the ancillary workers and to point out the disastrous consequences to their patients, are doing precisely the same thing. They are the people who should know what the consequences to their patients will be.
Today the doctors are engaged in a political strike and are challenging Parliament. They are engaged in a shoddy exercise to promote their own self-interest, and in doing so they are holding the sick to ransom.
Where are the letters to The Times now? Where is the condemnation from the Opposition Front Bench? Where are the banner headlines which we had in 1973 and which are sadly lacking today? When my right hon. Friend the Secretary of State opened the debate, she said that commercialism is a canker in the National Health Service. It is a cancer in the National Health Service, and we all know what we do with cancer—we cut it out, quickly. Labour Members expect the Secretary of State to wield her scalpel quickly and effectively. She knows that she has their unanimous and enthusiastic support.
Perhaps a warning ought to be given. The Government side of the House will brook no delay in the implementation of this party's policy to abolish pay beds from the National Health Service. Going further still, we on the Government side of the House see no part of our purpose to be guaranteeing the existence of a private sector. We wish to see a health service that is truly a National Health Service that is motivated by the ideals and the principles with which it was established in the late 1940s and not by the mean, tawdry, petty personal advantage of the consultants, as exhibited by arguments of the hon. Member for Sutton Coldfield.
On a point of order, Mr. Deputy Speaker. As you will know, several hon. Members still wish to speak. No justice is done to the House when hon. Members, particularly the hon. Member for Ormskirk (Mr. Kilroy-Silk), speak for 20 minutes after your request to limit speeches to five or 10 minutes.
Surely we deserve and the National Health Service deserves something rather better than the deplorable speech to which we have just been subjected. We hear from the Secretary of State frequently about ideological spite. I can think of no better demonstration of ideological spite than the nonsense that has just come from the hon. Member for Ormskirk (Mr. Kilroy-Silk).
There is one thing I should like to have quite clear: the Opposition are as dedicated as anyone to the concept of the National Health Service. We are proud of it, and we shall do all that we can to see that it works. We believe that there is today overwhelming evidence of mismanagement and of lack of understanding by the present Government towards all professional people working in the health services. I am sorry to have to say that, and it makes me very sad.
I regret to say that I was deeply disappointed by the Secretary of State's speech. I must tell her that I found it strident and unconstructive and not what the NHS deserves. She described a National Health Service totally different from the health service that I know and hear about. I simply do not understand how she can say to us that she is not anxious about what is happening today when the President of the Royal College of Surgeons has found it necessary to write
that is, the private medicine fight—
must not be represented as Mrs. Castle's proposals versus the interests of the medical profession. It is Mrs. Castle's proposals versus the standards of medicine.
The right hon. Lady looks away.
It is Mrs. Castle's proposals versus the health of the community and the safety of patients.
Does not that make one feel anxious?
But what is even more depressing is that the right hon. Lady appeared not to take in anything that was said to her by my hon. Friend the Member for Sutton Coldfield (Mr. Fowler). Unwittingly she demonstrated before us all just what the doctors, the nurses, the dentists and the administrators have said about her: that she is insensitive to their attitudes and their needs, that she does not understand how they think and work; and, above all, that she does not listen to what they have to say.
These are very serious charges. One hears them on every side today, and the right hon. Lady knows it. Her extraordinary statement earlier today that she is flattered by her unique position misses out, I suggest, her real achievement. For the first time in medical history she has united all the doctors in this country against her, and now the nurses and the administrators.
It seemed odd that when the Secretary of State was denouncing the Press she did not refer to the article in today's Daily Mail—the right hon. Lady does not look quite so happy now—referring to collapsing morale in her own Department. No doubt the Minister of State will refer to that.
The right hon. Lady was particularly unfeeling and inaccurate about the junior hospital doctors. Does she not realise that they are not only complaining about money and the immense number of hours they work each week—over 100 in many cases, as she knows only too well. I should like to know what other group of workers would be prepared to work such hours. They will also tell her, if she will listen, how they feel cheated and misled by her unkept promises of this summer and how they are anxious about their future.
The Opposition understand only too well why the junior hospital doctors have acted as they have. The causes lie directly in the Secretary of State's hands. As my hon. Friend the Member for Sutton Coldfield said, we deplore all industrial action in the health service, but the Secretary of State speaks with two voices. How bravely did she condemn industrial action when it was taken at the Westminster Hospital? Not at all. How loudly does she condemn the domestics who are refusing to feed the consultants at one hospital and the ambulance driver who refused to collect a collapsed patient because she was in a private home? We hear nothing about those matters from Labour Members.
Many parts of the Secretary of State's speech did not match the information we have. She said that the numbers of nurses coming into training were being increased. Is this so? My information is quite the opposite. The numbers have been increased for a very short time only and I understand that she is now instructing the training schools in some areas to reduce their intake by up to one-third because she is closing units. As she knows, there is likely to be considerable unemployment amongst nurses coming out of training in the next month or two, as was said by my right hon. Friend the Member for Renfrewshire, East (Miss Harvie Anderson) and my hon. Friend the Member for Wallasey (Mrs. Chalker).
The Secretary of State said at Blackpool:
The NHS is the unique expression of the unity of human society.
Those were splendid words. There is not much unity today between her and the junior doctors. She also said:
No other social policy expresses so completely our Socialist principles.
That is not what I hear. I am told that the state of the NHS is a perfect example of the disunity in society created by the Labour Party. Present Government policies express completely the destructive and vindictive nature of Socialist policies in health. I ask hon. Members opposite to try to understand what it is that is disturbing all these professional people. It is a simple truth that there cannot be treatment without doctors and nurses. There is no way round that. The Secretary of State is very willing to quote Aneurin Bevan. He recognised that there could not be good treatment unless doctors and nurses felt that their standards and opinions were respected and that the whole exercise was worth while, as my hon. Friend the Member for St. Marylebone (Mr. Baker) said in his excellent speech.
In the past few months I have met very large numbers of doctors and nurses in different parts of the country. I am told the same story on every side-that it is not a question of money, although there is a shortage of resources but that medical and nursing morale is at stake. The Secretary of State simply does not seem to understand this.
I should like to give two typical examples. At a meeting of doctors—many of them were young consultants—I was told that after up to 12 years' specialist training to get to their present posts, which they had been looking forward to, they felt no enthusiasm and no confidence in their future. They felt that they did not have satisfactory facilities in which to be satisfactory consultants. Their views are not listened to, and, because of union pressure, many hospitals are now fully staffed with porters, domestics and secretaries, so that financial economies—which, quite rightly, are having to be made—are made by cutting down nursing and medical staffs and closing beds, which means fewer patients and longer waiting lists. My hon. Friend the Member for Essex, South-East (Sir B. Braine) referred to this matter.
If, as the hon. Gentleman says, those in the medical profess- sion, particularly the consultants, are so disgruntled and are disillusioned with the National Health Service and with medicine, why are consultants applying to universites for their sons and daughters to take up medicine and why are there three or four times as many applicants to study medicine as there are places?
With due respect to a medical colleague, that is an irrelevant and pointless intervention. I shall deal with it when I come to the subject of emigration.
The consultants told me that by closing smaller hospitals we were closing the most economical and cost-effective units. This policy will further seriously handicap general practitioners, because they will not be able to investigate and treat their cases themselves. That will cause the waiting lists, which the right hon. Lady the Secretary of State says concerns her and which she wishes to reduce, to become even longer. Over and over again the consultants complain that there appears to be no sincerity about the way in which negotiations with them are conducted. That is what disheartens them most. They are fed up and are ready to explode on almost any issue. That is what has happened with the junior hospital doctors.
The other example is perhaps even more depressing. A group of nurses told me recently that they no longer felt as proud as they used to feel when asked what they did. They hesitate over saying that they are nurses. [HON. MEMBERS "Oh".] I am sorry, but that is true. I was as surprised as hon. Members opposite are as strident and aggressive about it Hon. Members opposite should do what I do—listen to the nurses, because I am telling the House what they told me.
The nurses told me that they were worried about the poor standard of nursing care that they are providing in some units. Even worse, they told me that, in their view, the standards of patient care were falling rapidly. I know from my experience that accidents occur regularly that a few years ago would have merited complete inquiries. Today, mistakes are so frequently made that no one takes any notice of them. Everyone does his best to cover up mistakes.
Earlier today the Secretary of State referred to the NHS in detail. It is not the NHS which I knew. In such a situation it is not surprising that emigration is increasing rapidly. Sections of health work are being denuded of a generation of doctors, who are our seed corn, as it takes up to 12 years to train a specialist.
I wrote to the Secretary of State on 7th October about that matter. She kindly replied to me on 20th October. Her letter began "Dear Mr. Vaughan". I do not know whether that was a compliment. In her letter the right hon. Lady explained the difficulty in obtaining accurate information. She said that as she was anxious about the situation she had urgently asked the regional medical officers to conduct a special study. I am sure that she was right to do so. She said that in the year ending 30th September 1975, out of a total of 11,000 consultants, 64 United Kingdom consultants and 42 senior registrars had emigrated. On the face of it that does not appear too bad. However, I believe that those figures are a considerable underestimate, certainly according to the doctors to whom I have spoken.
As a result of the Secretary of State's letter, I looked into one speciality. The right hon. Lady might have done that since she mentioned the subject. I inquired into radiology, where at least 33 senior specialists, six Conservatives—I should say six consultants—[Laughter.] I must try to cheer up this gloomy situation. I discovered that 33 senior specialists and 27 senior registrars had emigrated—a total of 43. In the same year 131 radiologists passed the specialist fellowship examination. The Secretary of State may well laugh at those figures. I made one little joke, but the right hon. Lady thinks that the whole subject is amusing. She demonstrates again how unfeeling she is. In the first three months of this year, eight consultants and six senior registrars emigrated. This means that at least one-quarter to one-third of the British-trained supply will be lost eventually from the United Kingdom.
The situation is much worse in the Edinburgh and Great Ormond Street hospitals. The hospital at Edinburgh lost three consultants, three senior registrars and two registrars, including two gold medallists, thereby denuding sections of those departments. It is sad that the staff who leave are the good people. They can obtain the good jobs. People smile when they are amused. They also smile when they are anxious. I should like to know the reason for the Secretary of State's smile.
Those figures are bad enough, but the profession tells me that it thinks that the true figures are much higher. In radiology we appear to be losing at least twice as many highly-trained X-ray specialists as expected—[Interruption]—Is the hon. Member for Penistone (Mr. Mendelson) carrying on another debate?
I shall not give way.
I shall not go into the problems of the filling of jobs. The falling quality of applicants is making many jobs extremely difficult to fill with suitable people. I have some horrifying figures which illustrate this. However, I ask the Secretary of State whether it is correct that she has just sent a circular to the anaesthetists asking them to lower their standards because of the difficulty of filling jobs. I should like to hear the answer to that question. Is it true? [HON. MEMBERS: "Answer."]
In radiology, of 79 posts vacant—that is, 14 per cent. of the total—50 were unfilled or unfillable. In 14 cases—that is, 20 per cent.—no appointment could be made because the standard of applicants was too low. I have the figures.
We have to consider how much the situation in the National Health Service is due to inflation and lack of resources. The Opposition are realists and accept that a great deal of the trouble does not lie with the Secretary of State but with the inflationary situation and the lack of resources. However, how much is due to mismanagement by the Government, to a complete absence of clear priorities—because I hear people say that they have no clear guidelines to which to work—and to the intrusion into medicine of political action, which the majority of people in the health service know to be irrelevant to the main needs of the National Health Service?
The pay bed issue is political. It is irrelevant to the main problems of the health service. We all know that there is a severe shortage of resources and that in the present economic situation economies will have to be made. These are matters for the Royal Commission. We have welcomed the setting up of the Royal Commission, but in our view it will be absolute nonsense if the Commission does not inquire into all the problems facing the National Health Service, especially that of pay beds.
The hon. Member for Loughborough (Mr. Cronin) spoke earlier in the debate and got in a great muddle because he clearly had not read the Expenditure Committee's report.
I come back, as I must again and again, to the point that over and above the material problems there is a widespread deep lack of confidence between all the health professions and the Secretary of State. We have no doubt that if the Government would conduct genuine negotiations with the professions, if they would see them as people who know what they are talking about because they have devoted their working lives to the service, this would transform the present situation.
There has been mismanagement on a huge scale. When one goes through the various consultations which are or are not supposed to have been taking place, one sees the extraordinary handling of the nurses' agencies, the handling of the memorandum on the management of hos- pital waiting lists, the handling of the consultants' contracts, and now the handling of the junior hospital doctors. It is no wonder there is a crisis of confidence.
We hear a great deal about the Labour Party manifesto, but the people who really know the situation would not have put that in any manifesto today. The tragic consequence is that many doctors who know say that they now feel they are not dealing with rational people. They believe that one side is behaving without reason. Once that conclusion is reached, it opens the door to violent counter-measures, as we found with the junior hospital doctors. Hon. Gentlemen on the Government side may laugh and ridicule, but the National Health Service deserves something better from them. The morale of the National Health Service is at stake today.
I should like to end with these simple questions to the Government, each of which carries a simple answer. Why do not the Government admit that they have misjudged the situation and the feelings of the health professions? There is no harm in admitting that—it would cost no money—but it happens to be true.
Why not call on the good will of all doctors and nurses and take their advice—a kind of health coalition—and say that for the first time in recent months the Government will hold genuine discussions with a willingness to see and meet the profesisonal point of view? There is no harm in that. That is not what the Government say.
Why not condemn all militancy? There is no place for militancy in the care of the sick. If pursued, as it has been, it creates militancy in non-militant people. We are seeing that now among the junior hospital doctors who are not normally a militant group.
Why not admit that there is no reason why legislation on pay beds should not wait until the Royal Commission has reported?
That would not cost any money.
Why not state publicly that, with the advice of the health professions, the Government will examine and set out immediate priorities, so that cuts are made with the agreement and assistance of the professional groups, and that the yardstick for setting priorities—I ask the Secretary of State to finish her conversation, because this is very important—will be the care of patients, not administrative convenience?
Lastly, why do not the Government state publicly their support for professional freedom, because in that direction lies freedom for patients too?
It is because I do not expect that the Government will do any of these things that I ask my right hon. and hon. Friends to vote in support of the motion.
Not for the first time, and not for the last presumably, the health service is declared by doctors to be on its last legs, on the edge of a precipice, going down a slippery slope—whatever metaphor comes first to their tongues when talking to the Press. Not for the first time either the emigration of doctors has been used as an example of their dissatisfaction".
Those are not my words but the words of The Economist.
In a recent editorial about the National Health Service The Times has robustly rejected talk that the NHS is on the edge of collapse. It says that
in primary medical care in particular it has few equals
and points out that in international terms the problems that the NHS faces at the moment—
soaring costs, uneven distribution and conflict between doctors and administrators—are widespread even in countries far more wealthy than Britain".
Even the fear about emigration which The Times says is real and which the Government have said they are concerned about has, according to The Times been too much exploited for purposes of propaganda.
The hon. Members for Sutton Coldfield (Mr. Fowler) and Reading, South (Dr. Vaughan) have spoken in the debate from the Opposition Front Bench. I have listened to almost all the debate and, in marked contrast to many speakers from the Opposition back benches, they made a petty, personalised and propagandist attack on my right hon. Friend.
Some hon. Members, including my hon. Friend the Member for Peckham (Mr. Lamborn) discussed the real issues. Others spoke about the problems of mental illness and mental handicap, and the hon. Member for Truro (Mr. Penhaligon) spoke about geriatrics. They know that the health service faces very difficult times, particularly in the next few years of financial difficulty.
I will take first the geriatrics. There are more than 6½ million people aged 65 or over in England and they comprise about 14 per cent. of the total population. Since 1961 the total population has grown by 7 per cent. The over-65s increased by more than 25 per cent., and that trend will continue. By 1980 nearly 15 per cent. of the population will be 65 or over. The number of over 75s—the heaviest users of health and personal social services—is expected to rise from about 5 per cent. of the total population to 5½ per cent. in 1980 and 6 per cent. by 1985. That means that the House must face an inescapable increase in demand affecting nearly every part of the health and personal social services, because those services are used mainly by the elderly.
We have not had much discussion of that problem. We have not had much discussion of how my right hon. Friend in the past 18 months has striven constantly to bring together the health and personal social services, to deal with the problems of cross-financing and integration between health and social services, has had to put up with the massive error of a reorganised health service, to which the Opposition contributed, and has sought at all times to make the health and personal social services work together.
We have heard only about doctors. What about the problems of social workers who throughout the country are facing financial stringencies? What about the case loads they face and their difficulties? Always from the Opposition we hear selective pleading. The hon. Member for Sutton Coldfield spoke a little more realistically than he has before about the financial problems faced by the NHS. But in constantly bringing forward their constituency cases his hon. Friends pleaded for more resources. I get letter after letter asking for district general hospitals and letter after letter making local publicity about the health service. Even at this late stage in the debate I plead for a better sense of proportion about the problems facing the NHS.
The medical profession can make a massive contribution. Hospital costs account for nearly 70 per cent. of total NHS costs. That gives an indication of the resources that could be released by making sensible economies. No one can make those economies better than can the medical profession.
To take one example; if in all areas the average length of stay in hospital were no higher than the average that applies in one quarter of the areas, the potential saving in marginal costs—mainly hotel costs—would be about £56 million. I do not give this example in the belief that all the savings needed could or should come from shorter stays. We face great problems and we need to look forward to the next few years with a spirit of preparedness to change our practices. Doctors must recognise that they make economic decisions every day of their lives.
Many matters have been raised in this debate, but let us deal first with agency nurses. The hon. Member for Wallasey (Mrs. Chalker) talked about the wards that are being closed. Other Conservative Members have also raised this issue. However, they should be quite clear about what they used to say about agency nurses. The right hon. Member for Leeds, North-East (Sir K. Joseph) said:
I expect hospital authorities to keep their use of agency nurses to the minimum necessary to avoid serious adverse effects on services to patients."—[Official Report, 17th July 1973; Vol. 860, c. 69.]
Similar statements were made at the time. I should have made it plain that the right hon. Gentleman uttered those words when in office.
I have been asked to give the figures regarding agency nurses. The facts are clear. We have been carefully monitoring this matter over the 14 regional health authorities for the past few weeks. There seems to have been a reasonably smooth transition. With three exceptions there have been no reports of bed or ward closures as a result of the phasing out of agency nurses. At the Queen Elizabeth II Hospital at Welwyn a half-occupied ward of 15 beds has been temporarily closed and moved elsewhere. At Bishop's Stortford a 10-bed surgical ward has been prematurely closed, but the ward was due for closure in any event. The third exception is at Lewisham Hospital, where two permanent staff members have resigned. It is open to debate whether those posts might have been filled by agency nurses. I know of no other cases, although they may exist. In the whole of the Mersey region, which includes the constituency of the hon. Member for Wallasey, there were only 20 to 25 agency nurses in employment when the new policy started. I believe that that puts the situation into a better sense of proportion.
Will the hon. Gentleman tell the House what the situation would be in the London teaching hospitals if all agency nurses were withdrawn now? Is it not a fact that in the South-East Thames Regional Hospital Authority, on which I serve, 80 per cent. of the agency nurses are engaged in the three teaching hospitals on intensive care duties and on difficult shifts?
That is one of the reasons for that hospital authority having very high costs. Of course, we recognise the problem. London is one of the most difficult areas in which to phase out agency nurses. The hon. Gentleman serves on a regional hospital authority: does he want agency nurses phased out? All the authorities we have consulted on this matter want them phased out, including the London authorities.
I am grateful to the hon. Gentleman for asking me a question in the middle of his speech. I am not holding a brief for the permanent continuance of agency nurses. However, no steps should be taken by the Ministers responsible for health to put in jeopardy the health of patients who are in teaching hospitals in London.
That is exactly the instruction we gave to health authorities. We told them that they should not put the lives of patients in jeopardy. None of them would wish us to do so, and the hon. Gentleman knows that well enough.
The issue of agency nurses has been shown up, as the Opposition know, to be minor. However, they do not seem to be able to make up their minds whether the issue of pay beds is a major matter, a matter of irrelevance, or the issue that changes the whole integrity of the freedom of medical practice. It would be helpful to know exactly what they think.
What needs to be made clear to the House is that it is the policy of the Labour Party to separate private practice from National Health Service hospitals in an orderly and reasonable way. The total banning of private medical practice would be a major step. I must tell the House that neither I nor my right hon. Friend would be prepared to contemplate such a step. It is one thing for the Government and individuals to believe that private medical practice does not deserve the financial support of the State so as to be buttressed in its existence within the service; it is quite another thing to propose to abolish private medicine.
Not all doctors who engage in private practice do it for motives solely related to financial gain. Whether we like it or not, and even accepting the arguments put forward by the doctors and the BMA, it is an undoubted fact that many part-time consultants work long hours for the service far exceeding what one could normally consider to be their open-ended contractual obligation. Some doctors find genuine professional satisfaction in being able to undertake private practice. I have never practised privately and nor have I wanted to do so, but I recognise that the belief of the great majority of doctors that the existence of private practice, however small, in some way safeguards the independence of their profession is a factor that no Government can or should ignore.
The Government have not ignored that factor. The profession's belief is strongly and passionately held. Much of the fire and fury coming from the profession stem from the ability of the BMA to misrepresent the policy of separation and to make many moderate doctors believe that the Government intend to abolish private medicine.
This view has been held by Opposition Members. Doctors are persistently told in propaganda reminiscent of that which came from the British Medical Association in 1946 to 1948 that the Government are in favour of the abolition of private practice. That is not the Government's intention. It is in order to convince the medical profession that this is not our intention that we have agreed, as Aneurin Bevan agreed, to maintain in legislative form a commitment that no change to abolish private practice could be under taken without separate distinct legislation, and that safeguard would be written into any legislation—
The profession has a vested interest in the matter, but not all doctors think the same. Even the BMA's own poll of doctors showed that they could claim only 75 per cent. support. [HON. MEMBERS: "Oh."] I am not condemning a poll of doctors. I believe that a policy of separation of private practice within NHS hospitals offers one of the few opportunities we have of ending a serious division of opinion within the NHS set-up.
Opposition Members constantly seek to portray the situation as a battle between the Government—particularly my right hon. Friend the Secretary of State for Social Services—and the medical profession. It is nothing of the sort. The facts are clear—namely, that ever since 1948, when a compromise was arrived at, this question has been a festering sore, and that sore has grown worse in the last few years. Why else did the House of Commons in 1971 in its Expenditure Committee Report take as its subject private practice within NHS hospitals?
As has been said already today, that Committee took a great deal of evidence on this issue. It divided strictly on party political lines. But when the then Tory Government came to answer that debate, their spokesman came down on a balance of judgment in favour of keeping the existing situation. That is a far cry from saying that a decision to separate private practice from the NHS challenges the whole future of the medical profession.
We have heard all these slogans before. These were the slogans we heard in the years from 1946 to 1948. We are now hearing the same kind of misrepresentation. I wonder whether the right hon. Lady the Leader of the Opposition, who goes to Blackpool and makes a commitment to restore pay beds understands the divisions. It is not merely the nursing unions that feel so strongly about pay beds—[An HON. MEMBER: "What about NALGO?"] That organisation represents a great many administrators, but it is not just the unions that adopt such a view. There is a substantial body of opinion that believes in separation of private practice from the National Health Service—[HON. MEMBERS: "Who?"] I refer to many major newspapers, many doctors and also to the Royal College of Nursing. That college now says that it would like the policy to be conducted by agreement. There does not seem much chance of it, although I hope that it can be done by a measure of agreement. The Patients' Association does not oppose the idea. [An HON. MEMBER: "Who are they?"] When I hear a comment such as "who are they?", I realise that some Tory Members seem to think that the only people who matter are a small group of doctors.
Doctors are very important in the National Health Service and we must rely on their co-operation. I would strongly reject any policy that started to be anti-doctor. There is no future in that. There is a great deal of sympathy on this side of the House for the cause of junior hospital doctors. If this debate has achieved one thing, it has eventually got out of the Opposition that they recognise that the issue facing the country about junior hospital doctors goes far wider than the NHS or the junior hospital doctors and involves the whole integrity of the present voluntarily agreed pay policy. At least we have got this out of the Opposition.
As to the question of pay beds there is a chance that a reasonably conducted policy, a phased separation, as we intend to introduce it in this House, could solve the problems of private practice for decades.
We all know that there is an interface problem between private practice and the NHS. As my right hon. Friend the Prime Minister said, the Royal Commission can look at that interface and discuss the difficult problems and maybe we can reach agreement eventually on the parameters of that interface.
My right hon. Friend has offered to consult the medical profession without any preconditions. She has asked them to come and discuss these problems. We have constantly tried to reach agreement. It is over 18 months since the Government came into office. During those 18 months my right hon. Friend has been criticised by many people for not phasing out pay beds. She has been criticised by people who believe that it can be done instantaneously. She has sought to proceed as far as possible by agreement.
When the doctors asked for a joint working party, my right hon. Friend established one and we tried to discuss in that working party how to phase out pay beds by agreement. We offered joint waiting lists to try to stop the queue-jumping of private practice. It looked for a moment as if we would reach agreement on joint waiting lists. It is hard to see how serious objection can be taken to such a policy. The profession's negotiators, despite the problems which they were fair enough to bring forward, thought that it might be possible to reach agreement. Months later they went back on that agreement, just as they have gone back on so much else in the discussions.
Let us contrast the way in which the right hon. Lady the present Leader of the Opposition, when Secretary of State for Education and Science, handled a similar difficult issue. When she came into office, did she consult the teachers about their policy on comprehensive education? Not a bit of it. She withdrew the controversial Circular 10/65 without any consultations at all and embittered the teaching profession.
What I am attacking is the belief, constantly and sedulously spread by those on the benches opposite, that my right hon. Friend has not consulted the medical profession. She has bent over to try to reach agreement on this issue and has been met by a medical profession that is not prepared to discuss these issues.
It may be that the Labour Government have more problems with the doctors than does the Conservative Party, but let that party be under no illusion. The problem of pay beds in the NHS would not just disappear if there were ever to be—I hope not—a change of Government. The Conservative Party too would face this problem.
It does nothing but harm to the NHS to have a division between the staff of the NHS. This is why the problem has reached such a proportion. [An hon. Member: "You started it."] We did not start this. The hon. Gentleman should look at the history of it. This issue came to the fore in a Select Committee of this House in 1971 and in the nurses' pay dispute in May and June of 1974. It came about because many nurses, besides feeling a resentment about their salaries, felt a real dissatisfaction about a system which allowed scarce skills to be allocated within the NHS not on the basis of need but on the basis of ability to pay.
Opposition Members may find it difficult to understand that there are many nurses who deeply resent that in a National Health Service hospital—[Interruption.) There are many nurses who are quite prepared to nurse private patients in private hospitals, and some may say that that is a little illogical.
The facts of life are that in a democracy we allow variation and differences of view. But what nurses find difficult to accept is that within an NHS hospital, using the same operating theatre and having the same nurses and the same X-ray apparatus, it should be possible for a patient to be admitted in one week because he can pay, although another patient who cannot pay should have to wait a year or even two years.
No; I have already given way to the hon. Gentleman because he is a member of a regional health authority and his views deserve respect.
It is now time that the House asked itself why we are having this debate—
The hon. Member for Gillingham (Mr. Burden) asks about foreigners. This country has an international reputation for providing skilled medical treatment for those who cannot always get it in their own countries.
They do not jump the queue. My right hon. Friend has made it clear that no foreigner can come and be treated in a NHS hospital if that is likely to be to the detriment of a NHS patient. What my right hon. Friend has said is that if there is a skilled surgeon or physician with a unique experience in a rare disease, we should make that knowledge available to people from other countries without payment for the individual consultant, as is done by whole-time people in the NHS at the moment, and that any fees paid to the consultant should go to the hospital. That is a principle which the Opposition find hard to understand.
What is the history of the medical profession's relations with the State? In a book entitled "Doctors and State Medicine", Gordon Forsyth writes about 1946 and 1948:
In retrospect it was a sordid squabble not lessened in its distasteful nature by the rank hypocrisy of some of the BMA's expressed fears.
Lord Platt, a distinguished physician, said:
A generation of doctors had been taught to disparage British medicine, to regard the Ministry of Health as its enemy, and to speak of the Health Service in terms of contempt. The profession had been brought down to the mentality of strike action.
That is what happened in 1946 and 1948. On this occasion it has not happened, it need not happen, and I trust that it will not happen.
Like other professions, the medical profession may often disagree with the policy of the Government of the day. But its members would be most unwise not to sit round a table to discuss the mechanisms for introducing such a policy even if they disagreed with it. The Government are open-minded about these matters and are prepared to discuss the methods and means whereby this policy can be conducted.
I now turn to the personal attack on my right hon. Friend the Secretary of State. Speaking in this House on one occasion, the late Aneurin Bevan said:
It has been suggested that one of the reasons why the medical profession are so stirred up at the moment is because of personal deficiencies of my own. I am very conscious of these. They are very great. Absence of introspection was never regarded as part of a Celtic equipment; therefore, I am very conscious of my limitations. But it can hardly be suggested that conflict between the British Medical Association and the Minister of the day is a consequence of any deficiencies that I possess, because we have never been able yet to appoint a Minister of Health with
whom the BMA agreed. My distinguished fellow countryman"—
he meant that distinguished Liberal, David Lloyd George—
had quite a little difficulty with them. He was a Liberal, and they found him an anathema. Then there was Mr. Ernest Brown who was a Liberal National, whatever that might mean, representing a Scottish constituency.
Perhaps the Scottish National Party should consider this.
They found him abominable. As for Mr. Willink, a Conservative representing an English constituency, they found him intolerable.
I am a Welshman, a Socialist representing a Welsh constituency, and they find me even more impossible. Yet we are to assume that one of the reasons why the doctors are taking up this attitude is because of unreasonableness on my part. It is a quality which I appear to share in common with every Minister of Health whom the British Medical Association have met."—[Official Report, 9th February 1948; Vol. 447, c. 36–7.]
What did hon. Members opposite do when they were in office? They changed their Minister of Health every year for 13 years so that they could never spend enough time in office to have a disagreement with the BMA.
Now we come to the Liberal Party, that great radical party. I am sorry that its Leader is not here, because we gather that tonight the Liberal Party intends to vote against my right hon. Friend. What are the grounds? They are that my right hon. Friend will not make a change in the terms of reference of the Royal Commissison appointed on the advice of the Prime Minister by the Queen. That is the charge. The Liberals agree with us over pay beds; they fought two elections on the same policy as we did. I agreed with almost every word of the speech from their health spokesman. The only conclusion to which one is led is to ask why they can even contemplate voting against my right hon. Friend.
The previous Leader of the Liberal Party once promised that he would march his troops towards the sound of gunfire. A whiff of grapeshot across the bows of the right hon. Member for Devon, North (Mr. Thorpe) seems to be sufficient to drive him from supporting a policy which has to be fought for. His predecessor in that office, David Lloyd George, had this to say about an encounter with the doctors.
I do not think there has been anything like it since the days when Daniel went into the lion's den. I was on the dissecting table
for hours but I can assure you they treated me with the same civility as the lions treated my illustrious predecessar.
If the Liberals claim to be a radical party, they should recognise that their credentials will be tested when there is a little sound of gunfire and that they should support a policy on which they fought elections.
I am not sure what the Scottish Nationalist Party thinks. I am not sure whether it intends to support my right hon. Friend, but it has supported—
Would not the Minister agree that the Liberals also fought an election on a policy calling for the successful management of the health service as we know it? Does he not know that it is the policy of his Government over pay beds which is one of the major obstacles to the success of the health service?
The hon. Gentleman and his hon. Friends voted a few months ago for our policy on pay beds in a debate in the House. I could say to them, "By all means criticise us if, when we produce legislation, you dislike the way in which we deal with it. You warned us that that would be the case." But we have not produced that legislation. We are still consulting the profession. It seems a little early to run away from the policy tonight.
As for the Scottish National Party, its spokesman said that it supported the policy on pay beds and he paid tribute to the health service in Scotland, although he did not see fit to mention that the expenditure per head on the NHS in Scotland is 19 per cent. higher than in England. He paid tribute to the work of the hospital doctors, however, and there was nothing in his speech to justify a vote against my right hon. Friend.
We are therefore left to ask why this motion has been tabled. The views of the Conservative Party on pay beds have at least been consistent. We know that they are in favour of privilege, but this is a strange motion. They think that it is the only thing on which they could get the House to agree—a petty, rather spiteful, personalised attack on my right hon. Friend.
My right hon. Friend has introduced a pension scheme which has the support of all hon. is Members. That hardly the action of a divisive politician who is not prepared to listen to anyone. She has improved the financing of the health service from 4·9 per cent. of the gross national product to 5·4 per cent. in one year—the greatest record of any Government with responsibility for the NHS. She deserves the support of this House.
|Division No. 365.]||AYES||[10.0 p.m.|
|Adley, Robert||Fisher, Sir Nigel||Knight, Mrs Jill|
|Aitken, Jonathan||Fletcher, Alex (Edinburgh N)||Knox, David|
|Alison, Michael||Fletcher-Cooke, Charles||Lamont, Norman|
|Amery, Rt Hon Julian||Fookes, Miss Janet||Lane, David|
|Arnold, Tom||Fowler, Norman (Sutton C'f'd)||Langford-Holt, Sir John|
|Atkins, Rt Hon H. (Spelthorne)||Fox, Marcus||Latham, Michael (Melton)|
|Awdry, Daniel||Fraser, Rt Hon H. (Stafford & St)||Lawrence, Ivan|
|Bain, Mrs Margaret||Freud, Clement||Lawson, Nigel|
|Baker, Kenneth||Fry, Peter||Le Marchant, Spencer|
|Banks, Robert||Galbraith, Hon. T. G. D.||Lewis, Kenneth (Rutland)|
|Beith, A. J.||Gardiner, George (Reigate)||Lloyd, Ian|
|Bell, Ronald||Gardner, Edward (S Fylde)||Loveridge, John|
|Bennett, Sir Frederic (Torbay)||Gilmour, Rt Hon Ian (Chesham)||Luce, Richard|
|Bennett, Dr Reginald (Fareham)||Gilmour, Sir John (East Fife)||McAdden, Sir Stephen|
|Berry, Hon Anthony||Glyn, Dr Alan||McCrindle, Robert|
|Biffen, John||Godber, Rt Hon Joseph||Macfarlane, Neil|
|Biggs-Davison, John||Goodhart, Philip||MacGregor, John|
|Blaker, Peter||Goodlad, Alastair||Macmillan, Rt Hon M. (Farnham)|
|Body, Richard||Gorst, John||McNair-Wilson, M. (Newbury)|
|Boscawen, Hon Robert||Gow, Ian (Eastbourne)||McNair-Wilson, P. (New Forest)|
|Bottomley, Peter||Gower, Sir Raymond (Barry)||Madel, David|
|Bowden, A. (Brighton, Kemptown)||Grant, Anthony (Harrow C)||Mates, Michael|
|Boyson, Dr Rhodes (Brent)||Gray, Hamish||Mather, Carol|
|Braine, Sir Bernard||Grieve, Percy||Maude, Angus|
|Brittan, Leon||Grimond, Rt Hon J.||Maudling, Rt Hon Reginald|
|Brocklebank-Fowler, C.||Grist, Ian||Mawby, Ray|
|Brotherton, Michael||Grylls, Michael||Maxwell-Hyslop, Robin|
|Brown, Sir Edward (Bath)||Hall, Sir John||Mayhew, Patrick|
|Bryan, Sir Paul||Hall-Davis, A. G. F.||Meyer, Sir Anthony|
|Buchanan-Smith, Alick||Hamilton, Michael (Salisbury)||Mills, Peter|
|Buck, Antony||Hampson, Dr Keith||Miscampbell, Norman|
|Budgen, Nick||Hannam, John||Mitchell, David (Basingstoke)|
|Bulmer, Esmond||Harrison, Col Sir Harwood (Eye)||Moate, Roger|
|Burden, F. A.||Harvie Anderson, Rt Hon Miss||Montgomery, Fergus|
|Carlisle, Mark||Hastings, Stephen||Moore, John (Croydon C)|
|Carr, Rt Hon Robert||Havers, Sir Michael||More, Jasper (Ludlow)|
|Chalker, Mrs Lynda||Hawkins, Paul||Morgan, Geraint|
|Channon, Paul||Hayhoe, Barney||Morgan-Giles, Rear-Admiral|
|Churchill, W. S.||Heath, Rt Hon Edward||Morris, Michael (Northampton S)|
|Clark, Alan (Plymouth, Sutton)||Henderson, Douglas||Morrison, Charles (Devizes)|
|Clark, William (Croydon S)||Heseltine, Michael||Morrison, Hon Peter (Chester)|
|Cockcroft, John||Hicks, Robert||Mudd, David|
|Cooke, Robert (Bristol W)||Higgins, Terence L.||Neave, Airey|
|Cope, John||Hooson, Emlyn||Nelson, Anthony|
|Cordle, John H.||Hordern, Peter||Neubert, Michael|
|Cormack, Patrick||Howe, Rt Hon Sir Geoffrey||Newton, Tony|
|Corrie, John||Howell, David (Guildford)||Nott, John|
|Costain, A. P.||Howell, Ralph (North Norfolk)||Onslow, Cranley|
|Craig, Rt Hon W. (Belfast E)||Howells, Geraint (Cardigan)||Oppenheim, Mrs Sally|
|Critchley, Julian||Hunt, John||Osborn, John|
|Crouch, David||Hurd, Douglas||Page, John (Harrow West)|
|Davies, Rt Hon J. (Knutsford)||Hutchison, Michael Clark||Page, Rt Hon R. Graham (Crosby)|
|Dodsworth, Geoffrey||Irvine, Bryant Godman (Rye)||Pardoe, John|
|Douglas-Hamilton, Lord James||Irving, Charles (Cheltenham)||Pattie, Geoffrey|
|Drayson, Burnaby||James, David||Penhaligon, David|
|du Cann, Rt Hon Edward||Jenkin, Rt Hn P. (Wanst'd & W'df'd)||Percival, Ian|
|Durant, Tony||Jessel, Toby||Peyton, Rt Hon John|
|Dykes, Hugh||Johnson Smith, G. (E Grinstead)||Pink, R. Bonner|
|Eden, Rt Hon Sir John||Jones, Arthur (Daventry)||Price, David (Eastleigh)|
|Edwards, Nicholas (Pembroke)||Joseph, Rt Hon Sir Keith||Pym, Rt Hon Francis|
|Elliott, Sir William||Kellett-Bowman, Mrs Elaine||Raison, Timothy|
|Emery, Peter||Kershaw, Anthony||Rathbone, Tim|
|Eyre, Reginald||Kilfedder, James||Rawlinson, Rt Hon Sir Peter|
|Fairbairn, Nicholas||Kimball, Marcus||Rees, Peter (Dover & Deal)|
|Fairgrieve, Russell||King, Evelyn (South Dorset)||Rees-Davies, W. R.|
|Fell, Anthony||King, Tom (Bridgwater)||Renton, Rt Hon Sir D. (Hunts)|
|Finsberg, Geoffrey||Kitson, Sir Timothy||Renton, Tim (Mid-Sussex)|
|Rhys Williams, Sir Brandon||Smith, Dudley (Warwick)||Trotter, Neville|
|Ridley, Hon Nicholas||Speed, Keith||Tugendhat, Christopher|
|Rifkind, Malcolm||Spicer, Jim (W Dorset)||van Straubenzee, W. R.|
|Rippon, Rt Hon Geoffrey||Spicer, Michael (S Worcester)||Vaughan, Dr Gerard|
|Roberts, Michael (Cardiff NW)||Sproat, Iain||Viggers, Peter|
|Roberts, Wyn (Conway)||Stainton, Keith||Wainwright, Richard (Colne V)|
|Rodgers, Sir John (Sevenoaks)||Stanbrook, Ivor||Wakeham, John|
|Ross, Stephen (Isle of Wight)||Steel, David (Roxburgh)||Walder, David (Clitheroe)|
|Rossi, Hugh (Hornsey)||Steen, Anthony (Wavertree)||Walker, Rt Hon P. (Worcester)|
|Rost, Peter (SE Derbyshire)||Stewart, Donald (Western Isles)||Wall, Patrick|
|Royle, Sir Anthony||Stewart, Ian (Hitchin)||Walters, Dennis|
|Sainsbury, Tim||Stokes, John||Watt, Hamish|
|St. John-Stevas, Norman||Stradling Thomas, J.||Wells, John|
|Scott, Nicholas||Tapsell, Peter||Welsh, Andrew|
|Scott-Hopkins, James||Taylor, R. (Croydon NW)||Wiggin, Jerry|
|Shaw, Giles (Pudsey)||Taylor, Teddy (Cathcart)||Winterton, Nicholas|
|Shaw, Michael (Scarborough)||Tebbit, Norman||Wood, Rt Hon Richard|
|Shelton, William (Streatham)||Temple-Morris, Peter||Young, Sir G. (Ealing, Acton)|
|Shepherd, Colin||Thatcher, Rt Hon Margaret||Younger, Hon George|
|Shersby, Michael||Thomas, Rt. Hon P. (Hendon S)|
|Sims, Roger||Thompson, George||TELLERS FOR THE AYES:|
|Sinclair, Sir George||Thorpe, Rt Hon Jeremy (N Devon)||Mr. Adam Butler and|
|Skeet, T. H. H.||Townsend, Cyril D.||Mr. Cecil Parkinson.|
|Smith, Cyril (Rochdale)|
|Allaun, Frank||Deakins, Eric||Hughes, Mark (Durham)|
|Anderson, Donald||Dean, Joseph (Leeds West)||Hughes, Robert (Aberdeen N)|
|Archer, Peter||de Freitas, Rt Hon Sir Geoffrey||Hughes, Roy (Newport)|
|Armstrong, Ernest||Delargy, Hugh||Hunter, Adam|
|Ashley, Jack||Dell, Rt Hon Edmund||Irvine, Rt Hon Sir A. (Edge Hill)|
|Atkins, Ronald (Preston N)||Dempsey, James||Irving, Rt Hon S. (Dartford)|
|Atkinson, Norman||Doig, Peter||Jackson, Colin (Brighouse)|
|Bagier, Gordon A. T.||Dormand, J. D.||Jackson, Miss Margaret (Lincoln)|
|Barnett, Guy (Greenwich)||Douglas-Mann, Bruce||Janner, Greville|
|Barnett, Rt Hon Joel (Heywood)||Duffy, A. E. P.||Jay, Rt Hon Douglas|
|Bates, Alf||Dunnett, Jack||Jeger, Mrs Lena|
|Bean, R. E.||Dunwoody, Mrs Gwyneth||Jenkins, Hugh (Putney)|
|Benn, Rt Hon Anthony Wedgwood||Eadie, Alex||Jenkins, Rt Hon Roy (Stechford)|
|Bennett, Andrew (Stockport N)||Edge, Geoff||John, Brynmor|
|Bidwell, Sydney||Edwards, Robert (Wolv SE)||Johnson, Walter (Derby S)|
|Bishop, E. S.||Ellis, Tom (Wrexham)||Jones, Alec (Rhondda)|
|Blenkinsop, Arthur||English, Michael||Jones, Barry (East Flint)|
|Boardman, H.||Ennals, David||Jones, Dan (Burnley)|
|Booth, Albert||Evans, Fred (Caerphilly)||Judd, Frank|
|Bottomley, Rt Hon Arthur||Evans, Ioan (Aberdare)||Kaufman, Gerald|
|Boyden, James (Bish Auck)||Evans, John (Newton)||Kelley, Richard|
|Bradley, Tom||Ewing, Harry (Stirling)||Kerr, Russell|
|Bray, Dr Jeremy||Faulds, Andrew||Kilroy-Silk, Robert|
|Brown, Hugh D. (Provan)||Fernyhough, Rt Hon E.||Kinnock, Neil|
|Brown, Robert C. (Newcastle W)||Fitch, Alan (Wigan)||Lambie, David|
|Buchan, Norman||Fitt, Gerard (Belfast W)||Lamborn, Harry|
|Buchanan, Richard||Flannery, Martin||Lamond, James|
|Butler, Mrs Joyce (Wood Green)||Fletcher, Ted (Darlington)||Latham, Arthur (Paddington)|
|Callaghan, Rt Hon J. (Cardiff SE)||Foot, Rt Hon Michael||Leadbitter, Ted|
|Callaghan, Jim (Middleton & P)||Ford, Ben||Lee, John|
|Campbell, Ian||Forrester, John||Lestor, Miss Joan (Eton & Slough)|
|Canavan, Dennis||Fowler, Gerald (The Wrekin)||Lever, Rt Hon Harold|
|Cant, R. B.||Fraser, John (Lambeth, N'w'd)||Lewis, Ron (Carlisle)|
|Carmichael, Neil||Freeson, Reginald||Lipton, Marcus|
|Carter-Jones, Lewis||Garrett, John (Norwich S)||Litterick, Tom|
|Cartwright, John||Garrett, W. E. (Wallsend)||Loyden, Eddie|
|Castle, Rt Hon Barbara||George, Bruce||Luard, Evan|
|Clemitson, Ivor||Gilbert, Dr John||Lyon, Alexander (York)|
|Cocks, Michael (Bristol S)||Ginsburg, David||Lyons, Edward (Bradford W)|
|Coleman, Donald||Gould, Bryan||Mabon, Dr J. Dickson|
|Colquhoun, Mrs Maureen||Gourlay, Harry||McCartney, Hugh|
|Concannon, J. D.||Graham, Ted||McElhone, Frank|
|Conlan, Bernard||Grant, George (Morpeth)||MacFarquhar, Roderick|
|Cook, Robin F. (Edin C)||Grant, John (Islington C)||McGuire, Michael (Ince)|
|Corbett, Robin||Hamilton, James (Both well)||Mackenzie, Gregor|
|Cox, Thomas (Tooting)||Hamilton, W. W. (Central Fife)||Mackintosh, John P.|
|Craigen, J. M. (Maryhill)||Harrison, Walter (Wakefield)||Maclennan, Robert|
|Crawshaw, Richard||Hart, Rt Hon Judith||McMillan, Tom (Glasgow C)|
|Cronin, John||Hattersley, Rt Hon Roy||McNamara, Kevin|
|Crosland, Rt Hon Anthony||Hayman, Mrs Helene||Madden, Max|
|Cryer, Bob||Healey, Rt Hon Denis||Magee, Bryan|
|Cunningham, G. (Islington s)||Heffer, Eric S.||Maguire, Frank (Fermanagh)|
|Cunningham, Dr J. (Whiteh)||Hooley, Frank||Mahon, Simon|
|Dalyell, Tam||Horam, John||Mallalieu, J. P. W.|
|Davidson, Arthur||Howell, Denis (B'ham, Sm H)||Marks, Kenneth|
|Davies, Bryan (Enfield N)||Hoyle, Doug (Nelson)||Marquand, David|
|Davies, Denzil (Llanelli)||Huckfield, Les||Marshall, Dr Edmund (Goole)|
|Davis, Clinton (Hackney C)||Hughes, Rt. Hn. Cledwyn (Anglesey)||Marshall, Jim (Leicester S)|
|Mason, Rt Hon Roy||Radice, Giles||Thorne, Stan (Preston South)|
|Maynard, Miss Joan||Richardson, Miss Jo||Tierney, Sydney|
|Meacher, Michael||Roberts, Albert (Normanton)||Tinn, James|
|Mellish, Rt Hon Robert||Roberts, Gwilym (Cannock)||Tomlinson, John|
|Mendelson, John||Robertson, John (Paisley)||Tomney, Frank|
|Mikardo, Ian||Roderick, Caerwyn||Torney, Tom|
|Millan, Bruce||Rodgers, George (Chorley)||Tuck, Raphael|
|Miller, Dr M. S. (E Kilbride)||Rooker, J. W.||Urwin, T. W.|
|Miller, Mrs Millie (Ilford N)||Roper, John||Varley, Rt Hon Eric G.|
|Mitchell, R. C. (Soton, Itchen)||Rose, Paul B.||Wainwright, Edwin (Dearne V)|
|Molloy, William||Ross, Rt Hon W. (Kilmarnock)||Walden, Brian (B'ham, L'dyw'd)|
|Moonman, Eric||Rowlands, Ted||Walker, Harold (Doncaster)|
|Morris, Alfred (Wythenshawe)||Sandelson, Neville||Walker, Terry (Kingswood)|
|Morris, Charles R. (Openshaw)||Sedgemore, Brian||Ward, Michael|
|Morris, Rt Hon J. (Aberavon)||Shaw, Arnold (Ilford South)||Watkins, David|
|Moyle, Roland||Sheldon, Robert (Ashton-u-Lyne)||Watkinson, John|
|Mulley, Rt Hon Frederick||Short, Rt Hon E. (Newcastle C)||Weetch, Ken|
|Murray, Rt Hon Ronald King||Short, Mrs Renée (Wolv NE)||Weitzman, David|
|Newens, Stanley||Silkin, Rt Hon John (Deptford)||Wellbeloved, James|
|Noble, Mike||Silkin, Rt Hon S. C. (Dulwich)||White, Frank R. (Bury)|
|Oakes, Gordon||Sillars, James||White, James (Pollok)|
|Ogden, Eric||Skinner, Dennis||Whitehead, Phillip|
|O'Halloran, Michael||Small, William||Whitlock, William|
|O'Malley, Rt Hon Brian||Smith, John (N Lanarkshire)||Willey, Rt Hon Frederick|
|Orbach, Maurice||Snape, Peter||Williams, Alan (Swansea W)|
|Orme, Rt Hon Stanley||Spearing, Nigel||Williams, Alan Lee (Hornch'ch)|
|Ovenden, John||Spriggs, Leslie||Williams, Rt Hon Shirley (Hertford)|
|Owen, Dr David||Stallard, A. W.||Williams, W. T. (Warrington)|
|Padley, Walter||Stewart, Rt Hon M. (Fulham)||Wilson, Alexander (Hamilton)|
|Palmer, Arthur||Stonehouse, Rt Hon John||Wilson, Rt Hon H. (Huyton)|
|Park, George||Stott, Roger||Wise, Mrs Audrey|
|Parker, John||Strang, Gavin||Woodall, Alec|
|Parry, Robert||Strauss, Rt Hon G. R.||Woof, Robert|
|Peart, Rt Hon Fred||Summerskill, Hon Dr Shirley||Wrigglesworth, Ian|
|Pendry, Tom||Swain, Thomas||Young, David (Bolton E)|
|Phipps, Dr Colin||Taylor, Mrs Ann (Bolton W)|
|Prescott, John||Thomas, Dafydd (Merioneth)||TELLERS FOR THE NOES|
|Price, C. (Lewisham W)||Thomas, Jeffrey (Abertillery)||Mr. Joseph Harper and|
|Price, William (Rugby)||Thomas. Ron (Bristol NW)||Mr. David Stoddart.|