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Mr. Alan Williams (Swansea, West) : Does the Minister accept that there is a genuine difference of opinion? Will he think in different terms to try to understand the point that we are making? Each of the 38 Members representing constituencies in Wales has to carry out on a much wider scale the sort of functions that are carried out in relation to health by the community health councils. I think it would be regarded in Wales as a step backwards--I suspect that the hon. Gentleman would regard it in the same way--if we said that instead of having 38 Members to carry out that function on behalf of all our constituents we should have only nine Members. There can be no pretence that the people of Wales would be better served or that there would be a more localised service. If the hon. Gentleman thinks in those terms, he will see why we are getting angry. We think that he does not understand the personal relationship available through a community health council which my hon. Friend the Member for Cardiff, South and Penarth (Mr. Michael) tried to emphasise.
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Mr. Grist : The right hon. Gentleman teases me by suggesting that if we were to follow certain devolutionary principles we might end up with nine Members of Parliament in Wales. That is perhaps worth the consideration of hon. Members. The multiplicity would undermine the ability of the CHCs to take a strategic view of the delivery of health service in their areas and it would complicate the working relationship between them and the district health authorities and the family health service authorities. I am afraid that the new clause would end the existing relationship between the CHCs and FPCs, or the new family health service authorities, as they are to be called. Even more misplaced is the proposal in the new clause that CHCs should be given a role beyond the NHS in relation to the community care responsibilities of local authorities, including personal social services and complementary housing provision. We have made it clear that in carrying out their community care responsibilities local authorities will have a clear duty to work with health authorities, family health service authorities, housing agencies, voluntary bodies, the private sector and users of services in the development and delivery of community care plans. CHCs will doubtless contribute to that process.
However, we regard as fundamentally misconceived the idea that CHCs should have a statutory role in respect of local authority services. Local authorities are directly accountable to their electorates for the provision of services and they will therefore have the duty of ensuring that users' views about services are adequately taken into account. Indeed, we have made it plain that we shall expect the social services authorities to have in place effective systems for users of services and their representatives to make complaints and representations, as members of the Standing Committee will be aware. I find unacceptable the idea in the new clause that the CHCs should act as ringmasters for a highly bureaucratic process in attempting what I believe is an impossible task--trying to bring together various voluntary bodies, charitable organisations and others to make them speak with one voice. I do not believe that it is possible to co- ordinate those bodies in the way suggested in the new clause. As I have said, the formal consultation about the Government's proposals ended on 28 February. We are still analysing the responses. The new clause is flawed in the ways that I have described. It is also untimely with regard to the consultation process that is being undertaken at the moment. I hope that the hon. Member for Cardiff, South and Penarth (Mr. Michael) will withdraw the new clause. If not, I invite the House to reject it.
Dr. Kim Howells (Pontypridd) : If the Government were to support new clause 3, they would go some way towards regaining a little of the credibility that they have lost during the Bill's passage. That credibility has been lost largely as a result of the Government's refusal to countenance any extension of consultation with those who use and operate the Health Service.
New clause 3 seeks to align community health councils with district councils in Wales and to create a mechanism that would allow meetings of the community health councils to take place on a district health authority- wide basis. I do not understand the Minister's great horror about that arrangement. The proposal that is currently floated by the Welsh Office is that there should be one
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CHC per district health authority. In Mid Glamorgan--the county with the highest population in Wales--that would have drastic repercussions for the level of representation through community health councils. Instead of the present four CHCs, the 535,000 inhabitants in Mid Glamorgan would be allocated only one CHC.Under the new clause Mid Glamorgan's CHCs would increase to six--one for each of the district councils of Cynon Valley, Merthyr Tydfil, Ogwr, Rhondda, Rhymney Valley and Taff-Ely. That population of 500, 000 would be subdivided into communities that would vary between 60, 000 and 160,000, each with its own characteristics, needs and existing resources.
The Minister knows that there are currently about 30 hospitals servicing the county of Mid Glamorgan. They are located in Rhondda, Taff-Ely, Ogwr, Merthyr, Cynon Valley and Rhymney Valley. Those areas and the health requirements of their population are by no means identical. Mortality and illness rates frequently tend to be higher in the older communities, in the central mining valleys of Rhondda, Cynon Valley and Merthyr, and in the Cyntwell and upper Rhymney valleys, and often much lower in the areas that are contiguous to the M4.
Within just one of those districts--Rhondda and
Taff-Ely--considerable sensitivity has to be exercised in administering the needs of an older and declining population in the north of the district and of a younger and growing population in the southern part of the district. The CHC's role in monitoring the quality of health provision, if organised on a district basis, could be much more sensitive than at present. Certain critical variables in each of those areas could be catered for if the provisions were based on a district model which in some ways are not catered for now. I am sure that the Minister is well aware of the difficulties of people in Mid Glamorgan in gaining access to the hospitals, especially to the new district general hospitals, such as the Prince Charles hospital in Merthyr, the East Glamorgan general hospital in the centre and the Princess of Wales hospital in Ogwr. People in many of the areas that are served by those hospitals do not find them easy to get to. One role of the enhanced model that we are proposing in the new clause would be precisely to allow the monitoring service to inform the public of the new arrangements affecting the district general hospitals, such as the new one that I hope will be built to serve the Taff-Ely and Rhondda areas. That would allow much more sensitivity and the input of greater local knowledge about access and people's ability to get to those hospitals. In that way, it would become much more of a two-way process. The decisions would not be being made in county hall, which might not be as sensitive as it should be to the peculiar topography and geography of the valleys in south Wales. It is not asking a great deal to ask that the potential of the expertise of local voices should be tapped by any new arrangement. That local voice should not be diminished by making the decisions more remote in terms of the lack of input of local expertise and information. The Minister seems to be over-reacting dramatically to what is simply an extension of consultation and of people's access to those decisions and the way in which they are made.
I congratulate my hon. Friend the Member for Cardiff, South and Penarth (Mr. Michael) on the way in which he moved the new clause. He has rightly highlighted and valued something about Wales that is unique--our
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identification with communities. That is something that we should treasure and look after. I advise Ministers that the new clause does just that.Mr. Ieuan Wyn Jones : In supporting new clause 3, may I say that we are discussing the important principle of the way in which community health councils can fulfil their primary role as a public watchdog. We are doing so against the background of a Bill that seeks to reduce the accountability of the district health authorities and all the other bodies that will administer the Health Service in Wales. The Minister will be aware of the criticism of Opposition Members in Committee about the way in which the new constitution of district health authorities and family health service authorities was being radically changed to introduce what the White Paper, but not the Bill, calls a more businesslike approach. In other words, they are being changed to make district health authorities run like businesses and to reduce accountability and the representation of local authorities on those bodies. The accountability and the effectiveness of the body would be reduced. The Government cannot have it all ways.
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We must make it clear, and the British Medical Association has informed us in its briefing for the debate, that there is widespread opposition to the Government's plans. That widespread opposition must be articulated in a democracy. The people of Wales have rejected time and again the philosophy of change in the Bill. If that is the case, the Government could at least give us an effective watchdog to ensure that the health changes that are being pushed through in the Bill are effectively monitored. That is an honourable argument for Opposition Members to put. There should be an effective monitoring arrangement and system.
The Minister sought to persuade us that, by making each community health council conterminous with the district health authority, he would make them more effective because they would monitor the same area and could make strategic decisions. But the people whom CHCs seek to represent do not see it that way. I inform the Minister, in common with my hon. Friends who have spoken for Mid Glamorgan, South Glamorgan and Powys, that the people of Gwynedd reject the plan for the basic reason that, as my hon. Friend the Member for Merthyr Tydfil and Rhymney (Mr. Rowlands) said, community health councils surely must be based at community level to make sense. That is the way that the people of Ynys Mo n see it.
I am in the unique position of speaking for a people who live on an island. They know the sense of community that that involves. They reject the principle that their views should be taken into account in a wider context, particularly being an island people. The people of Anglesey are angry that their CHC is to be abolished under the Bill. We must also consider the geographical areas which the CHCs, as envisaged by the Welsh Office, would cover. We have heard about the problems of Mid Glamorgan, South Glamorgan and Powys, and I can talk about the problems of Gwynedd. It would be intolerable if we had community health councils which sought to represent the views of people on a county-wide basis. What involves people in articulating their views is what happens to them in their communities. It is not what happens at the other end of the
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county ; it is what happens to their hospital, doctors, friends and relatives. They can empathise with their colleagues and friends within their own villages. They cannot do so with people who live on the other side of the county.Mr. Grist : Does the hon. Gentleman suggest that patients who go to ysbyty Gwynedd would have to be represented by their home CHC? Or does he think that an overall CHC could better track from home to hospital the complaint or worry of a person from Holyhead who goes to ysbyty Gwynedd? Surely that would be better than if the responsibility were split between two CHCs. That is our argument.
Mr. Jones : I was coming to my next point, which is that the management structure of Gwynedd district health authority is unique in being based not on discipline but on geographical areas.
Mr. Michael : Does my hon. Friend agree that the Minister's intervention seems inappropriate to the new clause because the new clause would provide consideration of the needs of the individual community and co -ordination between CHCs? I hope that the proposals for the break-up of the structure within Gwynedd health authority will not go ahead because that would remove the link between management and local communities.
Mr. Jones : Absolutely right. My hon. Friend makes his point effectively.
There could be an improvement in the management structure of Gwynedd health authority. The Minister knows that I have been highly critical of its operations in recent years. Where management is based on geographical breakdown rather than on discipline, there is a case for having CHCs for each geographical area within the county. The Government constantly tell us that we should put the patient first. If the patient is to be rooted in a community and the voice of that community is to be articulated, it should be under a smaller system of CHCs.
One of the new structures created by the Bill is NHS trusts. God forbid that any operate in Wales. I am not aware of any hospital that has announced that it wishes to seek trust status. If one did, the danger is that other district general hospitals may find that they cannot provide the comprehensive health care which they are obliged to provide under statute because of a lack of resources and they may wish to buy in services from neighbouring authorities. We need CHCs locally to consider that.
In fairness I should say to the House that I was impressed with the lobby which the Welsh Association of Community Health Councils organised a few weeks ago. Its message--each CHC area in Wales was represented--was that the Government's plans would be detrimental to the monitoring of the Health Service in Wales and that the measures contained in the Bill would not lead to better services. Therefore, it is vital to have an effective local watchdog.
I am not aware of any body, person or organisation that has expressed support for the Welsh Office proposals in its consultation document. If the Minister were to reply again, perhaps he could tell us whether, as a result of the consultation procedure, any body, organisation or group of persons representing the Health Service in Wales supports his proposals.
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Mr. Alex Carlile : I listened without surprise, but with accustomed dismay, to the earlier interventions of the Minister. They have confirmed the worst suspicions of people who live in rural Wales. Apparently, Welsh Office Ministers still consider Wales to be a small place somewhere near Cardiff. As a Member representing a rural constituency, it seems that Montgomery is simply being cast into the Cardiff mould for the decision- making on community health councils. It is too far north for community considerations to be bothered with.
When the Secretary of State limps out of the Welsh Office he will leave quite a legacy behind him--the county councils, which he was responsible for creating during the previous Conservative Government, and which nobody in rural Wales ever wanted. The Government usually find that when a new authority is created eventually people get used to it, and they acquiesce in its existence and get on with the job. However, 16 years after the creation of the new Welsh counties we still do not want them, and we have not got used to them. It is offensive to the people of mid-Wales to have further community facilities and democratic accountability--if there is any accountability in this--ascribed to the same level as those unwanted county councils. When the Secretary of State leaves office we shall still have his unwanted county councils and our representation in health matters in mid- Wales will have been reduced to the same poor level.
In the early part of the 1980s, the Boundary Commission for Wales made a provisional recommendation that the seat which I represent and the constituency of my hon. Friend the Member for Brecon and Radnor (Mr. Livsey) should be merged to form a single Powys seat. There was a detailed hearing of the merits of that before a deputy boundary commissioner, Mr. David Glyn Morgan. After careful consideration of the evidence, Mr. Glyn Morgan came to the sensible conclusion that it was absurd to combine the communities of Montgomery--the old county of Montgomeryshire--and Brecon and Radnor. Why did he come to that conclusion? Because he could see that they are two distinctive communities which require distinctive representation ; two geographical areas ; two traditional community areas, with traditional community ties ; two disparate communities. Therefore, he recommeded, and the Boundary Commission for Wales accepted, that there should be two separate constituencies. Exactly the same arguments apply to the number of community health councils in Powys. It is a particularly stark fact for the people of Montgomeryshire that we are not as well served by the National Health Service as other areas. We have no district general hospital. Every patient who requires acute treatment has to go elsewhere to a district general hospital--and not to just one but to one of a selection- -perhaps in Shrewsbury, Aberystwyth, South Powys, Hereford or Wrexham. It is ridiculous to suggest that a Powys community health council--bearing in mind what my hon. Friend the Member for Brecon and Radnor said about the size of Powys--could scrutinise the adequacy of health services made available to people in my constituency. It is likely to lead to a decline in accountability. We know what the Government are up to in their proposals concerning public bodies in Wales. They are reducing their size. In some cases that may have merit. However, they are being
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reduced in size so that the Government can carefully put into place those who sympathise with their political views. That is a recipe for patronage.Wales has been riddled with patronage for at least 80 years. It is time that there was a little less patronage in Wales and a little more democratic accountability. The putting in place of a few Tory business men and business women will not satisfy the people of mid-Wales.
Mr. Grist : If the hon. and learned Gentleman looks at the consultation document, he will see that we have left the appointments system exactly the same as it is at present.
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Mr. Carlile : That is a joke and a half. Of course, the Government have left the patronage system as it is at present, but it will be much easier to find six or nine Tory business men than 32 or 34 Tory business men. It will be jolly easy, thank you very much, to pick out the chosen few --the chairmen of the Conservative associations and so on--to fill these jobs. If ever there were a bit of obvious cynical politicking, this is it.
From our viewpoint in mid-Wales--it is a special viewpoint, for the reason I mentioned : that there is no district general hospital within my constituency--it is high time that the Welsh Office recognised the need, which many have spoken of in the past, for a new mid-Wales health authority and for community health councils to be based on the very large district council areas that already exist. I mentioned earlier in the debate the size of my own area. That seems to me as large as one community health council can cover and manage. I pay tribute to the work that has been done in the past by my constituency's community health council. I deplore its passing. My hon. Friend the Member for Brecon and Radnor was right to refer to the need for checks and balances. The trouble is that the Government do not care about the balances. All that they care about are the cheques--not the kind of checks to which my hon. Friend referred.
Mr. Rhodri Morgan (Cardiff, West) : I intend to refer to the problems that constituencies will face if the Government do not accept new clause 3. It attempts to ensure that the community health councils will be able to look after consumers in our constituencies and provide the services that the National Health Service is supposed to deliver.
My constituency will need to call on the services of the community health council in Cardiff. The result of the severe underfunding of the South Glamorgan regional health authority is that it now proposes to close six hospitals, three of them in my constituency--one large and two small hospitals. St. David's is the large one ; Glan Ely and the Ely ear, nose and throat hospital for children are the two small ones. The proposal is to close them during the coming financial year.
According to the document that was made public in February by the South Glamorgan regional health authority, consultations will be held on the closure of those hospitals immediately after 1 April. The community health council will take part in the consultations. The Minister said earlier, "If we have countywide community health councils, they will be able to take a more strategic line." That means that they would fit in with the regional health authority's thinking. They would not be so effective in representing the interests of the consumer. They would
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be able to understand what the management had in mind. They could be persuaded that the offer being made by the health authority--"We shall close down these six hospitals, reorganise the service and reduce the number of beds", and so on--was understandable. Being on the same strategic plane, they would be able to see that the health authority was doing the right thing. Of course, in reality, the Government are reacting to a severe underfunding crisis in South Glamorgan- -underfunding to the extent of £7.5 million. They are closing hospitals so that the land on which they stand may be sold. In other words, revenue underfunding in the county is being made good by the sale of capital assets.The type of problem that we in South Glamorgan face as a result of this clash with patient or consumer thinking is illustrated by the seminar that the NHS in Wales is organising this summer for the purpose of inculcating what it calls management thinking. It will be a wonderful seminar. It is being commended by John Wyn Owen, the director of the NHS in Wales. Indeed, the director has almost threatened that everybody involved in the NHS in Wales ought to attend. In the leaflet of invitation that was sent out on behalf of the NHS in Wales and the Yale university school of management he says :
"The need for the organisational development and the use of different management methods brought about by the White Paper"-- the White Paper "Working for Patients", not legislation "has made the programme of even greater relevance and interest at this time. I unreservedly commend it to you and look forward to seeing colleagues at this event."
Mr. Win Griffiths (Bridgend) : Does my hon. Friend agree that this is a serious waste of paper? As American health costs are two or three times those in the British Health Service, it is unlikely that the Yale university school of management will be able to offer us any advice on the provision of patient care at low cost.
Mr. Morgan : I could not agree more. The cost of this seminar in Llandrindod Wells will be £1,500 per person attending. How many holidays in Llandrindod Wells could one normally get for £1,500? In addition, there is £225 VAT. This is to enable people from Yale to teach us something. But, as my hon. Friend says, in terms of National Health Service administration costs, we could teach them something. We could teach these professors from the Yale university how to run a health care system with very low administrative costs. The NHS in Wales is trying to inculcate this sort of management bunkum, whereas what we want is more money for the system. We do not want whiz-kids uttering buzz words ; we want more medics delivering health care. Unfortunately, the elimination of community health councils will hardly help. It will lead to a culture in which management methods are finance-oriented--a culture in which, in the end, health care systems work for profit rather than for patient care. We need community-based CHCs to prevent that.
I listened very carefully to the Minister's remarks. I always find myself accepting that he is very sincere. He has an outgoing personality. If the electors of Cardiff, Central have anything to do with it, we shall discover at the next election just what an outgoing Member of Parliament he is. We in Wales do not want a transatlantic takeover. We do not want to be deprived of the ability adequately to resist the closure of hospitals. We want to be able to put forward the case for keeping the hospitals that we have. We do not want to see Ministers indicating to senior
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management staff of the NHS in Wales that we are heading for a finance-oriented system full of accountants and involving lots of expenditure on management conferences and new computer systems. We want a system whereby the CHC at community level represents the interests of the ordinary consumers of the NHS. If they want hospitals to remain open that the management wants to close, they should have the right to put their case as effectively as they can. If the Minister thinks that he can get South Glamorgan health authority to close St. David's easily, he has another think coming. There will be an almighty row. We are not willing to accept that, suddenly, because of revenue shortfalls, health authorities will be panicked into making short-term hospital closure decisions. That will be the rocky road to ruin. It will mean that health authorities are left with no alternative but to sell their capital assets to make good the shortfall in money that the Government should provide.Mr. Win Griffiths : We have had quite an interesting debate in the early hours of the morning. If we look at the Government's proposals once again--heaven knows, we have done so often enough--we see that they are based on a theory that has already been discredited in practice in many countries. In the United States, Switzerland, France and Germany, where there is much more of this so-called competition, average health costs are double those in the United Kingdom. The Government wish to bring into our Health Service market principles that are supposed to make the service more cost-effective and more sensitive to consumers' needs, but no health service in the world can support those claims.
On the basis of that discredited theory, the Welsh Office has already agreed to inject an additional £5 million into the Health Service to provide it with the information technology needed to enable the market system to operate. If the Government genuinely want to ensure that the new system is sensitive to the user's needs, a substantial increase will be needed in the resources made available to the community health councils. They are the statutory bodies charged with representing user and community interests in the NHS. Instead, there has been a Welsh Office consultation paper in which the Secretary of State for Wales proposes to reduce the number of CHCs from 22 to nine. The Minister suggested that the Welsh Office would listen to all the responses, but he suggested also that our new clause, which is much more along the lines of the existing system than is the Government's proposal, is not to be countenanced. It seems as though the issue has been prejudged and that this is a deliberate attempt by the Welsh Office to remove a genuine local focus for anxieties about the NHS in Wales.
My CHC in the Ogwr district of Mid Glamorgan, which is superbly serviced by Mr. Chris Johnson, its secretary, does a tremendous job monitoring developments. There is no way that that CHC, translated into the county of Mid Glamorgan with the same number of people, could possibly monitor the entire Health Service in the county ; it is out of the question. I hope that the Minister, in reviewing the responses he has received, comes to realise that that is the virtually unanimous opinion of all the people and all the organisations that have responded.
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Under the proposals, this extremely good community health council is destined to be swallowed, along with the three other community health councils in Mid Glamorgan, into one body with the same number of members--24. It cannot do the same job across the county as each of the present councils does in one district of Mid Glamorgan now. 4.15 amIn competitive business, commercial companies often take steps to ensure consumer satisfaction. There may be a move towards encouraging district health authorities, family health service authorities and service providers to assume more responsibility in this area themselves. However, in the commercial world, it is in the interests of the providers of goods and services to undertake that work in an objective manner. One cannot get such work done in the same way within the structure of a health authority. Patients do not have the same purchasing power as consumers have in the outside world. The two cannot be equated. In the National Health Service, purchasing power will lie with the procurers of the service, such as the district health authorities and the GPs who hold their own clinical budgets, rather than with the patients or the public at large. The imperative for the service providers will be to satisfy health authorities and GPs rather than patients. If patients benefit, it will only be by chance.
Community health councils as statutory and independent bodies must be recognised as having a primary responsibility for insisting on and measuring user satisfaction. They must be properly resourced to enable them to undertake that task effectively. Much of that input depends on the work of volunteers within the structure of community health councils. To imagine that the 24 good men and women will be ranged up and down the county of Mid Glamorgan--and this will be even less true of counties such as Powys--is to place a responsibility on them which cannot be sustained. We must look to community health councils that genuinely represent communities. Perhaps the Government do not fully appreciate that the councils are not only good at the provision of information, advice and assistance to individual members of the public, but are often the only groups performing such a task across the whole area of a health authority.
That part of CHCs' work is likely to increase substantially with the more complex pattern of services that the Government intend to introduce through the Bill. The Government are, unfortunately, seeking to introduce a far more market-style National Health Service. They will reduce the number of people who will provide an information service to patients seeking help in the Health Service. So far, community health councils in Wales have done an extremely good job with minimal resources. I should like the Welsh Office to review their work to see how it could be done more effectively, but merely to make a proposal to cut the numbers is wholly out of keeping with any form of providing an improved service.
The consultative document issued by the Welsh Office gives no confidence to the public that the CHCs will be able to do the job better when their numbers are slashed. The Department should accept that the CHCs will be even more important as part of the complex system that is being introduced.
Should the Bill pass unamended, we will move first to the commercialisation of the NHS and then to its
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privatisation. In other words, this measure represents the first step towards the privatisation that the Government are trying to avoid having tagged on to them. The public at large know that that will happen, and it worries them.The type of care that will be provided will be a precursor of what is now happening in America. We must face the fact that the more we introduce competition and the concept of cost-effectiveness in patient care, the sooner that American type of care will be on our doorsteps. Patients will become customers, cash will be king, cost-cutting will have a greater priority than patient care and access to treatment will be enhanced by personal payments. The Government frequently say that they are spending more on the NHS. They are hiding behind the facade of the retail prices index, which has no relationship to the real cost of providing health care and meeting the expanding needs of the NHS, faced with our aging population.
Mr. Grist : I have been listening to this farrago for long enough-- [Interruption.] The hon. Gentleman will appreciate that the vast bulk of the cost of the NHS is made up of pay, which is set against the cost of living index and therefore has a direct bearing on that index. Health authorities do not pay mortgages, which feature largely in the cost of living index. In other words, those issues have a great effect on the index.
Mr. Deputy Speaker (Mr. Harold Walker) : Order. All of that is a considerable distance from the substance of the new clause that is being debated.
Mr. Griffiths : Community health councils play an important role in seeing that health authorities are properly funded so that patients get the care they need. Despite the Government's claims about putting extra money into the NHS, hospital waiting lists continue to lengthen and, because of the aging population and the stress that many people face due to high unemployment and more costly mortgages, greater use is being made of the NHS.
Not for the first time, I was confronted this week with a case that many other hon. Members will have faced. An old-age pensioner telephoned me almost in tears saying that he had been discharged from hospital into his home without anybody to look after him. He said he could not cope and was feeling unwell. I had to contact the health authority and social services to ensure that that old gentleman was not left to his own devices.
Such people are not being pushed out of hospital because they are considered to be well enough to manage on their own ; they are having to leave to make beds available for others who are seriously ill. The CHCs, by monitoring developments of that kind, can highlight the need for a better- funded Health Service.
Why are health authorities in Wales--and, indeed, all over the country-- crying out for cash for patients, when operations are being rationed? At Christmas last year, the Princess of Wales hospital in my constituency stopped all non-urgent operations for three weeks when waiting lists were growing. That is a scandal, and the Bill does nothing to deal with it.
Mr. Alan Williams : I did not intend to speak, but I want to respond to one or two points made by the Minister. As he knows from my experience with my local health authority--he has been of great assistance in that regard
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--I have as great an interest as he has in devising an effective method of controlling what could otherwise be arrogant and arbitrary authorities, although we may disagree on how that is to be achieved. There is no health authority in Wales more arrogant or arbitrary than that in West Glamorgan, as the Minister knows from the case of the Singleton casualty unit. We start from the same premise : we want an effective monitoring system that represents public interests vis-a-vis the policy decisions made by health authorities. Nevertheless, I find it somewhat worrying--indeed, virtually grotesque--that a Bill that will change the system more drastically than it has been changed since the Health Service was established, so that even doctors are afraid that patients will be rendered into units of account by the budgetary system for GPs and the best-buy approach towards hospitals, also does something very different : it releases into that depersonalised system the very people who are least able to fend for themselves.As a barrister, the Secretary of State for Health will remember--as will some of my hon. Friends--that, when the House first debated the abolition of the death sentence, one of the arguments against a life sentence of more than 10 years was that people who had served a sentence of 10 years or more became institutionalised. A week ago, a gentleman came to my surgery having just spent 30 years in a series of mental institutions. Now, in the community, he will have to survive as an individual, against the changing background that the Government are trying to introduce. He will find himself desperately dependent.
The Minister said that there would be no alteration in the CHCs' primary role of monitoring the changing pattern of the NHS. As I have said, however, this is a time of the most rapid change since the establishment of the service. As my hon. Friends have said, at the very time when monitoring is most needed--particularly in rural areas--it is being reduced. We are in danger of making the CHCs more inaccessible, not more accessible ; more remote, not more available ; and more difficult to find and approach.
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Sitting alongside the Under-Secretary of State is the Secretary of State for Health, who has not enjoyed the greatest of eulogies in the past few months. But he at least is creating smaller CHCs in England than his colleague is seeking to impose on Wales. The Government are reducing the number of CHCs from 22 to nine, at the same time as they are halving the number of people who will be involved in them, and so halving the number of people available to the public and to carry out the very monitoring that he has admitted remains their primary role. The Under-Secretary must ask himself how CHCs will achieve their primary function on much diminished individual resources. There just is not the manpower. There is no logic, other than on paper, in saying that there should be one CHC for each health authority. In Wales, except in Dyfed, the Minister is saying that there should be one CHC per county. If that is what he wants, it would be more logical--but not necessarily the best thing to do--to say that rather than create a special quango we already have representative organisations at county level. They are called councils. If he thinks that a county basis is correct, a machinery already exists that is more democratic than the one that he is seeking to impose.
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Mr. Grist : The right hon. Gentleman will appreciate that we are not proposing to cut the amount of money going to CHCs. Therefore, the nine that we propose would be better resourced and so better able to carry out such work as patient surveys, which they may find beyond them at the moment. There is a pay-off there. It is difficult to know how 37 would be financed, particularly with a standstill on overall finances.Mr. Williams : The Minister says that he will halve the number of people and give them the same resource. If he is cutting back on the number of people, it would be logical to increase the resource in order to enable the smaller number of people to use more up-to-date techniques to achieve his and our objectives.
Mr. Grist : The right hon. Gentleman seems to have misunderstood me. The same amount of money will be given to a smaller number, so they will have more money available.
Mr. Williams : But the point is that it is the same money, not more money. Therefore, the financial resource is the same. There are just fewer people to use it and to take advanatage of it. But the Minister does not understand that. That is where he has gone wrong. I hope that he will listen instead of laughing.
The Minister said at the outset that he approached the debate in an open- minded manner, but he does not give that impression and I am saddened by that. This need not be a point of great principle between the two sides. If there is genuine consultation, he should be willing to listen and not take a pre-set position. He should not sneer when someone is putting forward an argument in a reasonable way. I could make a completely different speech, which I would much more enjoy giving and which the hon. Gentleman would much less enjoy listening to, if I wanted to make a political speech. Atypically, I have tried to be eminently reasonable in the debate with the Minister and his colleagues.
The Minister started at the wrong end. He talked of bureaucracy but he brought to us a plan drawn up by bureaucrats for bureaucrats. He started with the system instead of with the people. He should have started not with the number of individual health authorities, but with the 2.5 million patients. He should have asked himself, "What is the correct structure to enable the interests of 2.5 million people to be properly monitored, sounded and represented by and to the health authorities and the Welsh Office?"
The Minister should remember that we are talking not just about policy decisions, but about monitoring local implementation and the results of those decisions. That is what matters to our constituents. That is why I said that he started at the wrong end. I return to the parallel that I put to him earlier ; I am not suggesting that there should be 38 councils. He seemed to misunderstand my point. There is a parallel to be drawn. In Wales we have 38 Members of Parliament, representing 2.5 million people. Does the Minister seriously think that we would do our job more effectively if we each represented two or three times as many constituents as we do at present? If he thinks of his surgery and daily caseload, does he seriously believe that he would do the job more effectively if he was responsible for two or three constituencies? That is what he is saying about the health councils. He wants them to become more remote and more difficult for the public to
Column 336
get to, yet they are supposed to be more representative. He is actually creating the reverse of what, I am sure, he genuinely wants to produce.Will the Minister not be set and predetermined in his responses? There will be no crowing from the Oppositon if he says, "We have listened to the arguments and we think that some of the points that you have made were right. We reject other points, but on this particular point we think that the Opposition--not just as a party sitting on the Benches, but people in Wales, including the doctors, those in the Health Service, and the patients --are right. We acknowledge that we put forward a proposal in good faith, but on analysis it has proved to be wrong. Therefore, we shall be big enough to step back".
Mr. Michael : I had hoped that the Minister would respond to the generous invitation of my right hon. Friend the Member for Swansea, West (Mr. Williams) who was right to point out where the attention should be focused in this debate and to suggest that the Minister should start with the people, patients and the communities in which they live. That is what the debate is about and what the Minister has simply not understood.
Conservative Members have failed to respond to a constructive proposal. It is deeply disappointing that the Minister has been so negative. The Conservative party, generally, has been pathetic in this debate. We had a single sentence from the hon. Member for Pembroke (Mr. Bennett), who has otherwise been conspicuous by his absence. Apart from that, the Minister has been the single, lonely Conservative Member, rejecting the one opportunity open to him to build into this deeply unpopular and dangerous experiment with our National Health Service in Wales the representative of consumers in the community. As a Cardiff Member, I am ashamed of the Minister's response. The city of Cardiff, like every other community in Wales, rejects his plan and needs the new clause. His majority is not very large, so he will not be in the House much longer.
The Minister suggested that the CHCs--and there will be fewer of them-- would be better resourced. They have an impossible task. The hon. Gentleman is trying to emasculate them and largely to eliminate the voluntary commitment that they attract and on which their work depends. I was amazed to hear his extraordinary claim that the new clause would fragment the community health services in Wales. That is complete nonsense because it is his proposals that will destroy them.
I regret that the Minister demonstrated his ignorance of the commitment and effectiveness of people in the local community if they are supported and encouraged to help a service in which they believe. The new clause offers a mechanism to co-ordinate the views of the more local CHCs that the hon. Gentleman proposes so that, where appropriate, a single view can be expressed across a county or district health authority area. That mechanism is built into the new clause, so why is the Minister rejecting it?
The Minister suggested that the link between the CHCs and what are now called family health service committees would be removed. That is untrue. The hon. Gentleman could not have read the clause. Paragraph (a) states :
"shall assume in its area, such responsibilities and duties in relation to health matters and services as are undertaken by the existing Community Health Councils."
No element in the work of the existing CHCs will be removed if the new clause is accepted. It involves representation in the development of plans within a county
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council area because care in the community cannot simply be carried out by the local authority. We cannot ignore the overlap between the social services department, the health authority, the housing department and so on.The new clause is an intensely practical recommendation. The Minister's response is impractical because he ignores what is done by CHCs--the regular and frequent visits to all hospitals, clinics and day centres ; the fact that members of existing CHCs talk to patients and their visitors ; the fact that they see conditions in Health Service provision as they are. That is what we want on a more local basis, taking into account the development of care in the community, and co-ordinated countrywide to provide the single, coherent voice that the Minister says that he wants.
I regret that I have to conclude from the debate that the Minister does not believe in giving the consumer a voice ; that he does not believe in co- ordinating services in a way that involves the community ; that he does not understand how communities tick. He has proposed a plan that will render the representation of the consumer in the community meaningless, and he had better think again. Question put, That the clause be read a Second time :
The House divided : Ayes 55, Noes 140.
Division No. 117] [4.43 am
AYES
Abbott, Ms Diane
Barnes, Harry (Derbyshire NE)
Battle, John
Bennett, A. F. (D'nt'n & R'dish)
Bradley, Keith
Carlile, Alex (Mont'g)
Clarke, Tom (Monklands W)
Cook, Robin (Livingston)
Cousins, Jim
Cryer, Bob
Dalyell, Tam
Davis, Terry (B'ham Hodge H'l)
Dixon, Don
Dunnachie, Jimmy
Flynn, Paul
Foster, Derek
Griffiths, Win (Bridgend)
Harman, Ms Harriet
Haynes, Frank
Hinchliffe, David
Hood, Jimmy
Howarth, George (Knowsley N)
Howells, Dr. Kim (Pontypridd)
Hoyle, Doug
Hughes, Simon (Southwark)
Jones, Barry (Alyn & Deeside)
Jones, Ieuan (Ynys Mo n)
Kennedy, Charles
Kilfedder, James
Livsey, Richard
McAvoy, Thomas
McCartney, Ian
McKay, Allen (Barnsley West)
Madden, Max
Mahon, Mrs Alice
Maxton, John
Meale, Alan
Michael, Alun
Michie, Bill (Sheffield Heeley)
Morgan, Rhodri
Murphy, Paul
Nellist, Dave
Pike, Peter L.
Primarolo, Dawn
Redmond, Martin
Rowlands, Ted
Short, Clare
Skinner, Dennis
Spearing, Nigel
Wallace, James
Wareing, Robert N.
Welsh, Michael (Doncaster N)
Williams, Rt Hon Alan
Winnick, David
Wise, Mrs Audrey
Tellers for the Ayes :
Mrs. Llin Golding and
Mr. Ray Powell.
NOES
Alexander, Richard
Alison, Rt Hon Michael
Allason, Rupert
Amess, David
Arbuthnot, James
Arnold, Jacques (Gravesham)
Arnold, Tom (Hazel Grove)
Baldry, Tony
Batiste, Spencer
Bendall, Vivian
Bennett, Nicholas (Pembroke)
Blaker, Rt Hon Sir Peter
Boswell, Tim
Bottomley, Peter
Bottomley, Mrs Virginia
Bowden, A (Brighton K'pto'n)
Bowden, Gerald (Dulwich)
Bowis, John
Brazier, Julian
Brown, Michael (Brigg & Cl't's)
Burns, Simon
Butler, Chris
Butterfill, John
Carlisle, Kenneth (Lincoln)
Carrington, Matthew
Carttiss, Michael
Chalker, Rt Hon Mrs Lynda
Clarke, Rt Hon K. (Rushcliffe)
Colvin, Michael
Conway, Derek
Coombs, Simon (Swindon)
Couchman, James
Cran, James
Currie, Mrs Edwina
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