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National Health Service (Consultants' Contracts)

Volume 12: debated on Wednesday 11 November 1981

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Motion made, and Question proposed, That this House do now adjourn.— [Mr. David Hunt.]

10.27 pm

I thank my hon. Friend the Minister for Health for being present. No one in the House knows more about the subject of this debate and understands it better than he. Although our words may differ, the meditations of our hearts will be similar this evening. We agree on the importance of the reorganisation. I fully supported the Health Services Bill in Committee and have supported my hon. Friend in seeing the legislation put into practice. We are debating the matter because it is so important.

The debate stems from a letter that my right hon. Friend the Secretary of State sent to Dr. Nabarro of the joint consultants committee on 12 October. It stated:
"In Patients First, we argued that consultants should be employed by District Health Authorities, because we felt it was important for them to be fully involved in decision making at local level. However, I recognise that there is very strong feeling in the profession about this and I do not think it would be sensible to impose district employment on the consultant body against their will. By the same token, I feel I must take note of the views expressed by consultants in the large teaching centres that they are satisfied with the present system and wish it to continue. I have therefore decided that the best approach for the present will be to maintain the existing type of arrangement, with teaching Districts acting as employers, but with consultants working outside such Districts employed by the Regional Health Authorities.
That letter is important, because it tells us at least one thing, apart from the Minister's decision, and that is that the Minister does not agree with the decision. Nevertheless, he imposed it. I shall return to that point.

I have initiated the debate because, with my right hon. and hon. Friends, I have argued that consultants' contracts should be at the district level. The Minister will agree that I am being consistent with what I have said all along.

I also raise the issue because I have received a letter from the chairman-designate of the Peterborough district health authority, Mr. Gibson. He wrote to me complaining about the Secretary of State's decision, and he also wrote to the Minister for Health:
"The decision regarding the level of employment of consultants in the restructured health service is a great disappointment. It may be that the Department feels it has to recognise the very strong feeling within the profession on this subject, but one is bound to ask: what of the equally strong feelings of chairmen of districts as voiced at our recent meeting at St. Bartholomews? Are we not to be heard?
To make matters worse the distinction between teaching districts and others has been retained so that teaching bodies will act as consultants employers, a decision which, if I may say so, immediately demeans the non-teaching districts and labels them `third class.' In a stroke some districts are created more equal than others.… It is my belief that on a very fundamental issue some districts have had defeat thrust upon them. At the crossroads of decision expediency has been the chosen course".
Therefore, I represent not only my view, but that of my constituents and the chairman-designate of the district health authority.

What are the arguments against the Government's decision? I suggest that there are four and I shall deal with them in ascending order of importance. The first is that a minority of consultants have for a long time been employed by more than one district and have played off one district against another in order to do as they please. They have been able to do that with little fear of discipline, because the region is far removed from the grassroots where the consultants practise. The Government's decision will perpetuate the possibility of some consultants continuing to act in that way.

The second argument against the Government's decision is that it continues to foster elitism. Of course, doctors are important in hospitals, but we are increasingly moving to the idea of team spirit, with doctors being primus inter pares. That is not a view which doctors would like to have of themselves, but it is increasingly becoming the reality. Because of that, I was interested in what my right hon. Friend the Secretary of State said in the debate on the Gracious Speech. He said:
"Looking to the future, it appears that the key word for the 1980s is partnership—partnership in a number of areas."
My right hon. Friend listed three areas and added a fourth:
"a partnership concerns the health professions themselves. The National Health Service relies upon the dedicated work of its staff, and we must make the best use of its skills."—[Official Report, 6 November 1981; Vol. 12, c. 226–7.]
I do not understand how my right hon. Friend can speak in glowing terms of the need for partnership in the professions, with which I agree, while deciding to distinguish consultants from the rest of the professions by putting their contracts at the regional level whereas all other professions have their contracts at district level. This is bound to be viewed by the rest of the staff as a divisive move—a move which will pander to the self-esteem of the consultants and is the very antithesis of the partnership of which my right hon. Friend the Secretary of State was speaking so highly a few days ago.

The third reason why this Government decision is wrong lies in the financial area. My hon. Friend will know better than most that it is the senior doctors in any hospital who generate the most spending. That is of necessity the case. Yet, because of this decision, they will not be accountable to the accounting unit. The district is responsible for the disbursement of finance, but those who will generate the most expenditure are not responsible to the district. That seems to me to be a very difficult position to defend.

The fourth reason why the Government decision is wrong is, I believe, the most important one. It is wrong because it is out of keeping with the whole philosophy of the health services legislation. The House does not have to take my word for it, because the former Secretary of State for Social Services—now the Secretary of State for Industry—said:
"I want the new authorities to enjoy considerable autonomy in managing their affairs … Regions' responsibilities for strategic planning, the allocation of finance to the districts and the maintenance of financial discipline will remain."—[Official Report, 23 July 1980; Vol. 988, c. 506.]
As far as I can see from the record, those are the only three things that have been allocated to the regions under the new system.

My right hon. Friend, the then Secretary of State for Social Services, also said that
"there needs to be a substantial strengthening of the management of services right down at the local level. Those responsible for taking decisions in the hospital and in the community must have more authority, higher seniority and more autonomy. Perhaps the loss of an effective decision-making capacity by hospital managements was one of the worst consequences of the 1974 changes."
So my right hon. Friend outlined the philosophy behind the move, which my hon. Friend and I have supported so strongly. The regions were to go back to doing what they were originally intended to do—strategic planning, the general disbursement of funds, and the maintaining of financial discipline. The decisions, the autonomy, were to be at the district level.

My right hon. Friend went further, because he addressed himself to the question of consultants' contracts in that same speech, when he said:
"One of the errors made after 1974 was the insistence by the Department of Health and Social Security that there should be, as it were, a management pyramid for each support function. It was that, perhaps more than anything else, which had the effect of sucking decisions away from the ground, up the line, and which has been so heavily criticised. One of the contributory causes of the suction pump effect has been the fact that consultants' contracts are held at regional level. As I have made clear to the British Medical Association, I am very anxious that we should reach agreement with the hospital and community doctors' representatives that the new district health authorities should be the employers."—[Official Report, 27 October 1980; Vol. 991, c. 66–68.]
That was the view of the Government. It was the view in "Patients First". But it is not the view today.

In changing their mind, the Government have done a great disservice to their new reorganisation. The former Secretary of State made it clear on the last occasion that we had problems because practice did not accord with philosophy. I believe that we have made exactly the same mistake again.

Why has there been this change from "Patients First"? It is not a change of principle. If that were so, all the consultants would have their contracts in the same place, but some of them are at district level and some are at regional level. I am forced to conclude that the chairman-designate of my health authority was right when he said:
"At the crossroads of decision expediency has been the chosen course."
I have no doubt that in private senior medics threatened and bullied the Government and that this decision is the result. That is clear from reading between the lines in the letter from my right hon. Friend the Secretary of State. This is the unacceptable face of medicine. The House should recognise it as such. The nation will regret this decision, for it will impair the smooth working of the reorganised Health Service, and I believe that the consultants will regret this decision because, by it, they are using up much good will which they may wish to have in store at a later date.

I suspect that my hon. Friend the Minister will say that the Government are willing to review the decision in a year's time. I must tell him that if that is what he says, this House and the medical profession will understand that nothing is to be done about this decision. The senior medics have bullied their way over the Government's better instincts yet again, and we shall all be the losers. I do not expect my hon. Friend to announce tonight a reversal of the decision, but I urge him to agree at least to reconsider it.

10.42 pm

I understand very well the concern of my hon. Friend the Member for Peterborough (Dr. Mawhinney) over this matter. He has put his views very clearly. Both he and I have worked in great teaching hospitals. I appreciate how strongly and sincerely he feels about this subject. I am very grateful to him for bringing it before the House, and I am glad that I am able to reply to him.

This is an extremely important subject. As my hon. Friend knows, we have given a great deal of thought to it recently. I have some sympathy for my hon. Friend's views and the strong argument that he has just made. I share, for example, his view that we want to have all the authority and autonomy possible at the local district level. That is essential if the reorganisation of the Health Service is to go as we should all like to see it.

However, I ask my hon. Friend to consider this matter in the overall context of the Health Service. It is very important that the reorganisation goes ahead speedily and with the fullest co-operation of all the staff. My hon. Friend has put before the House the arrangements that are suggested—that the consultants and senior registrars will be employed by the region, except in the new teaching districts where the consultants are perfectly happy to continue to be employed locally. The teaching districts are in compact centres of population, so there are not the same problems for consultants who need to work over a large area of country and who would find themselves working in a number of district authority areas.

The level at which consultants should be employed has been a difficult problem ever since the National Health Service began. At that time it was decided that only consultants working in teaching hospitals should be employed locally. The others were to be employed by the regional hospital boards. This was seen as being extremely important to the medical profession, which was worried about maintaining clinical freedom in a salaried service.

The matter was examined again in 1974 when the Health Service was reorganised. Again, it was decided that the consultants should be employed by the region apart from those working in the teaching centres. With the present restructuring, the issue has emerged again. When we issued the consultative document on restructuring, "Patients First", we suggested that all the consultants' contracts should be with the new district health authorities. It seemed to us sensible then that if the new authorities were to be really effective and masters in their own house they should employ all the staff. We saw this as supporting the new authorities and also the staff.

Over 450 organisations, groups and individuals gave their comments. Some were in favour of district employment. They saw it as a great advantage if the new districts had direct responsibility for its consultants. They saw this as a help in providing services. They thought that it would enable consultants to be involved more directly in planning and carrying out the new district policies. They also thought, as my hon. Friend believes, that if all staff groups—doctors, nurses and technicians—were employed by the same authority it would create greater unity within the health teams. I was sympathetic to this view.

However, others took a different view. They pointed out the complications for a consultant with duties in several districts having to be responsible to all of them. They saw considerable difficulties in a relatively small district if a consultant were in breach of discipline or became ill. They thought that there would be extra administrative costs if contracts were spread over each district rather than concentrated centrally at the region. There were also extensive worries—we took note of them—that being employed locally could lead to situations in which a consultant could find himself in conflict with his employer if proposals were made by the employing authority which, in his view, were not in the best interests of his patients.

There was a conflict between the need to provide a local service and to preserve the best interests of patients and the need to have an employer who was not directly involved in the local service. It will come as no surprise to my hon. Friend to learn that we have received many letters on the subject. Discussions took place. There were meetings between the representatives of the medical profession and officers of the health authorities, and officers of the Department looked at the practical implications.

Perhaps the most significant conclusion was that it is not a simple choice between region and district. Not only does the work of many consultants involve them in the work of more than one district but on some specialities they are involved in work that can only be planned by the region. These are the regional specialities. It was also put to us that the regions have a more overall view of medical manpower generally and a better view to safeguard the distribution of consultants as well as seeing that the training posts available fit as nearly as possible into the career opportunities.

The choice was not easy. At this point, the report on medical education by the Social Services Select Committee was brought before the House. The Committee endorsed the need, suggested in "Patients First", for regions to maintain an overall strategic role over medical manpower planning and the distribution of consultants. However, as my hon. Friend knows, it came down in favour of consultants being employed by the districts, partly to ensure that the regions, where the Committee proposed that all the junior staff should be employed, were not administratively over-burdened, and also because it felt that the districts would in that way be encouraged to employ consultants rather than junior staff. That would benefit patient care.

The Committee's views are extremely important. Even after all the discussions took place, which were completed by that stage, we felt that we should re-examine the position and look at the Committee's recommendations very carefully. That we did. However, we had to recognise that virtually no medical professional body was in favour of district employment for consultants. The BMA and the joint consultants committee, which reports for the Royal colleges, argued strongly for regional contracts. That view was endorsed by hospital doctors generally, by general practitioners, and by the community physicians. In fact, it was endorsed by all sections of the profession.

It was thus quite clear that if we imposed district employment the new health authorities would start with an apprehensive and unhappy medical profession. We felt that that would seriously affect the success of the new authorities. On that basis we concluded that the consultants' contracts, other than in the teaching districts, should be held at the regional level. I hope that my hon. Friend will see the wisdom and strength of argument for the decision. I am very grateful to him for bringing the matter so fairly, clearly and sincerely before the House.

Question put and agreed to.

Adjourned accordingly at eight minutes to Eleven o'clock.