Localism is a big idea. It also a good idea. However not a new idea.
Here is Enoch Powell speaking during the Second Reading of the National Health Service Reorganisation Bill in 1973. He was stating the case against centralising measures for the health service. But the three objections he raised have a ratherontemporary feel, don't they?
Thus if my right hon. Friend was going to resolve the problem, he was, in fact, obliged to take the other alternative, as he has done, that of nationalising the community health services. That is the essence of this Bill: we have completed in the Bill the process of nationalisation of health care in this country which commenced with the National Health Service Act 1946.
I fear that in doing so we shall be found to have lost more than we have gained. The gain is obvious, such as it is. We have brought under one administrative umbrella—a word that I believe was used more than once yesterday afternoon by my right hon. Friend—all the health services operating or available in an area. As to administrative logic and tidiness, there can be no criticism and nothing left to desire. But I believe that for the sake of the shadow we have lost a great deal of substance.
In the first place, we have lost the only sources of independent policy, initiative and decision which existed outside the central Government in the whole range of health services. After drawing up the first hospital plan, I well remember, when, in 1962,I moved on to attempt a similar plan for community health services, how astonished and delighted I was to find that there was not one Minister of Health but 145 Ministers of Health: one Minister of Health and—at that time—144 local health authorities. I realised there were potentially 144 separate and independent sources of initiative, experiment, variation and adaptation to local conditions. I saw how rich were the sources of experience available to the health service under such a system compared with those that were still possible in the monolithic structure of the nationalised hospital service.
From now on there will only be one sort of policy and initiative in the community health services as in the rest of the National Health Service. There will be sources of information and opinion but this is something quite different from an authority which, having formed a view, can act upon it and be responsible for the consequences. That will have disappeared.
With it will go the independent status of the local officials. I do not know whether that is not just as important as the independence of local authorities. There one had men equal to any in the national Civil Service who enjoyed an independence and an independent responsibility which nothing can replace. They had an immediacy of contact with the people of their area. Every hon. Member, in assisting his constituents with their problems, has hitherto had reason to bless the existence of independent local authority officials of high calibre with whom he could deal directly and between whom and himself there could be completely unrestricted exchange of opinion and advice.
The Secretary of State for Social Services (Sir Keith Joseph) I am grateful to my right hon. Friend. I am agreeing with almost everything he is saying in what is a beautifully analysed speech. However, I do ask him to consider that the area health authorities, which he has just recognised will be agencies of infinitely greater potential and power than either hospital management committees or local health authorities will be able to pursue national policies by way of a wide range of initiatives. Any sensible Minister in any sensible Government will encourage the diversity and initiative which my right hon. Friend so rightly recognises are riches of the community.
Mr. Powell I am sure that my right hon. Friend and most of his successors would exercise their powers and duties in that way. But he has had to pronounce the fateful word "agency". They are the agents of the Secretary of State, who will be answerable to this House and the public for everything which is done or not done, not only as hitherto in the hospital service but in the whole range of community services. That means that even the most powerful community physician will be in a quite different position from the old medical officer of health, responsible to a local authority and to a local electorate.
The second great loss which I think there will be is through the growth of bureaucracy. It is inevitable that in bringing together under one umbrella, with the professed aim of co-ordinating them, services so subtle and diverse as the community health services, the family practitioner services, and the hospital services we shall find that one tier after another of administration will be erected in an effort to bring that co-ordination about.
A word about this concept of co-ordination. It is a delusion to suppose that in a department such as medicine and health care, which progresses by specialisation and by the growth of specialisation—I guarantee that every advance in health has come about as a result of a refinement of specialisation—co-ordination in the interests of the patient is produced by an administrative structure which will throw a roof over all those who ought to be co-ordinated. Co-ordination will come about, whatever is the administrative structure, only by direct links between one professional and another, one speciality and another, one function and the other. We may well find that we have impeded 1127 rather than facilitated that communication by this attempt to throw an umbrella over the whole.
The third, and perhaps most serious, loss is that we shall have taken away from local government, in the very period when we purport to be seeking to strengthen it, one of its most valuable and valued functions. We shall have removed from it services which attracted to local government some of the most dedicated people. We shall have taken away from it the functions, many of them functions upon which local government was built, which make local government respected by the electorate and central government.
These, then, are the three major losses —the growth of bureaucracy, the loss of independent sources of initiative and authority in the health services, and the removal of a major function from local government. This is the price that has to be paid for my right hon. Friend's solution to the dilemma of administrative division between the National Health Service and the community health services. I will not seek to deny my right hon. Friend his Bill tonight; but I am afraid that when we give it a Second Reading we shall be sealing the loss of things which once destroyed cannot easily be restored.