National Health Service

HC Deb 27 October 1983 vol 47 cc441-523 4.25 pm

Mr. Neil Kinnock (Islwyn)

I beg to move, That this House reaffirms its active belief in the principles of the National Health Service established by the Labour Government in 1947; pledges itself to maintain and to improve the standards of health care, free for all at time of use and need, to which the people are entitled; and calls upon Her Majesty's Government to reverse its stated policy of cuts in hospital and medical services. The motion has been necessitated by three factors. The first factor is that we consider the National Health Service and its future to be an issue of paramount importance on the agenda of the nation. We are sad that, by her decision not to speak in the debate, the Prime Minister has made it clear that she does not share our view of the primacy of the issue. I understand that there are several explanations for the right hon. Lady's absence. They include the fact that she wanted to leave the Government's Front Bench participation in the debate to the experts. I could not understand why she was quite so bothered about that, as she manages in foreign affairs without the assistance of her experts.

Our second reason for tabling the motion for debate today is the systematic and persistent reduction in the real standards of provision in the NHS between 1979 and 1983.

The third reason for the debate is the intensification of the attack on the NHS by the Government since they were re-elected on 9 June 1983.

Concern about the NHS is not limited to the Labour party, either inside or outside the House. I know that there is concern on the Government Benches. I read the papers and I listen and hear. I hear the complaints of the hedgers who have been ditched. These include the right hon. Members for Cambridgeshire, South-East (Mr. Pym), for Chelmsford (Mr. St. John-Stevas), for Chesham and Amersham (Sir I. Gilmour), and now the right hon. Member for Guildford (Mr. Howell) has joined the honourable ranks of those who are continually offering their encoded messages and warnings to the Government about the way in which they are proceeding.

There are new figures on the scene. We now hear from the right hon. Member for Shropshire, North (Mr. Biffen), the Leader of the House, and the right hon. Member for Worcester (Mr. Walker), the Secretary of State for Energy. When issues about the welfare state and unemployment are raised, the right hon. Member for Waveny (Mr. Prior), the Secretary of State for Northern Ireland, seems to be in a permanent state of suspended resignation. I understand that when the onset of the cuts following the election became obvious, the Secretary of State for Social Services made it clear that he disagreed with them. We see him now on television justifying the cuts and wagging his finger. The right hon. Gentleman seems to be in a permanent state of animated suspension. His protestations that there are no cuts will not wash with us.

As I have said, concern about the NHS is not limited to either side of the House or to the House generally; it extends beyond this place. More importantly, it is to be seen with greater intensity and is expressed with greater frequency by all the organisations that represent the health professions, including the Royal College of Nursing, the Royal College of Physicians, the Royal College of Surgeons, the Family Planning Association, the National Association of Health Authorities, Age Concern and all the trade unions. The list continues, and includes the Junior Hospital Doctors Committee of the British Medical Association and the BMA itself.

Recently, the secretary of the BMA said: Many Authorities have been compelled to have recourse. to measures such as transferring moneys from their capital accounts in an attempt to meet the cuts without making immediate reductions in services to patients, and this may well have long-term serious effects on the Service. It is already clear that if the cuts are carried forward into next year there will be serious consequences for patients. That was said not by a Labour party spokesman, but by an organisation that is generally not terribly generous or close to the views of the Labour party. However, it is united with us, as are many others, in unremitting antagonism to the way in which the Government are deliberately subordinating themselves to an utterly unrealistic economic and public expenditure policy, thereby seriously eroding the NHS, Britain's proudest possession.

The Secretary of State, who hears from the organisations that I have mentioned, describes them as vested interests. That is how he described them in his Conservative party conference speech. Yes, they are vested interests, but their interests are vested in patient care, healing and recovery. Those are the vested interests to which I should think the Secretary of State would want to listen. They have a vested interest not only of professionalism—the highest in the world—but of decency and altruism. The right hon. Gentleman should listen to those people.

Of course, the Secretary of State protests that he is not after those vested interests. He says that the cuts are after "the administrative tail". If his protests were valid, the people who should feel most reassured are the surgeons, physicians, nurses, auxiliaries—all those who demonstrably are not in any "tail" in the Health Service. They are what he calls the front-line personnel—the doctors and the nurses. However, those people are alarmed. They are not reassured by the Secretary of State's protests, or the protests of the Prime Minister, that the National Health Service is safe only in the hands of the Conservative party.Those practitioners are not reassured, because they are losing jobs, and they see the deteriorating services and the lengthening waiting lists. Day by day they are up against the realities of the consequences of cuts. Our motion has been tabled because of the testimony that we have received from those people of the contempt with which the Government are treating the National Health Service.

When I put that view the Secretary of State shakes his head and says that what I say is exaggerated. He points to what he calls The NHS facts that give the lie to Mr. Kinnock. The right hon. Gentleman said so in the Sunday Express last Sunday. He may seek to give the lie to me, but that does not fool me. What bothers me is the way in which the lie that he wants to give is accepted by so many people in the country.

Let us look at what the right hon. Gentleman describes as the facts in this article entitled: The NHS facts that give the lie to Mr. Kinnock". It says: Fact 1 is that"——

Mrs. Jill Knight (Birmingham, Edgbaston)

Is it in order Mr. Speaker, for the Leader of the Opposition to accuse my right hon. Friend of telling lies?

Hon. Members

Oh!

Mr. Speaker

Order. That word was used earlier this week, and I made a statement about it yesterday. It is, of course, not in order for any Member to accuse another of telling lies in this Chamber.

Mr. Kinnock

I am sure, Mr. Speaker, that you were listening, whereas the hon. Lady clearly was not. I was quoting the Sunday Express. However I understand the hon. Lady's confusion when I use the words "Sunday Express" and "lies".

Mr. Speaker

Perhaps I should make the issue clear for the Leader of the Opposition and also for the House. It is not in order indirectly to accuse another Member of lying by attributing the words to others.

Mr. Kinnock

Wounded innocence is not an emotion that usually becomes me, but when the whole attribution is to me by a paper outside, it is difficult for me to accept your stricture on this occasion, Mr. Speaker.

The Secretary of State, referring to fact 1, said: Spending on the NHS has risen 17 per cent. more than prices. That is a rather selective view of the statistics. Indeed, it is over-simplification to the point of utter distortion. Let me explain the Secretary of State's own figure to him. He will know that if the figure is true, it is true only in relation to the retail price index, not in respect of medical costs. It is not much good making an evaluation of increases in expenditure in the National Health Service when the very things on which the expenditure is to be made have increased in price by double the amount of the retail price index. If the Secretary of State is such an observer of the truth, I am sure that the editor of the Sunday Express could have found another little line to put in there to qualify properly the statistic that the Secretary of State used.

Then there is fact 2, as the Secretary of State described it.

The Secretary of State for Social Services (Mr. Norman Fowler)

Before the right hon. Gentleman leaves fact 1, is he denying that the resources that the Government made available over the past four years were sufficient to cover—more than cover—the demand through demographic growth in this country?

Mr. Kinnock

I can give the right hon. Gentleman the figures for growth of resources. I have them here: 7.7 per cent. alleged growth of resources, 4.5 per cent. of which was entirely related to demographic changes and 2.5 per cent. related to technological change, leaving what the Americans would describe as zilch for any advancement or improvement in the Health Service. If the Secretary of State wants to claim credit only for stagnation—just trying to meet the increase in costs of the Health Service in respect of demographic change—why has he tabled the amendment that is on the Order Paper claiming improvements? Clearly, improvements have not taken place. I do not ask the House to take my word for that, or even to take the Secretary of State's figures for it, because the figures that I am using are his. I ask hon. Members to go to any hospital or surgery in this country and to look at any waiting list, to see whether there has been an improvement over those years.

Fact 2, said the Secretary of State, was that the Health Service is treating more patients than ever before". I am delighted at that. I share the Secretary of State's pride and delight in that fact. However, it hardly explains the fact that the number of people on the waiting lists, using the most recent figures, was 770,000. That is a record in British history. It is a recorded fact—a statistic that the Secretary of State manages conveniently not to include in articles in the Sunday Express or in speeches to the Tory party conference, even though he gives them in parliamentary answers.

Fact 3 is that the health service is employing more front line staff like doctors and nurses than ever before. That is fine. But the Secretary of State should acknowledge that the figures that he produced are largely a benign legacy from the arrangements that were made by the outgoing Labour Government of 1979—[Interruption.] They were the result of that Government's contract which gave nurses a 37½-hour week, and thereby required even that incoming Government——

Mr. Tim Eggar (Enfield, North)

rose——

Mr. Kinnock

—to add an extra 22,000 nurses.

Mr. Eggar

rose

Mr. Kinnock

Again, if that is not true, why does the Secretary of State permit that to be printed in Hansard in his name?

Mr. Eggar

On that point—[Interruption.]

Mr. Speaker

Order.

Mr. Kinnock

I am glad to give credit where credit is due, but I cannot give any credit. Neither I repeat, more importantly——

Mr. Tim Smith (Beaconsfield)

rose——

Mr. Kinnock

—can those working in the service give any credit to the Government for providing resources.

It is the events since 9 June which have been most alarming, and which have prompted today's debate. Throughout the general election, the Conservative party studiously avoided making explicit promises about the NHS, relying only on the public expenditure White Paper of last February, which promised cash provisions for 1984–85 and 1985–86 reflect increases of 5 per cent. and a further 4 per cent. over the higher provision made for 1983–84. That was the phrase it used. Two days before the general election, on 7 June, the Secretary of State said: these plans will be subject to further consideration and upward review. There is no question of a downward review taking place on the public expenditure White Paper figures already published. We know now that was a premeditated falsehood—[Interruption.] In this debate we are talking about patient care, standards of health care and levels of provision. The fact is that since the election there has been—

Mr. Smith

rose——

Mr. Speaker

Order. I hope that this is a point of order, not an intervention.

Mr. Kinnock

—premeditated—[Interruption.]

Mr. Smith

Is the use of the term—[Interruption.]

Mr. Speaker

Order. I am waiting to know what the phrase is.

Mr. Smith

Is the use of the term "premeditated falsehood" by the Leader of the Opposition about my right hon. Friend the Secretary of State permitted?

Mr. Speaker

Order. I do not think that we should get too sensitive about this.

Mr. Kinnock

Obviously, there is dreadful overmanning in the Conservative party. Even Back Benchers have parliamentary private secretaries now.

Mr. Fowler

I am not in the least concerned about the phraseology that the right hon. Gentleman uses, but how does he justify what he has said, given that the figures that we used are precisely the same figures as we are keeping to?

Mr. Kinnock

If the right hon. Gentleman did not have such sensitive friends, I was about to inform him of that in my next phrase. Since the general election there has been not just a downward review—that would be a matter of small concern—but the delivery of three major blows to the NHS.

When we talk about resources, we are talking about the same overall amount and a retraction of resources for essential parts of the service. I shall tell the right hon. Gentleman why. We all know that the overall public expenditure figure in the public expenditure White Paper is being adhered to. Is not the star chamber sitting on it? Inside that fixed, rigid overall limit we now have a new theory. It is called a cash limit on the total NHS budget. The right hon. Gentleman knows what has happened. There was an overshoot of £100 million on the general practitioner service, which is beyond the Government's control. As a consequence, the Government decided to take that overshoot of £100 million out of the hospital services.

The first of the three major blows was on 30 June when the Government announced that the resources of the health authorities would increase by just 1 per cent. each year for the rest of the decade. The Government are well aware that that compares with the 1.2 per cent. that they said was necessary just to keep the NHS at a standstill. We have reason to believe, from a leak reported in the Financial Times, that officials believe that the figure should be 1.5 per cent., not even 1.2 per cent. The Government are not even providing the 1 per cent. that they said would be necessary. They will provide 0.5 per cent. because they say that the rest of the money can be made up by the magic efficiency savings. The Government are not even prepared to provide the 1 per cent. that they said was necessary to maintain a standstill.

In his announcement on 30 June the Secretary of State said that even that 1 per cent. is not a commitment and health authorities must ensure that their plans are flexible enough to cope with more or less resources."—[Official Report, 30 June 1983; Vol. 44, c. 135.] That was said by the man who is lecturing the Health Service on good administration and management.

The next blow to the NHS came on 7 July when the Chancellor of the Exchequer announced the public expenditure cuts, which included a cut of £140 million for the NHS. That was justified by overspending and came out of the same equation about the alleged overshoot on general practitioner services that I mentioned earlier.

Health Services, which is not an offshoot of Labour Weekly, suggested: The Government was panicked into cutting the NHS on the basis of one month's aberrant figures for family practitioner drug prescriptions. The DHSS has in any case consistently fixed the general practice budget too low by doing it in advance of the pay round. Dr. John Ball of the British Medical Association says: When it happens once, that is chance. When it happens twice, it is coincidence. When it happens three times, that is enemy action. That enemy action and the further enemy action by the Chancellor of the Exchequer means that NHS resource growth is now down to 0.21 per cent. of current levels of expenditure. That is nil growth at best, but what it really means is a big cut because of increasing patient demand, which vastly outstrips the resources that the Government are prepared to provide.

The final part of this modern disaster trilogy occurred on 26 July when the Chancellor of the Exchequer announced the first manpower cuts in the NHS since the 1950s. Up to 8,000 people were to be removed from the NHS work force. The Minister of State said: We had already decided before the election that discussions and negotiations would go ahead with health authorities on manpower control. However, they just did not tell anybody during the election. For anyone to suggest that there was any acknowledgement in any shape or form anywhere by anyone during the election that 8,000 jobs were to go is nonsense.

There has been a recovery since 26 July. Thirteen of the 14 regions protested. Consequently the Secretary of State is requiring the removal of only 4,837 jobs—just over 0.5 per cent. of NHS manpower. The real loss of jobs is much bigger than that, because the basis on which the figures were calculated on 31 March 1983 was that there was an extraordinary number of vacancies in the NHS, largely because of reorganisation. Therefore, the actual job loss is likely to be much nearer 12,000, or possibly slightly more. The right hon. Gentleman claims that the manpower restrictions need not lead to a poorer service. That is marvellous. With fewer doctors and nurses, the NHS is not a poorer service. That is a good equation, especially when there is not a big enough budget to expand on replacement technology for human effort in the NHS.

Doctor Rees, chairman of the hospital junior staffs committee of the BMA, said: Patients can expect deterioration in availability of care, particularly in over-stretched services such as renal dialysis". Any reader of The Times will know what he means by that. Any Sunday Mirror reader will know what he means by that. He also mentions special care baby units. Anybody who watches "Panorama" will know about that, let alone the unfortunate people who have children needing special baby care. He also mentions deterioration in acute surgery, and in less glamorous but very necessary areas such as care of the elderly. There is a vastly increasing number of the elderly. In addition, a threat now hangs over the general practitioner service.

When the Secretary of State spoke to the Pharmaceutical Society in July, he said that the Government could not permit unlimited expenditure simply because there was a demand for it. We have to make sure we know what determines that expenditure and put ourselves in a position to influence more directly the factors by which expenditure is determined. The Government influence the factors all right. They cut. That is how they influence the factors. Of course, the right hon. Gentleman claims that cuts need not follow from a combination of nil resource growth, increased demand and reduction in staff. There need not be a deterioration, although there is nil resource growth, fewer doctors and nurses, paramedics and ancillaries and a guaranteed increase in demand. There is a wondrous elixir called efficiency savings. We are all interested in efficiency. We must be. We all want value for money. That is excellent. Our hearts thrill at the prospect of an improvement of standards of patient care". That is what the amendment to the motion states. It should be combined with "prudence", one of the Prime Minister's and my favourite words.

Let us consider the efficiency promoted by the Government's policies. First, they have been efficient in increasing charges in the NHS by £321 million in the past four years—an increase of 200 per cent. Another of their brilliant ideas for efficiency involved charging overseas visitors for medical care. The Secretary of State said that those charges would provide a total of £6 million to help everybody else in the NHS.

Mr. Robin Corbett (Birmingham, Erdington)

Where is it?

Mr. Kinnock

My hon. Friend says, without rehearsal, "Where is it?" I, too, am beginning to wonder. No monitoring has taken place even though the figures for this first year's operation are supposed to be issued at the weekend, as the Secretary of State promised last year.

Let us examine the practical experience of hospitals. In the first six months of the year, the Royal Free hospital raised £167 from charging overseas visitors. The Royal Liverpool hospital, which has a great port nearby and could have expected many overseas visitors and casualties among seamen, raised just £71—[Interruption.] I see that help has arrived for the Secretary of State, from his advisers. Thank god for the cavalry!

Hillingdon hospital, which is the nearest big hospital to Heathrow airport, had a real boom year, by raising £778 from charges to overseas visitors. The fund is a bit short of £6 million. Bath district health authority, which I suspect is not under the control of the Militant Tendency, decided in July this year to drop all charges because it considered that the procedure was a fantastic waste of administrative time and effort and enormously inefficient.

What about prudence and privatisation? Those words thrilled the hearts of those at the Conservative party conference. During the past four years the Government have fastidiously encouraged health authorities to contract out. The consequence of such urging speeches by the right hon. Gentleman was that the expenditure on contract services for laundry fell by 30 per cent. and on cleaning by about 12 per cent. In September the DHSS told local authorities to put out to tender their requirements for laundry, cleaning and catering. Those are essential outlays for the average household, but the essential tasks of hygiene and cleaning in the NHS are now to involve the private sector.

Calderdale district health authority wished to build a new laundry costing £2 million. It would save £18,000 per annum by not contracting out, but the Government insisted that it would be cheaper to contract the work out.

The next problem involves the abolition of the fair wages resolution, which was introduced by dear Winston himself. How is it possible to get efficient labour when one pays low wages to the labour force? The workers are not the only people who object to cuts in their wages. The hon. Member for Stirling (Mr. Forsyth)—I do not know whether he is in the Chamber, but he is an expert on this topic—said that the Secretary of State was giving unnecessary ammunition to opponents by getting rid of the fair wages resolution.

Mr. David Evans, chairman of Brengreen, a cleaning company and a contributor to Tory party funds, accused the Secretary of State of astonishing political ineptitude. I wonder whether he will renew his subscription next year. Such people are afraid of the cowboys taking their work, and they are quite right. The Secretary of State's manpower restrictions on efficiency give local authorities a direct incentive to contract out, even when it is more expensive to do so.

Newcastle district health authority at present contracts out its laundry services. It has reported that if it could accept a tender from Darlington district health authority it could save £100,000 a year. However, such a tender would contravene the manpower restrictions because, to save £100,000 a year, the authority would have to employ 10 more people and it is not allowed to do so. Where is the efficiency saving in that procedure? How is the Health Service funded and operated more efficiently by that procedure? The Government's directive means that health authorities may have to accept unrealistic tenders. Once such a procedure begins, it is difficult to unscramble it. The teams in the health authorities are split up, the equipment is sold, and it is difficult to put things together again.

The magazine Laundry and Cleaning News—I do not know how often it has been quoted in the House, but it is an estimable organ—says: A contract of some 8–10 years would be necessary to justify investment in new plant. Efficiency"— that word again— would not come into play for such long contract periods. The magazine illustrates that the Government are concerned only with dogma, not with efficiency. It seems that contracting out can lead to poorer standards.

Crothall's—another contributor to Tory funds, incidentally—had a £200,000 contract with East Surrey hospital. The ladies who worked for that company simply mopped the operating theatres with wet cloths, so nurses had to reclean the theatres to the required standards. I am glad to report that that has now been changed.

How is it possible to guard against such incidents if the definition of "efficiency" is the lowest possible cost and the lowest possible wages? The process of tendering causes the NHS increased administrative costs which it cannot offset and which do not add to efficiency. Where is the efficiency saving? The Secretary of State drew cheers from the Tory party conference when he said that his plan was to cut administrative costs, thus freeing more funds for patient care. That claim was rubbish then, it is rubbish now, and it will continue to be rubbish because the Government do not promote efficiency by propounding that view.

The Conservatives have a poor record on efficiency. They voted to keep what Aneurin Bevan described as the patch quilt of high cost paternalism at a local level. They also voted to keep the national insurance system, even when an alternative was proposed, although that insurance system was the most expensive compulsory medical insurance scheme in Europe. That history has continued. They have shown a preference for the combination of private profiteering and Victorian philanthropy, which is the essence of ancient and modern Tory attitudes towards the NHS. Fortunately, there have been gaps in between. A different attitude may return some time, but it does not now predominate.

The Secretary of State wishes to make the Health Service more efficient. The Opposition concur with that wish. The problem is not whether the objective is achieved, but how it is achieved. It is difficult to squeeze the Health Service much harder in the hope of efficiency because it is already the most efficient medical system in the western world. I see hon. Members who have not used the NHS for years shaking their heads. The figures are not mine, but those of the OECD and of Mr. Maxwell, who is a recognised authority on this subject.

Those figures show that on any comparison with France, Italy or the United States, the administrative costs of the NHS not only represent a tiny 6 per cent. of total running costs, but are smaller by factors of three and two than any comparable service anywhere in the world. Why do we not have pride in that and build upon it rather than permanently prosecute the NHS—which is what the Government are doing? Our Health Service also takes a smaller proportion of gross national product than do the services in most comparable countries such as Canada, Australia, the United States and EC countries, except Greece.

Of course the NHS is not perfect, and we cannot say that we want to preside over waste. Of course we want to reduce any such waste and to achieve greater efficiency, but the fact remains that we are asking for more from the best in the world. The Government's policies show that they do not regard the opportunities for new and better care, new technology, care for old people and the saving of more children's lives as opportunities for investment in compassion, modern technology and efficiency, but as a burden upon public expenditure. That is their best attitude. Their other attitude is the recognition of pain as an opportunity for commercial exploitation.

Far from being a burden on public expenditure, the facilities and opportunities that modern medicine affords mean that the grave issues of life and death—not on a grandiose scale of war and peace but in the intimate matters of which child shall hear, which old person shall not be cold and which 55-year-old renal failure patient shall live and which shall die—are on the doorstep of modern Governments. Such issues cannot be evaded, as the Government are trying to do.

The Government should greet with joy—with rejoicing, may I say—the opportunity that they now have to invest in liberating people from the fear and insecurity of unnecessary pain, and its prolongation, which go with the waiting lists, the health cuts and the sackings of qualified staff. According to the British Medical Association, 3,500 doctors are now unemployed. That is an unmitigated crime against the British people.

Are the Government not prepared to learn that the British Health Service is not some attractive but expendable bauble that they can allow to decay? The Health Service is above partisan politics. It is cherished and will be fought for by people of all political views. The Government should understand that the British people's affection for the NHS does not arise out of sentimentality. The public's affection is born out of its usefulness, dependability and utility. That is why they will fight to save it.

The NHS cannot be dismembered or dismantled by British Prime Ministers or foreign economists, because it is not theirs to dispose of. It belongs to the British people. They will strive to retain their proud possession because they depend upon, need and use it. They know that in defending it they are defending themselves. They are defending a service that is compassionate in its concept, efficient in its administration and effective in the alleviation of suffering. It is a service which now needs full-hearted and full-funded support to improve upon the superb level of patient care that it provides.

I beg the Government, not merely on behalf of the Opposition but on behalf of millions of people beyond. to reverse their policy towards the NHS and to invest in the combat with pain, the conquest of disease and the provision of facilities for the British people. If they do that, they will earn our gratitude, whatever political difficulty it might give us. There is something which lies beyond any disagreement that we can have in the House. It must be the extent of service for and the practical commitment to the welfare of all British people—every last one of them.

5.4 pm

The Secretary of State for Social Services (Mr. Norman Fowler)

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: reaffirms its commitment to the National Health Service and to the maintenance and improvement of standards of patient care; congratulates Her Majesty's Government on the progress made over the last four years; and endorses its efforts to ensure the best value for money spent on patient care.". One point is basic to this debate. Not surprisingly it is one of the many points that the right hon. Member for Islwyn (Mr. Kinnock) has ignored. It is simply that: All social services have to be paid for in one way or another from what is produced by the people of Britain. We cannot create a scheme which gives the nation as a whole more than we put into it. [Interruption.] I am sorry that Opposition Members do not like those words. They are not mine but those of Clement Attlee in a broadcast on the eve of the introduction of the National Health Service in July 1948. That, of course, was a time when the Labour party had a real leader—[Interruption]—and the badge of that leadership was that he was prepared to tell the public what was actually needed to sustain the Health Service and the social services of this country.

The basic charge against the right hon. Gentleman is not his inability to describe the problems of the Health Service. No problem has yet been invented which he cannot trip past with a glib phrase. [Interruption.] The real case against him is his total bankruptcy of ideas and of policies to deal with the problems he describes. He inhabits a land where the generalisation reigns supreme. [Interruption.]

Mr. Speaker

Order. The House listened with great attention to what the Leader of the Opposition had to say. It should listen with equal attention to the Secretary of State.

Mr. Fowler

That, of course, is why the right hon. Gentleman finds himself where he is today. He is the acceptable facade. He complains that the Prime Minister is not replying today. I am not sure why. Goodness knows why he should want to be knocked about three times a week and not just twice.

Let us get behind the right hon. Gentleman's generalisations and set out the facts about the Health Service against the charges he makes. He charges that the Government have cut the Health Service budget. The fact is that, even after taking account of the July measures, the Government are currently spending £15.5 billion on the National Health Service as compared with £7.75 billion in 1978–79. That is an increase of more than 17 per cent. against the retail price index. Those resources have been adequate to provide for the increase in the number of patients and demographic change.

The crucial point is that there is no merit in itself in spending money. Merit lies in what that money achieves. What really matters to the British people and to patients is what we get out of the money we spend on patient care. Once again the facts are clear.

According to the latest available figures, we were treating 640,000 more inpatient and day cases in 1981 than we were in 1978. We were treating 2 million more outpatients and emergency cases. We were treating 18 per cent. more geriatric inpatients and 14 per cent. more geriatric outpatients. We provided more than 2 million more courses of dental treatment. We gave 620,000 more sight tests. Almost 400,000 more people, many of them elderly, were visited at home. Those are the facts.

That means that more patients are today being treated than ever before, and that is the result not just of increased resources and of the skill and devotion of the staff, it is a result of the more effective use of resources inside the Health Service. By any objective measure, the Health Service has improved substantially during the past four years, and is continuing to improve.

Mr. Tam Dalyell (Linlithgow)

On several occasions I have brought forward private Members' legislation on the subject of renal dialysis. Could we have the figures for the waiting lists for renal dialysis, if they are available?

Mr. Fowler

I am coming to that point. The hon. Gentleman makes an entirely fair point about the many problems that the Health Service faces, and one of the most serious and difficult is that of kidney failure. The present position is that in 1981 we treated about 1,500 new patients, as against fewer than 600 10 years before. That is the measure of the improvement. The numbers increased by more than 50 per cent. in the five years to the end of 1981, and the number of kidney transplants performed in the United Kingdom in 1982 passed 1,000 for the first time, which is more than twice the number five years before and more than any other European country. Indeed, we have the specialist facilities now to increase the number of transplants substantially, if only we had more donors.

The right hon. Member for Islwyn also talked about waiting lists. He quoted, inaccurately, the present waiting list figures. The present waiting list is 726,000, compared with 752,000 in March 1979. What he should compare it with is the figure to which we brought it down in September 1981, which was 619,000. The hon. Gentleman must face the fact that two events that added more patients to the waiting list were the strike of 1979 and the strike of 1982. Those two strikes added almost a quarter of a million patients to waiting lists. At least in 1979 the Labour Government—I pay credit to them for that—tried to do something about it, but in 1982 we did not hear at any stage one word of criticism of the industrial action that was hurting so many patients. That was the practical demonstration of the Labour party's commitment to patient care.

Mr. Kinnock

I am glad that the right hon. Gentleman brought up the subject, because I recall him saying previously that 3.1 million days were lost because of the strike in 1982 and that that was the reason for the longer waiting list. However, as he knows, the most recent figures show that 800,000 working days were lost, which we regret deeply. If he is worried about additions to the waiting list—140,000 people on the basis of 800,000 days lost—why is he not worried about the fact that the equivalent of losing 4,837 workers from the Health Service because of his cuts is one million days lost? How much will that affect the waiting list?

Mr. Fowler

That is an absurd analogy, but what I welcome in what the right hon. Gentleman just said is that this is the first time in the House that anyone sitting on the Labour Front Bench has regretted anything about the 1982 strike.

The next charge of the Opposition is that hospitals are being unnecessarily closed. That is an extraordinary charge—and something that was missed out of the right hon. Gentleman's speech—to come from the party that imposed the biggest capital cuts in the history of the National Health Service. Between 1976–77 and 1977–78, they cut capital spending by more than 20 per cent. Those capital cuts were the direct consequence of the economic policies of the Labour Government. The result of Labour's failure to develop social and economic policies together was a Health Service run by the IMF. The right hon. Gentleman knows full well—or certainly should know—that the Labour Government approved 272 hospitals for closure, which is more than twice the number under this Government. They also approved the closure of more beds. He should remember what the former Secretary of State, now Lord Ennals, said then: The price of keeping surplus hospitals open is a lower standard of care than we could get by concentrating our hospital services to give a more efficient service to patients. I do not deny for one moment that there are difficult decisions about hospital closures. It is part of my case against the right hon. Gentleman that he seeks to disguise the fact that there are difficult decisions that must be taken in the Health Service. We must make decisions about, for example, the small maternity hospital in Norfolk that was shown on "News at Ten" last week. A case can be made for keeping open such a hospital. However, it costs £150,000 a year; for almost a quarter of the year it had no patients; and the average number of patients is two. If the authority closes it, it will save over £100,000 a year in revenue and will gain a large sum in capital. Those factors must be taken into account by any Government worthy of that name.

Mr. Harry Ewing (Falkirk, East)

This debate must be difficult for the Secretary of State, because he must be aware that he is making a very bad speech. No civil servant with any career prospects would have written that speech. Is the Secretary of State aware that the hospitals closed by the Labour Government were old hospitals that had been replaced by new ones? The difference now is that the new hospitals that the Labour party built are being closed by him and his colleagues, and in some cases new hospitals are not even being opened. In Scotland the Government refused to fund 900 beds in new hospitals, as a result of which they stand empty and we cannot get patients in need into those hospitals.

Mr. Fowler

That is a foolish attempted rationalisation of the policies of the Labour Government. If the hon. Gentleman is serious about that, I shall ask my hon. and learned Friend the Minister for Health to read in full the speech that David Ennals, now Lord Ennals, made on hospital closures, which bears no relationship to what the hon. Gentleman just said.

The right hon. Member for Islwyn attacked us about manpower. The facts about manpower are that we employ more than 1 million people in the National Health Service in England, or 820,000 full-time equivalents. We are seeking a reduction in posts not of the 30,000 predicted by Mr. Bickerstaffe, not of the 20,000 predicted by the TUC, but of 4,800—just one half of 1 per cent. In judging that, we should remember that between September 1978 and September 1982 the number of staff in the National Health Service increased by about 70,000, or almost 9 per cent.

That growth was fastest in front-line staff—doctors, nurses and professional and technical staff. The increase in the number of nurses in the hospital and community health services of 46,000 increased nursing services and allowed a reduction in their hours of work. In England, there are now more than 5,000 more doctors than in 1978–3,500 in the hospitals and 1,700 more general practitioners. That is the background against which the Government's action over manpower levels should be considered.

We must also recognise that the Health Service is not only the largest employer in this country but the largest in western Europe. The pay bill accounts for 75 per cent. of revenue expenditure on hospital and community health services.

Dr. M. S. Miller (East Kilbride)

Will the right hon. Gentleman give way?

Mr. Fowler

No, I shall not.

There can be no effective planning for the future of the NHS without a clear understanding of the way in which manpower is used and the way it should be deployed in the future.

We inherited a system where manpower information was both inadequate and out of date. That was something we had to put right. Therefore, not last July but in July 1982, we asked health authorities to bring forward clear manpower targets for the year to 31 March 1984. Those plans showed not a levelling out of manpower, for which we had asked, but 7,000 new posts. The majority would not have been nurses or doctors. They would have been concentrated on the administrators, the ancillary staff and the work staff.

Mr. George Foulkes (Carrick, Cumnock and Doon Valley)

Will the right hon. Gentleman give way?

Mr. Fowler

No.

We asked for those plans to be adjusted. In discussions with the regions we allowed for new developments, and four regions are taking on extra staff. However, the total picture that has emerged is a reduction of just half of 1 per cent. of Health Service manpower—equivalent to about £40 million of expenditure.

Mr. Foulkes

Will the right hon. Gentleman give way on this point?

Mr. Fowler

No, I shall not.

Mr. Speaker

Order. This is an appropriate moment to inform the House that I have a long list of hon. Members who wish to take part in the debate. Interruptions do not make it easier for them, for me or for the Secretary of State.

Mr. Fowler

I have, Mr. Speaker, already given way several times.

I find it very difficult to believe that a service that employs 820,000 people, including 170,000 ancillaries and 105,000 administrative and clerical workers, cannot find manpower savings of 4,800. It is totally ludicrous to say that a saving of one half of 1 per cent. strikes at the foundations of the Health Service.

As the Griffiths inquiry said, and hon. Members should consider this: better management of resources must mean better use of manpower". There is a wider point. The Health Service is not a provider-oriented service. It is about serving the patients and the public, and not always in the hospital setting. Let us consider, for example, the problems of providing primary health care in our inner cities. That is a matter on which we received an important report from the study group chaired by Professor Acheson. Although we placed the main responsibility for action on those providing the service locally, we also recognised the importance of giving some special support. We have already given health authorities a total of £1 million for the training of health visitors and district nurses in line with the Acheson proposals, but there are other measures on which central action is now needed.

Therefore, I have decided that additional funds should be made available for new centres to create group practices in inner city areas such as London, Birmingham, Manchester, Liverpool and Newcastle. I have decided that there should be a 60 per cent. grant for the improvement of poor quality practice premises in inner city areas compared with the present 33 per cent. I have decided that other primary health care projects in selected inner city areas—for example, the development of night nursing services and improved supply of the aids and equipment used by district nurses—should also be improved. A total of £9 million will be provided for this initiative over the next three years. My hon. and learned Friend will give some more details when he replies.

Those steps are only part of our efforts to tackle the problems of primary care in inner cities, but above all they seek to demonstrate our determination to develop the Health Service to meet the needs of the community and of patients.

Those are some of the facts about the Health Service. The charges that the right hon. Gentleman makes are bogus. The policies he offers are empty because he has no realistic economic policy to underpin his social aspirations. Above all, the analysis that he offered today was dismally inadequate. Whatever divides the parties, let us at least be frank about the demands that the NHS will meet. We must meet the increases in demand that will stem from demographic change, particularly the increase in the numbers of the very old, which will continue to rise sharply until the early 1990s, although it will slow down after that. We must meet increases in demand for the new treatments made possible by medical advance, although we should not forget that some advances can save money rather than add to the costs.

Those will be major challenges for the Health Service. They are challenges that other countries are now facing. Overcoming those challenges will require imagination and willingness to change. The solution to those challenges cannot just involve slogans and demands for ever more resources. We have provided extra resources, and as we have pledged, we shall be providing extra resources in the future. But it is also vital that we should develop further policies to extract maximum value for the money we use. That will sometimes mean savings on existing budgets. For example, the cost of drugs now prescribed has increased to almost £15,000 million. We must cut that bill.

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

What is the right hon. Gentleman doing about it?

Mr. Fowler

I shall tell the hon. Lady. With the cooperation of the pharmaceutical industry, drug prices were reduced by 2.5 per cent. from the beginning of August this year. That will provide a saving of £25 million in the drugs bill this year. I am now holding discussions with representatives of the industry on the scope for further savings next year. We shall be looking particularly at the profit rates that are allowed and the controls on levels of promotional and advertising expenditure. The industry has a good record as an export earner and I do not want to undermine those achievements, but we must also ensure that the NHS is not paying too much for its drugs.

Another example is the amount spent on catering, cleaning and laundry. That has risen to £900 million a year, yet until recently little has been done to test whether the in-house services that are generally used are giving best value. The Government's view is that there is no reason why those activities should be an unchallenged public sector monopoly. If a private firm can provide the same standard of service for less money, it makes sense to bring it in, particularly as the savings go direct to patient care.

We must also examine better ways of doing things inside the Health Service generally. There are enormous areas of spending in the Health Service. We spend £150 million a year on office equipment, telephones and printing and almost £300 million a year on energy costs. The evidence of performance indicators of local health authority spending shows, for example, that one hospital pays four times as much for its laundry to be cleaned as another and that it costs more than 30 per cent. more to run the ambulance service in one county than in the next door county.

The evidence of the audits show that one authority could increase its efficiency and save £80,000 a year simply by rationalising its stores. Shortly we shall have the evidence of the first Rayner scrutinies that are again likely to show potential savings in areas such as the use of transport and the storage of supplies.

Differences in performance such as these should raise questions for management, who should ask why those differences exist and how they can be reduced. They cannot all be explained by the differing numbers of the elderly, local geography or the differing state of hospitals.

Above all, what the Health Service needs today is better management of itself. That is why I appointed Roy Griffiths to look into this question earlier this year and it is why I welcomed his report on Tuesday. By any standards, the Griffiths inquiry team was an experienced and distinguished group of managers, and included Brian Bailey with his trade union and health authority experience. I point out to the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) who tried to interrupt earlier, that it is not so much that I find her public comments on this group an insult, which they clearly are, but that, above all, they are deeply ignorant.

The Griffiths inquiry team endorsed the initiatives that we have been taking to improve management performance, in particular the ministerial review of performance. It stressed the importance of decisions being devolved to managers capable of taking them and being held accountable for them. Griffiths is not recommending new tiers of authorities or administration; he is not recommending the establishment of two quangos in my Department. He is, above all, not recommending centralisation, but the very opposite. Devolution does not work if decisions are always drifting upwards.

His diagnosis is, first, that devolution will not work without an effective general management function. As he observed: if Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge". Secondly, he points out that if we could get good management at a local level we would have the opportunity of securing major cost improvement of a kind not so far seen in the National Health Service.

The right hon. Member for Islwyn talked about no further economies being possible, but I refer him to page 13 of the Griffiths report, which says: Major cost improvement programmes can and should be initiated within the NHS, aiming at much higher levels of efficiency to be sustained over much longer periods than at present … It is almost a denial of the management process to argue that the modest levels of cost improvement at the present required of the NHS are unachievable without impacting seriously on the level of services". Thirdly, what stands in the way is management, as Griffiths puts it, by lowest common denominator. The Griffiths team's advice is that we strengthen the process of consensus, which must still be the objective, by the establishment of a clearly definable general manager whose job it is to get things done.

The aim of the initiative is to make devolution work. We want all day-to-day decisions to be made as close to the patient as possible. I should have thought that that was an objective that would be shared by both sides of the House. Devolution cannot work if decisions have to be deferred upwards. It cannot work in the absence of an effective management process which means that the centre continually has to interfere. The Government are committed to the Health Service and will remain committed to it. We also want a modern service, a service equipped to meet the challenge of the 1980s and 1990s and not one where change is always seen as the enemy.

I am in no doubt about either the problems we face today or the problems that we shall face over the next few years. That is why it is all the more important that we get the maximum value from the resources that we use and above all, the maximum value for the patients. We shall not be thanked in later years for ducking the decisions that need to be taken now to improve the Health Service.

The Labour party, behind the facade of a new leader, still offers no economic strategy and therefore no means of putting its hopes into practice. Worse than that, it refuses to recognise, let alone make proposals to tackle, the problems inside the Health Service itself. Their case does not deserve support. I ask the House to reject it.

Several Hon. Members

rose——

Mr. Speaker

Order. I have already told the House that I have a long list of right hon. and hon. Members—over 40—who wish to take part in the debate. I hope that this is a day on which all right hon. and hon. Members will bear that in mind when they make their speeches.

5.35 pm

Dr. David Owen (Plymouth, Devonport)

I have lived all my life in a medical background. My father was a general practitioner and worked for over 25 years in the NHS. I was brought up to believe in two great freedoms—the freedom he experienced in 1945 when war was over and the freedom that he felt as a family doctor in 1948 when he no longer had to charge any of his patients for the care that he gave them. There are millions of people—Conservative, Labour, Liberal, SDP and Nationalist voters—who believe in the principles of the Health Service and who still look to the Health Service for their care and comfort.

I worked in the NHS for six years. I was Minister for Health for two and a half years and the proudest time that I have ever had as Minister, not barring the time that I spent as Foreign Secretary, was working as part of the team that increased by nearly 1 per cent. of the gross national product the resources put into the NHS. I look back at the Health Service, and I approach this debate with a deep sense of foreboding for the future.

With respect to the Secretary of State, and even the leader of the Labour party, who I am sorry to see has left the debate so quickly after having spoken in it——

Mrs. Dunwoody

He will be back.

Dr. Owen

I am glad that that is so.

The focus of the debate is on what happened after the general election in June. Much of the Secretary of State's defence rested on what he had achieved over the four years before the election. It would be folly to deny that there has been an expansion of resources in some significant parts of the NHS or that spending kept pace with the demographic pressures within the Health Service. My charge against the Government—I intend to substantiate it—is that for the first time in the history of the Health Service not only will there be an absolute reduction in the numbers of staff employed in the Health Service this year, but there is a real chance of no growth in real terms in health resources.

The Secretary of State is the first to point out the demographic pressures on the Health Service. Some 10 years ago, there were 2.5 million people aged over 75 and there are now 3.25 million. In 10 years' time there will be 4 million people over 75. The Health Service spends six times as much for each person aged over 75 as it does for those between the ages of 16 and 65. It has to spend 26 times as much through the personal social services. In this debate no hon. Member should discuss solely the National Health Service. What is happening to the personal social services up and down the country is even more worrying.

In January 1983 the Government issued a circular entitled "Health Services Development: Cash Limits and Manpower Targets for 1983–84". It laid down the following cash limit targets for 1983–84. The revenue cash limit for the whole NHS was £8.4 billion. Allowing for an inflation rate then estimated at 5.5 per cent., that meant an increase in NHS services valued at £98 million in cash terms. In percentage terms, the Government were increasing the NHS budget by 1.2 per cent. in real terms. That was before the election. Leaving out the "efficiency savings" of 0.5 per cent., the Government were budgeting for an increase in NHS services of 0.7 per cent. in real terms for 1983–84. It was barely possible then for the Government to claim that they were safeguarding the NHS. Successive Governments have accepted that 1 per cent. inflation-proof growth in real terms is needed—many people believe that the figure should be 1.5 per cent.—to ensure that the NHS can stand still and keep pace with the demographic pressures from the elderly and the mentally handicapped as well as with the effects of modern medicine in enabling sick infants to live, often, to middle age.

In August 1983 the Government issued a revised circular, laying down revised cash limit targets for 1983–84. The revenue cash limit for the whole NHS was cut to £8 billion. Allowing for a reduced inflation rate of 4.5 per cent., that meant an increase in NHS services valued at only £17 million in cash terms, as opposed to £98 million. That represented a sharp reduction compared with the January target. In percentage terms, the Government have now decided to increase the NHS budget by only 0.2 per cent. in real terms for 1983–84. That figure still includes the January component of 0.5 per cent. "efficiency savings". Leaving that out, the Government are now budgeting for a net decrease in real terms of 0.3 per cent. in NHS services for 1983–84. That is not the action of a Government who promise to safeguard the NHS.

The other day the Secretary of State was manhandled by local health authority workers. They were wrong to do that, and the right hon. Gentleman called it a negation of democracy. In a way, he was right to say that. However, there are other ways of negating democracy. One of the most powerful ways of doing so is by going to the electorate on a platform that people believe in, saying that the Health Service will be safeguarded, and then cynically tearing up those promises within months or even weeks. That is what the Secretary of State has been forced to do by the Chancellor of the Exchequer.

The Minister for Health (Mr. Kenneth Clarke)

rose——

Dr. Owen

I shall not give way as the hon. and learned Gentleman will have ample time in which to make his point when he replies to the debate.

In July, the Secretary of State announced that the NHS could plan for the next 10 years on the basis of approximately 0.5 per cent. real growth per annum, although he admitted that it would be difficult to manage that. That target was calculated on the basis of the January figures. However, the revised figures announced in the August circular have eroded the base position to 0.2 per cent. growth, producing a revised figure of minus 2.8 per cent. growth per annum for the next 10 years. In other words, on the basis of the Government's most recently revised targets, there will be a sharp contraction in NHS services beyond 1984.

The Secretary of State has criticised the cut in capital spending with some justice, because the fabric of the Health Service is decaying and putting added pressures on the revenue budget. Indeed, capital spending accounts for only 6 per cent. of the total resources devoted to the NHS.

The effects of cuts on local authority personal social services are the most damaging and worrying of all.

Mr. Kenneth Clarke

rose——

Dr. Owen

I shall not give way. Mr. Speaker has asked us to be brief and the hon. and learned Gentleman will have half an hour in which to reply to the debate.

The figures in the January circular disclosed that the Government had estimated a net decrease in real terms of 1.3 per cent. in 1983–84 in total personal social services expenditure by local authorities in Britain. It is hard to make such estimates for a forthcoming year. However, the revised figures in the August circular demonstrate that the Government have now budgeted for, or anticipated, a larger net decrease in real terms of 2.4 per cent. in 1983–84 in total personal social services expenditure. No wonder that we all find in our constituencies that cuts are being made in meals on wheels and in the domiciliary services. In addition, it is increasingly hard to cope with the mentally handicapped patients, who have rightly been returned to the community, but for whom there are insufficient resources. Psychiatric and geriatric patients leaving hospital have to face inadequate community care facilities. Hard-pressed social services and social workers are having to refuse to provide much-needed telephones, and find that they are unable to meet the minimum requirements of the disabled. The pressures are building up, and that in turn will have an effect on the NHS. The Secretary of State knows perfectly well that joint financing—that most crucial measure introduced by us in 1975—is now barely able to fund projects that lie between the health and personal social services, because local authorities are unable to meet their revenue commitments.

I had hoped that the Secretary of State would say in his statement that he would somehow increase the facilities for joint funding. I welcome what he has done about the Acheson report. It is true that health care facilities in the inner city lack resources. But is the £9 million extra over and above the August figures for the revenue budget? Is it new money from the Chancellor of the Exchequer, or does it come from those "efficiency savings"? We have heard a lot about those savings. In Plymouth, a joint geriatric orthopaedic ward that was to absorb the orthopaedic work previously carried out at the royal naval hospital and so reduce waiting lists, will not now open although there is a four-year waiting list for outpatients. That means increased waiting lists, longer delays before treatment, pain for the elderly, immobility and further difficulties in keeping the elderly at home.

As a result of the combined effects of cash limits and manpower targets, Goucester health authority is having to postpone three priority schemes. I gather that a 24-place unit for mentally handicapped people that is ready to open will have to remain empty. A 12-place unit for severely handicapped people, and a day unit for treating alcoholism will not open. We can all cite similar examples. For many years I have had some contact with the Hospital for Sick Children in Great Ormond street. I see the research workers and physicians who deal with leukaemic patients and with bone marrow transplants, and they are constantly worried about resources. The work is heavily dependent on "soft money" or voluntary contributions, and the hospital finds that it is unable to finance very necessary projects. Doctors belonging to the BMA, hospital consultants and family practitioners are openly admitting now that lives are in danger because of the shortage of resources.

I turn to the Secretary of State's so-called manpower targets and savings. The key point is that in the January circular the Government were working on the basis of an increase of 0.7 per cent. to 1 per cent. in overall staff numbers compared with that at 31 March 1982. That was then reversed in the August circular, with the Government looking for an absolute reduction of 1 per cent. in staffing levels between the regions. I often argued from the Government Dispatch Box that some hospital closures were necessary. Every proposal to close a hospital is rejected. Indeed, the best way of predicting the timing of a general election is to look at the way in which the number of hospital closures has fallen. That method never fails to point to the timing of an election. The first six months of 1983 were no exception to the rule. Hon. Members have not been realistic about the need to reduce some of the acute hospital services and to concentrate facilities. If the resources saved were directed towards geriatric hospitals or facilities for the mentally ill or handicapped, many of us would accept it, but the fact is that they are not channelled in that direction. Those reductions are absolute.

Why is this debate being held in the absence of the Secretaries of State for Scotland and Wales? Conservative Members should also ask that question. Why are those Secretaries of State not answering this debate? Why is this an English debate? The answer is that the manpower savings and the cackhanded way in which they were introduced in the middle of the year are unique to England. That raises some very serious questions about the competence of the Secretary of State, and particularly that of the Minister for Health.

There are serious questions about the way in which manpower savings have been implemented, let alone the case for them. No doubt the NHS needs savings, efficiencies and redeployment, but I fear that, as always, the Cinderella services suffer most—the psychiatric, geriatric, mentally handicapped and community services. That is the real charge against the Government.

The leader of the Labour party is still not in his place to listen to the debate. I hope that he does not think that the House gathered only to listen to his speech. If he concentrated more on the real issues he would carry more conviction in the country.

Mr. Willie W. Hamilton (Fife, Central)

Where is the Prime Minister?

Dr. Owen

I agree that the right hon. Lady should be here. If the alliance controlled the Supply Days it would have tabled a censure motion on the Government, and the Prime Minister would have been called to account from the Dispatch Box. We must worry not only about the snare of the fowler, but what lies behind the fowler—we are after the thatcher. The Secretary of State has been forced to make these changes. In Cabinet he has had to concentrate on safeguarding the unemployed; he has had to look after the social security budget. I understand his problem in choosing priorities. It is sad that the health and social services must suffer.

The figures I have quoted are damaging to the Government. I am sure that they are accurate, but if they are not I hope that the Minister for Health will correct them in the greatest detail. The figures have been investigated with great care. It is the first comprehensive assessment of the real financial implications of the cuts. We are way below the minimum expenditure needed in real terms for this year—and projected forward for future years—to safeguard the NHS.

Will the Secretary of State again next year ask the Health Service budget to accept the overspend on the family practitioner committees and, effectively, the drugs bill? Is he prepared to do something about generic prescribing? Doctors in hospitals cannot prescribe just any drug. Unless the hospital consultant underwrites a specific drug, the hospital's pharmacist will provide the nearest equivalent. Of course, we cannot take away the rights of a hospital doctor or a general practitioner to prescribe certain drugs. But it should be made clear to GPs that usually a pharmacist will provide the nearest chemical equivalent unless the doctor specifically asks for a named drug. That would save substantial sums of money. There are other areas of health spending that need to be investigated, not least spending on advertising and so on. I am, therefore, not against any cuts or any savings.

I come to the management proposals for the NHS. I have lived with the problems. Three weeks after taking office I had to implement the arrangements made by the previous Conservative Secretary of State, now the Secretary of State for Education and Science. The scheme had to be operated by nurses, doctors, administrators and ancillary workers. They eventually built up consensus management. The present Secretary of State is now giving up all that. I warn him that establishing a general manager for every unit will bring severe problems. There is merit in nurses, doctors and administrators working together, although I accept that it is not always successful. Rather than implementing the general manager principle across the whole of the NHS—one more reorganisation being globally applied—why does not the right hon. Gentleman carry out pilot studies in a few areas where he feels that consensus management is not working? He could then come to the House in a year or two and, if it has worked well, say that he wishes to implement it throughout the country. That would carry more conviction.

As to the board that the Secretary of State is to chair, I urge him to bridge the gap between the Civil Service in the Elephant and Castle and the health administrators in the regions and districts, who understand the management of the NHS. He should bring them on to the management board and into the DHSS. The greatest problem has been the artificial separation between the Civil Service in the DHSS—which shifts between social security and other Departments—and those who have the nitty-gritty problems of handling the NHS.

It is time that the Government and the Secretary of State demonstrated that they believed in the Health Service. I wish that the Prime Minister were here. Would it not have been marvellous for the morale of the Health Service if, when she had her eye operation—I am pleased that it was successful—she had had it in an NHS hospital and could have left it congratulating the hospital staff on its success? Around the world there would have been pictures of the British Prime Minister treated by the NHS. She would undoubtedly have received just as good treatment from the NHS, with its eye surgeons of international repute, as ever she received from the private sector. The right hon. Lady does not appear to understand that she is the Prime Minister of the whole nation. She appears to have an obsessive interest in the privatisation of everything. The market place is taken into health and education. For those reasons most of us fear her hand on the NHS. The indictment of the Government is that the NHS is not safe in their hands.

5.55 pm

Mr. Steve Norris (Oxford, East)

I am grateful for the opportunity to speak on this important subject. I speak as one of the few Members of the House who are active members of a health authority.

I have the honour to represent the new constituency of Oxford, East which was created mainly from the wards of the old Oxford city seat, but to which have been added areas formerly represented by my right hon. Friend the Minister of State, Home Office and my right hon. Friend the Secretary of State for Defence. Both my distinguished right hon. Friends have earned the affection and respect of their former constituents over the years. I pay tribute to them for their support for, and hard work on behalf of, those wards.

It is a particular pleasure to pay tribute to my hon. Friend the Member for Oxford, West and Abingdon (Mr. Patten), the Under-Secretary of State for Health and Social Security. As hon. Member for Oxford since 1979, he gained the respect of his colleagues both inside and outside the House. He was one of the first new Members to become a member of the previous Conservative Government. I am delighted to see him on the Front Bench in his new role at the Elephant and Castle rather than at Stormont Castle. I convey to him the warmest regards of his former constituents who hold him in the highest esteem. I thank him for the countless personal kindnesses extended to me both before and after the general election. He has been a true friend and guide throughout my first weeks in the House, and I am sincerely indebted to him.

Specifically in the context of today's debate, my constituency houses some of the most impressive NHS facilties within the Oxford region, if not the country, at the JR2 John Ratcliffe hospital, the Churchill and the Warneford and Littlemore hospitals, among others. Health care is a vital issue to my constituents.

I have a great personal interest in the NHS and in health care delivery services, having been a member of the old Berkshire area health authority from 1979 until the demise of areas last year, when I was appointed to the new west Berkshire district health authority, of which I am currently vice-chairman. Working so closely with the health authority adjacent to my constituency and within the Oxford region has provided me with a most useful education in Health Service economics and management at a practical level. It has meant that I have been able to understand the implications of activity within the service in my constituency, and thus I hope to do a better informed job on behalf of those I represent.

On this occasion I feel strongly that it would be of benefit to the House to share some of the observations that come from operating close to the heart of the service from the realistic standpoint of those who bear the responsibility of carrying out the policy of the Government on a day-to-day basis. In all the great furore that has surrounded recent events, I have sadly heard all too little being said that was based in any way on a realistic understanding of how the Health Service is actually operating. It does nothing but damage to the NHS when the argument is all about emotion, and facts are ignored.

I shall confine my remarks, in what I understand should, by tradition, be a non-controversial speech, to the most recent event that has supposedly impacted so crucially on the NHS—the circular HC 83 (16) on cash limits and manpower targets for 1983–84. First, a criticism. I have to confess many misgivings, which are shared by those working in the NHS, about the application of the manpower targets. Those misgivings arise on two grounds. First, their imposition appears to me and many others in the Health Service to cut directly across the supposed increased freedom of management which was held out to be one of the principal benefits behind the recent painful reorganisation. While I welcome the statement that my right hon. Friend made to the House on Tuesday about the work of Mr. Griffiths and his colleagues, the management concept that he endorsed on that occasion as outlined by Griffiths, and with which I heartily agree, cuts right across the idea of arbitrary control of selected individual criteria in district management by the Department in London.

Categorisation has hindered rather than helped those of us who try to administer the Health Service. From what I can see, Griffiths has, if anything, pointed out the necessity to reinforce management structures. While that need not be taken to mean an increase in numbers, it makes nonsense of their being, in the main, of category "B" status.

Ambulancemen are another example of which I am sure the Secretary of State is aware, but I shall not go on. Equally, it is not yet clear—at least at district level—what power of virement we have between the two categories and whether there is still a firm requirement to reduce category "A" staff. No doubt my hon. and learned Friend the Minister will touch on that in his reply.

Frankly, I must repeat what I understand Mr. Griffiths to have said—that the less the Department tries to interfere in the day-to-day running of district and regional health authorities, the better for the NHS.

However, there is another and even more important aspect of this discussion of manpower targeting, and that is the effect on individual districts. I want to illustrate the position by referring to my authority. We agreed with the regional health authority in west Berkshire that a base line of 5,699 whole-time equivalents in March 1983 would be reduced by the princely number of 51. Those base line targets were produced for us by our quarterly computer print-out.

The authority met to discuss the position and two revealing facts emerged. First, by the administrator's own admission—I do not censure him or his colleagues in any way; indeed, their hard work and dedication to the Health Service over many years does them great credit—the authority was not in a position to know exactly what its present manpower levels were so as to effect a comparison at today's date with either the assessment or the target. No doubt in due course the computer will reveal all—albeit several weeks out of date—but for practical management purposes the information was not available, and there is no real machinery for regulating a managed vacancy factor or a manpower watch monitoring scheme. Sadly, there never was a more self-evident justification for the emphasis that my right hon. Friend the Secretary of State has laid on the need to come to grips with the control of manpower in the Health Service. My authority will attach considerably more attention to that in future. It is remiss of us not to have done so previously.

The second fact to emerge, which it is important to remember in the context of what we have heard today, was that our authority probably—I stress "probably" because we are not sure of the exact figures—already had a staffing level that was possibly 100 below that set by the Secretary of State, because the normal mechanism of drag on recruitment processing generally comes into operation in the Health Service as elsewhere. Therefore, it will in practice be unnecessary to make any reduction in substantive posts in the health authority in order to achieve the targets set for 1984. That may be a reflection on the system of targeting employed. No doubt my right hon. Friend would be disappointed if the matter were to be allowed to rest there by my authority or by any other. However, it puts into perspective the extraordinary claims that somehow his action has reduced the Health Service to its knees and that we are now, as a result of these extraordinarily modest measures, incapable of operating the National Health Service. The reality of our example simply does not bear that out, as indeed my right hon. Friend has consistently and rightly maintained.

I am pleased to have had this opportunity to provide just a small local example—I ask the House to forgive its parochial nature—of what nonsense it is to suggest that the measure is anything other than modest in the extreme.

We have also been subjected to the budgetary adjustments that the Chancellor was recently regrettably forced to make on this year's allocations. Again, Oxford region and my authority were no more immune from those adjustments than any other. I have no doubt that some authorities have fared worse and others better, and I make no particular claim in that regard. However, the reality of an individual case may help to belie some of the screams of anguish that I hear regularly paraded before me in the House and elsewhere.

The Oxford region acted in a constructive and responsible way to absorb the budget adjustment by means of deferring some capital spending, extending the Milton Keynes commissioning period, and bringing forward some regional development reserves and unspent balances. Of the required adjustment, £300,000 was allocated to reductions in regional and district health authorities' cash spending. Net of joint finance money allocated to my health authority, the reduction required in west Berkshire was £36,000 against an annual revenue budget slightly in excess of £56 million, including those service developments which were initiated as a result of development money being available. At that stage in the financial year when we came to consider the £36,000, it was clear to us, as, I hope, a prudent authority, that we were likely to undershoot our cash limit not by a huge amount in relation to our total budget, but by sufficient to accommodate the £36,000 completely. In other words, the net effect on the spending of the Health Service in the district is precisely nil. Our treasurer attributes the likely underspending to two factors: first, to the drag on implementation of structural improvements which we foresaw in our annual plan, which is not untypical of any organisation in the public or private sector; and, secondly, to the lower rates of inflation in outturn against our original budget forecasts.

That is the real picture behind the recent actions of the Government—a modest manpower proposal, the effect of which, in itself, is truly negligible, and a so-called cut in expenditure which amounts to no more in many authorities than an alteration to the technical underspend at the end of the financial year. Whatever else those measures may achieve, there seems little evidence here that they will produce anything like the effect for which they have, falsely, become so notorious.

There are two conclusions to be drawn, one by Conservative Members and another by those who have levelled somewhat intemperate invective at the Government. Conservative Members, believing as we do in the NHS, must be more vigorous than we have been in the past in putting across our clear message, if only there is a will to hear it, that the service is an excellent one in general and that we are determined to achieve better value for money from the immense and increasing resources that are committed to the NHS to improve patient care by more efficient delivery of service to the point of need.

As to those who are crying so loudly at this moment, I can only remind them of the cautionary tale of the boy who cried wolf. If the real and important negotiations over the future of the Health Service are conducted in such an unnecessarily hysterical fashion, it can only do harm to the service and patients for whom the complainants claim so heartily to care.

There are still large savings to be made and real economies are there for the making in the NHS. We can do much more within our existing resources to improve patient care standards as a result. The Government have shown their willingness to come to terms with the task, and I entreat those otherwise so ready to be critical to lay aside the inflated invective and join us in the constructive provision of an efficient and effective NHS for the British people.

6.8 pm

Mr. Donald Stewart (Western Isles)

I am glad to be called after the hon. Member for Oxford, East (Mr. Norris) because I want to congratulate him on his excellent maiden speech. He comes to the House with the extra authority of having been the vice-chairman of a health authority. Within the constraints of a maiden speech I think that all would agree that he made a robust and pertinent contribution to the debate. Therefore, we look forward with anticipation to his contributions in future debates.

Politics is essentially about priorities and it is abundantly clear where the Government's priorities lie. They lie in increased expenditure on armaments at the expense of a caring public health service and I hope that that is becoming clear. The Government's response to the problems of public expenditure is to attack the NHS by crude, short-term budget cuts across the board. The NHS may not be perfect, but since its inception millions of people have enjoyed the security gained from knowing that such a service exists and that the level of service does not depend upon their ability to pay.

I do not want to argue the pros and cons of private medicine, but without the resources of the NHS as the foundation and fallback security, private medicine would be dead because the costs would be exorbitant. Private medicine exists because of the NHS, and it is a parasite on the NHS.

Scotland has an unenviable record at the top of the international league for deaths from heart disease, lung cancer and other complaints. We should be increasing the resources put into the NHS, not cutting them. The need for better health provision is obvious. Only a Government totally devoid of compassion could, in cold blood, cut health expenditure. The cost cuts in Scotland have been made by a Government who had the backing of only one quarter of the population. As has been pointed out, Britain still spends a smaller proportion of its gross national product on health care than most advanced countries. That is the yardstick by which nations will be judged by civilised people.

In Scotland, hospital waiting lists have been lengthening rapidly and progress in reducing the waiting times in the past 10 years has been reversed. An increase in health expenditure of between 1 per cent. and 1.5 per cent. will be required simply to maintain the current position. Yet the Government go for cuts. The Glasgow Herald on 3 October 1983 stated: So far, Scottish Health Boards have saved money and avoided pay-offs by freezing posts. The result of this policy has been less hostile publicity but a growing number of haphazard ward closures, longer waiting lists and overcrowding. All the talk about the cuts of 0.5 per cent. and so on cannot disguise that fact. The people are aware of the realities, despite the arithmetic of the Secretary of State. The position is worsened by the cuts in social work departments which have been forced on Scottish local authorities by the Government.

The Government's proposal to health boards to contract out ancillary work is based not on efficiency but on ideology. It is a device to allow their friends in big business to rifle the public purse. The Government will use the abolition of the fair wages clause to reduce wages which are already abominably low. The case for privatisation has been proved wrong in the economic arguments. The Conservative manifesto boasted: Even after allowing for price rises, the nation is spending substantially more on health, and getting better health care. The Glasgow Herald pointed out that the reality in many parts of Scotland is a return to the bad old days of overcrowded and understaffed wards and low morale even in some our showpiece hospitals. The Government make a serious mistake if they imagine that concern for the future of the NHS is confined to the Opposition Benches. As the right hon. Member for Plymouth, Devonport (Dr. Owen) said, there is as much concern among Conservative voters as among other sections of the population that the service be maintained. The Secretary of State need not think that in bashing the NHS he will receive the plaudits of his supporters. Most people would regard expenditure on the NHS as having the first call on the national exchequer.

The Government must take several steps to safeguard the NHS. First, expenditure must be increased to provide for an updating according to the costs and the calls being made on the service.

The Government could also demand that generic drugs be put on prescriptions instead of expensive brand name drugs. The Secretary of State told us that he would have consultations with the drug industry. If they are anything like the consultations that the Government have had with the tobacco industry, there is not much hope of advance. The Government could ensure a substantial improvement in public health and a lowering of National Health Service costs by banning tobacco advertising, yet they have never taken that step, which shows their reluctance to take on the tobacco firms.

Scotland's priorities are not the Government's. My party stands beside the doctors, nurses, other National Health Service workers and, most importantly, the patients in defence of one of society's finest creations which enhances the quality of our lives.

6.15 pm

Sir David Price (Eastleigh)

I join the right hon. Member for Western Isles (Mr. Stewart) in his congratulations to my hon. Friend the Member for Oxford, East (Mr. Norris). We all agree that our debates are enhanced when people talk from personal, current experience. I shall not give my credentials; I believe that most of the House know that I have a close and continuing involvement with the National Health Service.

I shall put one general proposition to the House. The current challenge facing the National Health Service is one of expectations exceeding resources. I make no party point, but I believe that this situation has existed since the National Health Service was created. I believe too, and I am sure that the right hon. Gentleman will agree with me, that it is a great deal more fundamental than just a few per cent. more in resources.

When we talk about a free National Health Service we should be more careful to make a distinction and talk of it as being free to the patient at the point of delivery of the service. It is not free in terms of resources. We should make it clearer that it is a partnership that we must go on nourishing between taxpayers, all who contribute to the service, and all who use it. In many cases they are the same people but not as much as we sometimes believe. According to the Royal Commission on the National Health Service well over 60 per cent. of the use of the National Health Service is by people who, broadly, one would expect no longer to be taxpayers or who are too young to be taxpayers. It is important to maintain the partnership between user and payer.

The concept of a free and comprehensive National Health Service provided at public expense represents an open-ended commitment on the demand side, although the resource side will always be finite.

The demands on the National Health Service have clearly been stimulated over the past 30 years by the remarkable advances in medical science. We are increasingly able to alleviate pain and to treat conditions in areas previously denied to us. That has undoubtedly prolonged—if I may use an advertising phrase—active life. We all welcome and rejoice in that. It has, however, resulted in people remaining alive who are wholly or largely dependent for their daily existence upon other people. We think immediately of the very old and the severely disabled whose disability may date from birth. It is all admirable, but it has increased significantly the resource demands upon the service.

Many of us who care about the service have been slow to come to grips with increased demand. I hope that the new departmental Select Committee on Social Services will give that aspect of the service high priority.

I should like, in that respect, to quote to the House what I believe to be a useful document prepared by my right hon. Friend called "Health Care and its Costs". It states: In some instances improved treatment methods can lead to net savings, because they reduce the need for prolonged hospital treatment". We can all think of examples. The document continues: but more often medical progress calls for increased expenditure. Innovations often extend demand by bringing more patients within the range of active treatment. We think immediately of the hip joint replacement. The document goes on: Many new treatments require more highly trained staff to handle the increasingly complex techniques, instruments and drug regimes involved, and this means that, in turn, manpower costs per case will often rise. New techniques and treatments may also mean the purchase and maintenance of expensive equipment. Additional costs will also rise because new treatments need careful monitoring: and some may entail a financial commitment lasting for the rest of a patient's life. We welcome all this progress, but I do not believe that as a House and a society we have faced up to the resource consequences. I welcome the advances, but I wish that we would try to get a better measure of the consequences upon resources. I agree very much with what the right hon. Member for Plymouth, Devonport (Dr. Owen) said about the enormous importance of partnership between the National Health Service and the local authority social services. If we are to implement care in the community more, as I am sure all of us would wish to, we have to give greater consideration to the resources going into the community side of health care.

The right hon. Member for Devonport mentioned the over-75s. I do not think that his figures are quite right, but I do not quarrel with his broad thesis. The figures that I acquired yesterday from the Library show that in broad terms 3 million people in the community are over 75 and that over the next 20 years the figure is expected to rise to 3.8 million—a 20 per cent. increase.

On average hospital and community services spend nearly nine times—not six times—as much per head on people over the age of 75 as on people of working age. If there is to be a 20 per cent. increase in the number of people over 75 over the next 20 years, the forward planning of resources to meet this new demand will be daunting; but we cannot avoid facing up to it. Beyond the party badinage resulting from a new Leader of the Opposition, we must all consider how we will be able to provide the necessary resources, which I am sure all of us want to see provided, to fulfil the growing demand of the National Health Service. Whoever are the Government of the day, they have no choice but to determine priorities. It is easy to talk about priorities but it is harder to put them into practice. I hope that I carry the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) with me when I quote what the previous Labour Government said in their health document, "The Way Forward". The right hon. Member for Devonport was probably one of the authors. They said: Public expectations of the health and social services will frequently outrun supply and sometimes hard decisions will be needed to hold back some services to allow others to be developed. This recognition of the need for priority should particularly appeal to the right hon. Member for Islwyn (Mr. Kinnock), the new leader of the Labour party, who I understand is a great fan of the late Aneurin Bevan, who once said that priorities are the language of Socialism. I hope that the whole House will agree on the need for priorities. We should therefore look to the Social Services Select Committee for its advice on these very priorities.

We must not plan the future of the National Health Service outside the context of attainable economic growth within our economy, otherwise frustrated expectations will be even greater than I suspect they are now. Again, we have the evidence of the Royal Commission, which was set up under a Labour Government and reported to a Labour Government. The Royal Commission wisely observed: The financial resources available to the National Health Service are finite … although we naturally hope that resources will continue to be made available on a generous scale it would be unrealistic to suppose that the fortunes of the National Health Service should be insulated from those of the nation. That is fundamental if we are not to have a cleavage between expectations and what we can provide. Looking ahead, that is what worries me. If people think that there is frustration now, I invite them to consider that in 10 to 15 years' time there could be a major imbalance between demand and resources in the service.

The start was made on this matter under a process known as the resources allocation working party, which was set up under the previous Labour Government and continued by the present Government. We all know that the purpose of RAWP—to get a fairer allocation of resources between regions—was in principle accepted by everyone, until there was a movement of resources away from those regions which came out best in the analysis to those which came out less well. As I come from a region which was a beneficiary of this move, I shall leave the argument there. The London area, which appears to have been a loser under this change, does not find that in practice the principle with which it may have agreed in theory is quite so acceptable.

The search for efficiency in the service must not be a once and for all effort, made necessary by the immediate needs of departmental cash flow.

I believe that the better use of resources must be a continous process. Our service must be geared up to continuing improvement. The medical input of better treatment and so on will help to achieve that. But it should not be a once and for all effort.

Who should decide priorities within the Health Service? In England we have 14 regional health authorities and 192 district health authorities, yet they are all financially dependent on the Government. They do not have a completely independent existence. How do we decide priorities? I should like the views of the Select Committee on this matter. It is not enough to say that the Secretary of State decides in the broad. We must get down to where it really matters—resource allocation in the districts.

This should be decided as near to the patient as possible. That is why I strongly support the Government's proposals on direct personal management. In the hospital service today no one is in charge at any level. There are committees galore. I was once connected with a London teaching hospital and I remember that the ward sister was the linchpin of the organisation, because she was genuinely in charge of her ward. She may have been awkward at times but she ran a tight ship, to use a naval expression. I believe that getting the ward sister and the matron back with their old powers is essential. This need not in any way cut across the idea of proper consensus consultation, but direct personal authority is essential.

I very much support the principles and the persons of general management in our hospitals. I wish them every success. I say welcome back to the matron and the 'ward sister.

6.29 pm

Mr. Max Madden (Bradford, West)

Today and in recent weeks the Government have been dangling a series of assertions in front of the noses of the British public and now the Government and the Conservative party appear to be extremely unhappy, injured and upset at the British people steadfastly refusing to believe those assertions. The Government have been saying—the Secretary of State said it again today—that the National Health Service is the largest employer. They do not say—they in fact conceal—that the Government are sacking doctors and nurses to join other doctors and nurses on the dole. This is the first time that doctors and nurses in the Health Service have been sacked.

The Government say that there is more money in the Health Service, yet they conceal the fact that the resources in the Health Service are not sufficient to meet existing needs, still less anticipated needs. They talk a great deal about patient care, yet they conceal the number of hospital closures, bed reductions, manpower cuts and the way in which other forms of provision in the National Health Service are being reduced, all of which is having a direct impact on patient care.

Conservative Members criticise hospital administration, yet they conceal the fact—although we have lifted the veil a little today—that adminstration costs in Britain are a fraction of those in other countries with services comparable to the NHS. The claim by the Coservatives that the NHS is safe in their hands is not believed by the people, who have every justification to doubt their word.

If that is the case nationally, it is certainly the case in Bradford, West, which I represent. My constituents face the closure of Thornton View hospital, which for many years has provided excellent care for very elderly patients. The threatened closure is opposed fiercely by a wide range of individuals and organisations in the city of Bradford, including the community health council and Bradford city council.

When the closure of the hospital was originally suggested by the district health authority it was claimed that the saving would be about £433,000. We know from later information that that authority has before it proposals which could possibly save £462,000. Thus, the financial argument for the closure—the only argument that has been advanced—falls. In other words, there is no financial argument to justify the closure of the hospital.

My constituents argue that the alternative arrangements proposed for patients from Thornton View, if the hospital is closed, are wholly inadequate. The only long-stay provision of 23 beds is in ward 7 of Leeds road hospital, a pre-war hut-type building in an isolated location. It offers less light than the existing hospital, the sanitary accommodation is inadequate, it is as far from a bus service as Thornton View and the access to the hospital is just as steep. The district health authority would need to spend about £80,000 to put that ward into even a minimal condition to receive patients. The closure of Thornton View would leave the authority with 59 fewer long-stay geriatric beds and 35 patients in wholly inappropriate accommodation.

I urge the Secretary of State—I have been doing so for some weeks—to meet a deputation from the city of Bradford so that he may learn at first hand the strength of feeling among, and hear the comments of, the local people about the closure of the hospital. I hope that before he makes an announcement about the future of Thornton View he will meet that deputation so that he may hear the full case for the hospital remaining open.

Thornton View hospital has been occupied by the staff since the early part of August. They have been anxious that the patients should not be transferred and their occupation has been supported enthusiastically by the local community, which is the finest vindication of the case for the hospital remaining open. I hope that the Government will see sense, will recognise the case for it remaining open and will announce that it will remain open indefinitely.

I come to some of the other cuts which are affecting local authorities and the impact they are having on the personal social services. The cuts are resulting in local authorities considering the closure of residential and other facilities for the elderly. There is a growing lack of these facilities, with great pressure on the places available. In Bradford, the health authority does not have sufficient long-stay geriatric beds, yet the general health of the elderly is extremely poor. There is little investigation into the needs of the elderly, who do not report illness or disability in the way that they should. We need an independent inquiry into the needs of the elderly in the city of Bradford.

Hon. Members have referred to the increasing numbers of very elderly people in the community. The number aged 85 and over in Bradford will increase considerably in the next 15 years. The people in that age range need seven times the resources of people aged 65 to 74. The closure of Thornton View hospital would result in a shortfall of between 52 and 66 beds, and if there is no additional provision in the next 15 years the shortfall by then will be between 90 and 104 beds.

As for the latest proposals for the reorganisation of the NHS, much has been said about the Griffiths report and the need for more efficient management. I appeal to Conservative Members to remember that we are talking about people, not bags of flour or packs of butter. These people are sick and in need of care. They should be treated with dignity. They have the right to expect the best possible care from the NHS.

In my constituency unemployment averages 30 per cent. In parts it reaches 40, 50, even 60 per cent., but I fear that some Conservative Members do not understand the impact of mass high unemployment in terms of illness and attitudes. We have acute poverty, with families suffering from depression as a result of family unemployment and fathers who have been unemployed for one, two, three years and more, and that has a big impact on community care because community care means family care. How can young mothers who cannot get their children into nursery school, because all the places are taken, be expected to provide proper community care for sick or elderly people?

In the city of Bradford babies are being weaned on baked bean juice, instant mashed potato and Cup-a-Soup. That is happening in many areas of high unemployment. Men must walk 10 miles for a £40-a-week job, yet they do not even have the benefit of a Tebbit bike. We in areas of high unemployment face years of poverty, the depression of mothers with young children and children continually ill through poor food and damp housing. That is the reality of Britain today.

Despite all that, the Government say that there are not the resources to devote to the NHS. They ask from where the money can come, and I will make some suggestions. They could find £10 billion if they choose to cancel the Trident nuclear submarine programme; they could find millions more if they reduced the burden falling on Britain because of our membership of the Common Market; and they could find millions more by refusing to accept the stationing of cruise missiles in this country.

It is interesting to note how the Americans are proposing to build hospitals in this country for American service men associated with cruise missiles. They are also providing scores of houses for American service men involved with those missiles. The Government could find millions of pounds by expanding the economy instead of squandering the North sea oil revenues to finance mass unemployment. They could find millions of pounds by not embarking on ludicrous proposals to reorganise local government. They could find millions of pounds by not imposing equally ludicrous civil defence requirements on local authorities. They could find millions of pounds by not giving large tax handouts to the very rich. They could find millions of pounds by not allowing unfettered overseas investment, thereby preventing more and more people from acquiring fine arts and property blocks in New York.

Those are some of the ways in which they could find more money for the National Health Service. Those are some of the ways that they could find more resources to build a better National Health Service. If they chose to find the money in some of those ways instead of creating more unemployment, more poverty, more misery and more depression, especially in inner city areas, they could greatly improve the NHS.

I am grateful for this afternoon's announcement that there is to be some increased provision for the inner cities—for the record, I note that the leader of the SDP, the right hon. Member for Plymouth, Devonport (Dr. Owen) left the Chamber some time ago—but I ask the Government whether the £9 million will be fresh money or money that will be juggled and removed from existing budgets.

Today, as yesterday, the Labour party is speaking for the people of Britain. I hope that the Government will heed what the people are saying. They are saying loudly and clearly—whether the Government have the wit to listen or heed is another matter—that they expect a proper level of resources for the NHS. These are resources to which they are entitled and which they know are available if the Government choose to use them.

6.42 pm

Mr. Francis Maude (Warwickshire, North)

I cannot hope to match the rhetoric of the hon. Member for Bradford, West (Mr. Madden), who spoke with great passion. I am grateful to you, Mr. Deputy Speaker, for giving me the opportunity in this debate to make my maiden speech. I am not quite the last of the new intake of Members to get off the mark, though the list of those who have not done so is gradually diminishing.

My constituency is more recreated than new. It has been absent from the political map of Great Britain for about 98 years. It disappeared under the hand of the Boundary Commission of 1885. I would be delighted to follow the convention of paying tribute to my predecessors from that time, but, even in the healthy climes of Warwickshire, North, I have not been able to find anyone who remembers them.

Warwickshire, North was created from two previous parliamentary seats—the old seat of Meriden and the old seat of Nuneaton. It has been used to a high standard of parliamentary representation. The old seat of Meriden was one of the most marginal seats in Britain and changed sides politically at each election. It had a series of talented and hard-working Members of Parliament, including my hon. Friend the Member for Ashford (Mr. Speed), my hon. Friend the Member for the new seat of Meriden (Mr. Mills) and, between them, Mr. John Tomlinson, who was my Labour opponent in June. All three of them served their constituencies and the House with distinction. They worked for their constituents most conscientiously and all are remembered in Warwickshire, North with gratitude and affection.

The Member who represented the old Nuneaton constituency, from which I have the town of Bedworth, was Mr. Les Huckfield, who I believe worked hard for his constituents wherever they were. I am sure that he will make his involuntary absence from the House a temporary one.

It is customary to talk about one's constituency and I find it a pleasure to do so. It is in the area of the west midlands which is precariously balanced between but excluding Birmingham, Coventry, Nuneaton and Tamworth. It contains a wide range of activities and occupations. There is an example of virtually everything except, I think, deep-sea fishing. There are four flourishing coalmines with industrious and extremely realistic work forces. There are many square miles of extremely efficiently husbanded farmland. There is a multitude of small, specialised and innovative engineering firms, about whose interests I shall have much to say on other occasions. It contains a number of towns and villages which are expanding and which are providing housing for people working in Birmingham and Coventry. All in all, it is a demanding, stimulating and delightful constituency which I am proud to represent.

The Health Service is increasingly perceived not to be short of resources. There is a mismatch between needs and resources. This explains the apparent paradox that there are too many acute hospital beds while there are still long but, I am glad to say, decreasing waiting lists. There are thousands of beds in acute hospitals that are not being used by those who need acute medicinal care.

About 20 years ago provision was made for people not in need of acute care in cottage hospitals, which we now have to call community hospitals. Nursing care was provided with overall medical supervision from general practitioners. In our wisdom, we chose to get rid of them, but they had many advantages. I believe that in future we shall have to look towards that sort of provision if we are to match needs to resources. The cottage hospitals were cheap to run and they were local. That was especially important in rural areas where people wanted to visit elderly relatives in hospital. The fact that they were close to the areas that they served was an enormous advantage. They were small and because of that they were efficient and cheap to run.

The problem is to decide how we shall pay for that sort of hospital. We must look to much more effective management of resources within the Health Service. There are many parts of the service which are overmanned and it is folly to ignore that unfortunate fact. These areas are not overmanned only by ancillary workers. In some parts of the service there is an over-provision of medical resources and, as I have said, we must match resources to needs.

There is a massive inertia built into the present NHS management structure. I served for a short period as a member of a district health authority shortly after the reorganisation of the NHS. It took an extraordinarily long time for any changes to be made. I believe that the fault lay with the system of consensus management which arose in the early 1970s. No one person carried final responsibility for what actually happened. Members of the district management team took it in turns to act as chairman of the team, and that meant that the system had inefficiency built deep into its structure. I am delighted that the Griffiths report recommends the appointment of chief executives and general managers, who will carry the can for the units that they run. This is an essential step if we are to get inefficiency out of the system.

Many part-time members of district health authorities do a good job, but even those with a will to do so have difficulty in rooting out inefficiency. They do not have the time to do so and in many instances management is incapable of providing the information on which they need to act. It came as no surprise to some of us that in the recent review a number of authorities were unable to provide figures and information on the number of people that they employed. If anyone in the private sector tried to run a business in that way, he would not be around for long. It is astonishing that such a situation was allowed to continue for so long. It is a source of delight to me—and it should be to the entire House—that dramatic and radical action is being taken to improve the level of efficiency of management.

There exists an attitude which has fossilised the way in which we view the National Health Service. The idea seems to be propounded by Opposition Members that it is uncaring and uncompassionate even to contemplate the possibility that the Health Service is working at less than full efficiency. It is as though, in allocating money to the Health Service, one puts a label on it saying "NHS", and then one cannot follow where it goes. One cannot find out how it is spent. One assumes that because it goes to the Health Service it is automatically going to a good cause. One does not improve the Health Service just by pumping in money to make the statistics look better. The Health Service exists to provide a service to patients, and we must make sure that the money goes where it is needed.

It is therefore folly, when a private contractor can provide an ancillary service better than the direct labour force, to set one's face against it. The right hon. Member for Islwyn (Mr. Kinnock) made a number of points in his passionate speech about the way in which private contractors can operate. One cannot guarantee that a private contractor will provide a perfect service, any more than one can guarantee that a direct labour force will provide an adequate and efficient service. The difference is that if a private contractor falls down on the job it is possible to replace him immediately. As the privatisation of ancillary services develops, there will be an increasingly large number of firms which are able to take on the work at short notice. There will be competition and efficiency in those important services.

Discussions about the National Health Service have been surrounded for some years by a cloud of muddle and cant. Now we have to tackle the real problem, not so much of shortage of resources as of making sure that the resources we have go where they are needed. That is the challenge for the future, and it is a challenge that the House must face.

6.51 pm

Mr. Laurie Pavitt (Brent, South)

It is a custom of the House to say kind words to a maiden speaker. I do so on this occasion with great pleasure for two reasons, first, because the hon. Member for Warwickshire, North (Mr. Maude) reminded us of our old friend John Tomlinson, who was well liked on the Labour Benches, and, secondly, because in the course of his first speech the hon. Gentleman came out with a Commons in-joke, which amused the House highly, and that rarely happens. I shall not repeat which one it was, because he will know.

I shall make only one comment on the content of the hon. Gentleman's speech. He is quite right about the concept of the community hospital. I invite him to pursue the matter further by getting from his hon. and learned Friend the Minister for Health the DHSS document "Community hospitals of 1974". That document would, in my view, repay study by him and by all hon. Members. It was a remarkable attempt to marry primary care with institutional care.

The only other thing that I shall say to the hon. Gentleman is the customary phrase that we all look forward to hearing him again, but I can tell him that, although he is a charming person, his hon. Friends will think that when he speaks they will not get the time to speak, and we shall think that when he speaks it will cut our time. We welcome what he said. He has a lot to say. We hope that he will have the opportunity to speak on another occasion, but that he will make his speech brief.

Much of our debate today has been about the way we interpret what the Government are doing about local issues, and that is right. Hon. Members have put forward their constituency cases. I speak as the Member representing Brent, which has a district health authority second to none, so the House will not be surprised if I, too, come constituency-wise. We see the division that exists. The Secretary of State and his hon. and learned Friend juggle the figures and give us much arithmetic and many statistics, but we all know that what they say does not match the reality in our own areas.

I am extremely worried about recent events in my area—not just the manpower cuts, but the whole way in which the matter has been handled. Brent is an example of the right hon. Gentleman's desire to have more and more power in his own hands and to exercise that power through his regional chairmen.

I am proud of the stand that my district health authority took in resisting the cuts. I want to tell the House of some of the consequences of that stand. People were appointed—not elected—to serve on the DHA to put patients first and to use their local knowledge. They were not expected to dance like puppets when the Chancellor of the Exchequer jerks the strings of puppet number two—the Secretary of State—to conform with some economic and outmoded doctrine.

The round of cash cuts that we had was deplorable. Every authority, including Brent, has a year's estimates. Suddenly, after three months, to impose cuts was unforgivable. The manpower cuts were described by my right hon. Friend the Leader of the Oppostion. The number in my area was 110, but in reality it is 320 because, as we have a wise and prudent health authority, we had not filled posts. Posts were waiting to be filled. Now that prudence is being penalised.

I shall say a word about the consequences of the expenditure cuts. At the Central Middlesex hospital, much-needed equipment—an electrocardiograph machine, resuscitation machines, air flow fans, and other items for the use of patients—has had to be cut out. A sum of £1.2 million has been cut from the capital programme, and four wards will have to remain closed because of cash cuts. It shows beyond peradventure the truth of the statement by the regional medical officer of the north-west Thames region, that these cash cuts must inevitably cut into patient care, service, treatment and all that goes to make up National Health Service provision.

Government policy has led to one of the most inefficient demands on Brent's resources in 1982–83 amounting to nearly £1 million. We had to pay £529,539 for agency nurses, and a further £416,000 for other agency staff. That is entirely because, following the secondary reorganisation that took place, there was so much juggling of posts that the authority was unable to cope with the straightforward job of filling posts through the normal channels. Some of the 200 posts that are vacant are for nurses, while awaiting the outcome of the last reorganisation.

The district health authority's decison led to an unprecedented intervention by the regional chairman. It was the subject of a devastating first leader in the The Guardian under the heading Dame Betty in a pickle". Dame Betty Patterson is our regional chairman. There was an appalling blackmail threat, which I hope the Government will reject, to sack all members unless they were prepared to accept a diktat from the region. The members took the matter to the High Court, and Mr. Justice Forbes' comments are worth repeating. He said that if the region's counsel was right, it would enable a regional authority to stampede a subordinate body into following its wishes". He went on to say: One approaches with a certain amount of distaste a system that envisages that the junior body is just a body of yes men". Is that what the Government want? Is that the planning—that something comes from the Elephant and Castle to the regional chairmen and there are a lot of yes men with rubber stamps?

In this connection, let me quote the letter that came to all the dissident members last week from Dame Betty. It said: I am, therefore, writing to inform you that a special meeting of the North West Thames Regional Health Authority is due to take place on next Monday 31st October 1983, which will consider seeking the consent of the Secretary of State to the termination of your appointment as a member of the Brent Health Authority". To her credit, Baroness Cox, who was recently appointed, and who is a strong supporter of the Conservative party, was one of the rebels. I think that the Government thought that her appointment would be yet another method of having their own way. If the Secretary of State consents to the sacking of the members of the Brent DHA, he will make plain his own dictatorial ambitions. I remind the Secretary of State that the last king who claimed the divine right to rule was Charles I. When we take parties of schoolchildren around the House, we always tell them the story of the consequences.

The Government have accepted and approved urban aid for Brent, which is one of the most deprived areas in the country. At the same time they have cut funds in the rate support grant for the social services and back-up services in the NHS. The Government have demanded the reallocation of funds from Brent to Bedford. Brent has one district nurse for every 4,800 patients, whereas Bedford has one for every 2,800 patients. There are cuts in my area, but not in Bedford.

The Minister's style was typical in the nurses' dispute last year. Generally in the Health Service his style is "divide and conquer". In most areas, particularly mine, there is a threat to one hospital and another has to be sacrificed. The Central Middlesex hospital was under threat. Now the Wembley hospital is to be either partially or fully closed on the excuse that, if that is done, the Central Middlesex hospital will be preserved. I sought an assurance from the Minister for Health, but I did not get it. All he said was that there was no formal application to close Wembley hospital". The hon. and learned Gentleman did not say anything about the informal pressures behind the scenes. I look forward to hearing more about that.

The result of the last round of cuts is that 31 hospitals are earmarked for closure. At the moment 2,000 deaths from renal failure could be averted. That number will increase. As a deaf person, I am affected by the closure of the unit for the deaf, which is unique in this country, at the University College hospital. One of the illnesses that it dealt with, from which tny right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley) suffers, is tinnitus. I could give a list of various illnesses and patient care that will be affected.

When the manpower targets are reached, 10,000 nurses will be on the dole. The Government have altered the way in which they collect the figures. I have been carrying out a six-monthly check. The figures that I want are no longer available. On my last check, the figure was 8,600 a year ago.

I accuse the Secretary of State of soft-soaping the nurses last year on their pay claim. The right hon. Gentleman made it clear that the nurses would not be worse off than the rest of Health Service personnel. The Government gave the nurses a pay award of 6 per cent. and then immediately gave the doctors 9 per cent. That was reneging on the Government's commitment.

In his report, Griffiths reveals a complete ignorance of the effect on the whole spectrum of nursing skill and on the patients. Instead of talking to Sainsbury and Roy Griffiths, the Secretary of State should listen, as I did yesterday, to people such as Trevor Clay, the general secretary of the Royal College of Nursing. I have his permission to repeat his remarks. He said that, in spite of the Secretary of State's denials in reply to a question that I asked last Tuesday, the proposal in the Griffiths report represents a more massive change in human terms than either of the previous reorganisations of the NHS and the tier services that were too much at first and were then decreased.

Is the Secretary of State aware of the input of nurses at all levels of patient care? Is he aware of the millions of pounds that have been spent since the Salmon report on management training? Is he aware that all that has been discarded in the Griffiths report?

I should like to ask the Minister for Health two questions. He need not reply today. He does not always reply at the end of the debate, but he is always courteous enough to write to me afterwards. First, what will happen to the four chief nursing officers—one for each county in the United Kingdom—who, for the past 40 years, have been in direct contact with the Minister? Secondly, what is happening to the Whitley machinery? There is a great deal of discussion and reorganisation in all Whitley sectors of the NHS. Will the Minister make a statement about the stage that he has reached in the rearrangement and reorganisation of those staff negotiating bodies?

I offer the Minister some public expenditure savings. Generic substitution of prescriptions has been mentioned. At a stroke, I can save the Government at least £30 million and anything up to £200 million if, on 2 December, the Government tell the Whips not to block my Generic Substitution (National Health Service) Bill, allow it to have a Second Reading, and let other hon. Members support it in Committee. The Secretary of State says that he could now claw back £25 million out of the £35 million revealed by the Public Accounts Committee as being excess profits of the drugs industry. I hope that he will have another look at the debate on the unfair prescription charges for women who have had a breast amputated. Women pay £21.50 every year for the rest of their lives for chemotherapy. I ask the right hon. Gentleman to use his influence with the Cabinet so that cancer is added to the eight designated diseases eligible for free prescriptions.

Successive Tory Ministers have pursued NHS management. It is an obsession. Because of their knowledge of industry, commerce and the City of London, they think that all the answers can be obtained. There is nothing new about that. I have a copy of the "Grey Book". Fortunately, the Griffiths report did not cost us the £250,000 that the McKinsey report cost. Because the McKinsey report was unintelligible, it was necessary for the Department to produce the "Grey Book" to interpret it.

I advise the Minister to take his departmental working party to heart on this issue. Page 13 of the "Grey Book" mentions "Participation of clinicians". It states: The management arrangements required for the NHS are different from those commonly used in other large organisations because the work is different. The distinguishing characteristic of the NHS is that to do their work properly, consultants and general practitioners must have clinical autonomy, so that they can be fully responsible for the treatment they prescribe for their patients. It follows that these doctors and dentists work as each others' equals and that they are their own managers. In ethics and in law they are accountable to their patients for the care they prescribe, and they cannot be held accountable to the NHS authorities for the quality of their clinical judgments so long as they act within the broad limits of acceptable medical practice and within policy for the use of resources. I apologise for putting all that on the record. What was said in 1972 applies to the proposed executive managers and the scheme that will now be inserted into the NHS structure.

The Minister knows that our administrative costs are low. I shall not go into that argument, already covered by my right hon. Friend the Leader of the Opposition. Management is being considered as if it were an adding machine at a check-out. The patients having treatment in hospital are not being considered. I shall give an example of some of the nonsense proposed. Treatment for hernia takes two to seven days. When assessing the time needed, one has to consider whether the patient has had a colostomy or is elderly. Only the doctor can decide that. It would be nonsense for executive management to say that, because of the area, the time limit for hernia treatment must be two and a half days. such thinking would apply to every disease. Doctors' control is now challenged by the Griffiths report.

The Government's attitude is the same as the cynical adage of the medical profession. When the Secretary of State considers the NHS, he says: Thou shalt not kill but need'st not strive officiously to keep alive. In all its sectors, the NHS is being eroded. It is not being knocked down. Just as the upsets involved in the job changes caused by the previous reorganisation are settling down and just as the tremendous trauma in middle management and all specialties is resolved, the NHS will be shaken up yet again. The Government are perpetrating nonsensical acts on devoted and committed NHS personnel. The Government have found a prescription for setting doctors, nurses and auxiliaries against one another. They have now found a prescription for conflict in NHS middle management. From whichever discipline an appointment is made, there is bound to be a row.

I am afraid that the NHS will remain convalescent until such time as a Labour Government can restore it to health.

7.10 pm

Mr. Nicholas Fairbairn (Perth and Kinross)

Like the right hon. Member for Plymouth Devonport (Dr. Owen), I have a medical background. My father was in practice with a cousin of Clement Attlee whom he frequently met in the early 1920s. I myself partially qualified in medicine and pioneered the birth control services of the Brook advisory centres in Scotland. When the right hon. Member for Devonport said that the greatest moment in his father's life was when he knew that he did not have to charge his patients, he seemed to suggest that thereafter nobody was charged for health care. In fact, the patient no longer had to worry about the charge, but the nation did. From then on everybody had to worry about the charge because we all became contributors to the National Health Service.

The Leader of the Opposition talked nonsense when he said that the NHS was the proudest and most priceless possession of the British people. Health is the most priceless possession of every person in this country. A service which helps those who are ill and restores them to health is also priceless—I wish that "priceless" was the right word in every sense—but it will be the nation's proudest possession only if the service is medically effective and not bureaucratically extravagant.

The virility of the Health Service is to be judged not by its expenditure, or by the global figure of those employed, but by whether it is a good medical service which everyone, whether well or ill, must pay for. We have doubled expenditure on the Health Service in the past four years, which means that we have doubled its cost. In the past 10 years the number of people that it employs has doubled. Although those facts seem to be good, that is not a good criterion to use. Political parties or Governments should not consider extravagance to be an achievement.

I hope that Scottish Members, especially the hon. Member for Fife, Central—I cannot remember the funny names since constituencies have changed——

Mr. Pavitt

Mr. Hamilton.

Mr. Fairbairn

"Hamilton" is not a funny name, but a funny person.

Scotland has a different NHS structure. The Government have looked after the nurses, the doctors and the services, but when a service spends more than a quarter of the entire budget of the Secretary of State for Scotland we must ask whether the money is being spent wisely and properly. The health board in my constituency spends two and a half times as much on ancillary staff and administration as it does on medical staff. That is a bad state of affairs.

I congratulate my hon. Friend the Member for Warwickshire, North (Mr. Maude) on his thoughtful and provoking speech. I was pleased to hear him refer to cottage hospitals rather than community hospitals. When asked to close a cottage hospital to save a tiny sum of money, the health authorities sought to take the money from the medical services and not from the administrative and ancillary services.

Ninewells hospital, in the Tayside region, has 46 miles of carpeted corridor and is the most expensive building to heat in Scotland. It is only two thirds full, it is inefficient and its costs are three times more than originally estimated. If the Leader of the Opposition had been Scottish instead of Welsh, he would have said that the NHS was spending money on Scotland's most priceless possession. Ninewells hospital is a monument of disgrace. What should have been spent on health was spent on bureaucratic empire building and extravagance. The Health Service must be examined in the light of such facts.

The NHS is a service of care, medicine, love and health for those in difficulty and need, and not for those who enter the medical bureaucracy to exploit, as I believe has been the case. Under the Scottish health boards are the area executive groups. Then come district executive groups, followed by sectors and units. Each of the separate area health boards costs £100,000, although they do not contain one person who will make a worthwhile or commanding decision. We are talking about the lowest common factor and the multiple of greatest expense.

The Scottish Health Service would have plenty of money if that money were well spent. Giving the Health Service more money will not necessarily improve the situation. The Health Service must improve the use of its undoubtedly adequate resources. The word "cuts" is a medical, surgical and statistical one. Some refer to economies or prudence as a term of abuse rather than of virtue. I take the simple view that the doctors who are not practising, the nurses who are not nursing and the administrators who are not involved in clinical matters deliberately put pressure on the most sensitive areas so as to upset the public, worry the patients and prevent their empires, expenditure, staff and clinical enlargement from being diminished.

The secretarial staff for group practices and consultants is unnecessary and exaggerated. The number of X-rays taken, drugs given and prescriptions offered are out of all proportion to what any person who personally had to consider expenditure would ever medically and responsibly prescribe. There is unnecessary expenditure on everything in the Health Service except patients and the service. Health is the golden cow, not the Health Service.

All hon. Members want the Health Service to be better. Anyone who says that there is one person, country, sex or party who does not want it to be better is being unbelievably naive and cynical. The Health Service does not get better because it is more expensive, bigger, builds more hospitals, has more machines, employs more secretaries and ancillary staff or takes more X-rays. It can be judged only on its effect. I hope that the Leader of the Opposition's statement that pain is an opportunity for commercial exploitation will stand for ever in shame at his door. No doubt that will prove to be the pattern, level and thickness of his philosophy. For him, pain is an opportunity for political exploitation. He did not impress me as being worried about patients. He used patients and public concern as a means of making himself appear politically acceptable.

Mr. John Home Robertson (East Lothian)

What about the cuts?

Mr. Fairbairn

What is wrong with cuts? If the hon. Gentleman had a wife who bought 1,000 fur coats, houses that she did not want and ran cars that she did not use and he said, "Would you mind spending the money on the children and not wasting it on all of this rubbish," would he describe that as cuts? I would say that such action was virtuous and an example of sensible housekeeping. It would be an example of someone minding about what they are supposed to mind about. The Health Service is supposed to mind about health and patients—not about the Health Service. The Opposition are not anxious about the welfare of all. They assume that officials are not corrupt, all-powerful or interested in their own empires. They assume that they are interested only in patients.

Mrs. Dunwoody

Would the hon. and learned Gentleman please retract the suggestion that anyone who works in the Health Service is corrupt? I am sure that he did not think about that statement. He does himself no credit to behave in such an extraordinary way.

Mr. Fairbairn

I am not suggesting that anyone is criminally corrupt. However, when someone says that he needs another secretary, office or more radiographers, is he considering the interests of the patient or his own power? That is what I mean by corrupt. There is such corruption in all bureaucracies, whether in private or public concerns. Such corruption should be controlled sensibly.

It is important that we spend properly the money that we take from citizens who might one day be extremely ill. That is the sacred trust for health. We must tell the Health Service, as the Government are doing, "Physician cure thyself."

7.24 pm

Mr. Willie W. Hamilton (Fife, Central)

The hon. and learned Member for Perth and Kinross (Mr. Fairbairn) made many wild assertions and allegations about waste in the Health Service in Scotland and elsewhere. He also cast aspersions on the behaviour of my right hon. Friend the Leader of the Opposition. We shall not take any lessons in morality from the hon. and learned Gentleman.

Mr. Fairbairn

Or the hon. Member for Fife, Central (Mr. Hamilton).

Mr. Hamilton

My record on morality is——

Mr. Fairbairn

Pretty bad.

Mr. Hamilton

My record on morality will stand up well to a comparison with that of the hon. and learned Gentleman, so he had better shut up about such matters.

The now absent leader of the Social Democratic party implied that, because no statement on management structures in the NHS in Scotland had been made, presumably everything was all right. The Under-Secretary of State for Scotland should say—in a statement comparable to that made by the Secretary of State for Social Services today and not in a written answer—whether he intends to impose the same form of management structure that is being imposed in England and Wales on the Health Service in Scotland.

I agree with my right hon. Friend the Leader of the Opposition that we are under no illusion that a large service such as the Health Service—it costs about £15 billion a year to run—cannot be improved. I have sat on the Public Accounts Committee long enough to find gross inefficiency in the Ministry of Defence, let alone the Health Service. If we want savings, we should scrutinise defence spending rather than the possibility of employing independent contractors in the Health Service.

My hon. Friend the Member for Falkirk, East (Mr. Ewing) pointed out in an intervention that 500 brand new beds in Scotland remain empty and unused because the Government insist that there is no cash to pay the nurses and doctors necessary to service them, not because there is no demand.

The Under-Secretary of State for Scotland (Mr. John MacKay)

Will the hon. Gentleman give way?

Mr. Hamilton

No. I get tired of participating it debates on the Health Service in which Scottish Ministers, who spend most of the time sitting on their backsides, want to intervene. If the Government want to reply to assertions made by Scottish Members, they should arrange for a Scottish Minister to reply during the debate.

Expenditure on the Ninewells hospital enormously exceeded the original estimate. It was built by private contractors—as was the children's hospital in Glasgow. It cost several million pounds and it virtually fell down a few years later. Costains built the Glasgow hospital with other private contractors. Litigation to determine who was responsible for that crass inefficiency and waste of money is now under way. Blame must lie with the private contractors as well as with the managers in the Health Service. The same will probably be true of the private contractors who are threatening to take over catering, laundering and cleaning services in hospitals.

Of course we want to have efficiency, but how can we measure it? I ask the Minister to confirm or deny that, for example, the fair wages resolution has gone down the drain, so that the management is under no obligation to pay fair wages, but is under some compulsion to cut the wages of workers in the laundry, catering and cleaning services. There is evidence that some of them are reducing the sickness benefit provisions, holiday provisions and pension provisions of those workers. There is no doubt that they can get their services more cheaply by exploiting all those workers. I challenge the Minister to deny that that is happening and will happen increasingly when private contractors get their hands on the services.

The Under-Secretary of State for Social Services (Mr. John Patten)

rose——

Mr. Hamilton

I shall not give way. The Minister will have half an hour in which to reply at the end of the debate, and I said that I would take only a short time.

This week we have had two major speeches from the Foreign Secretary and from the Secretary of State for Social Services. The Opposition have been equally impressed by both. Clearly we have a Government of all the talents, but I wish that sometimes they would reveal those talents. The two contributions from the Foreign Secretary, yesterday and the day before, and the Secretary of State's speech today are a sad comment on the calibre of Cabinet Ministers at the head of major Departments of state.

It was unfortunate that this afternoon the Secretary of State followed my right hon. Friend the Member for Iswlyn (Mr. Kinnock), because his was a brilliant speech of idealism—for which we should not apologise—and reality. It faced the issues as we see them—the need for efficiency, but the need for humanity and for more resources for the Health Service. There is no doubt that the service is suffering greatly right along the line from a shortage of resources, despite what the Secretary of State said. The Government talk about the Health Service being safe in their hands, and the Prime Minister went even further and said "only in our hands", but she takes care never to use it. She contracts out of the Health Service, just as she contracts out of using the railway system. When she practises what she preaches, we shall begin to believe her.

This afternoon my right hon. Friend said that all over Britain there is increasing evidence from professional people and ordinary working people in the service who are not normally supporters of the Labour party—including doctors, surgeons, nurses and ancillary workers—and from trade union leaders that they cannot cope and that patients are suffering. Patients and children are dying because there is no money to provide the services that they need. The Prime Minister is on record as writing to someone saying that the Government are sorry, but that children will die because the Government do not have the money to save them. However, they have the money. The Prime Minister, when faced with the Falkland Islands war, used the words "whatever the cost". There was no question then of tailoring our requirements to the economy, and within weeks £2,000 million of public money was committed to 12,000 people living 8,000 miles away, who were denied nationality by the same Government who now say that they are British people. That is hypocrisy and cant. The will is not there to provide money for the Health Service, and the Government intend so to starve the service as to make it a second class service so that it will drive people into the hands of insurance companies and the private sector.

Mr. John Mackay

rose——

Mr. Hamilton

I shall not give way. The Minister should arrange to make a speech on the Scottish service when he gets the chance.

At present about 20,000 nurses and ancillary workers are unemployed. Nurses and doctors who have been trained at public expense cannot find jobs. I have a family example that I shall draw to the Minister's attention. As the House knows, I married for a second time a year ago, and my second wife's son-in-law is a member of the Royal College of Surgeons. He is 35 years old. He is a brilliant surgeon but he cannot find a job. He wishes to be a general practitioner and to do some surgery. He has been to Scotland and to various parts of England in pursuit of jobs, and some people have told him that he is over-qualified.

Mr. John Patten

rose——

Mr. Hamilton

I shall not give way.

Mrs. Knight

The hon. Gentleman is not interested in the answer.

Mr. Hamilton

If the Minister has an answer, instead of wasting my time now, he can write me a letter. If the Government have £9 million, presumably of new money—we have never been told whether it is new money—to establish group practices in the inner cities, how can my son-in-law take advantage of that? I hope that the Minister will go further and say that the Government will set up those group practices using only the 3,000 or more doctors who are now unemployed. I hope that the Minister will reply to that important point, because it is an outrage and an obscenity that those thousands of young men and women who have been highly trained at public expense are now in the dole queue. It is an indefensible position for the Government to sustain, and I hope that the Minister will answer the question that I have posed.

7.37 pm

Mrs. Jill Knight (Birmingham, Edgbaston)

I never cease to be amazed by the Labour party. I never cease to marvel at the ease with which it distorts a picture to suit its case, especially if it is an emotional case. The House has been treated to a remarkable exhibition during the past 10 minutes, with an hon. Member making wild allegations while the two Ministers who could have replied to him directly were not allowed to do so. The "facts" put forward by the hon. Member for Fife, Central (Mr. Hamilton) cannot be very strong if he will not allow them to be challenged. He was not interested in the answers, and it is extraordinary that, especially when there is an emotional case, facts go out of the window and in comes the beating heart.

What are the Opposition talking about? Expenditure on the Health Service has more than doubled in four years. Surely no one, except someone who was rather unbalanced, could imagine that that represents poor treatment of the Health Service by any Government; but Opposition Members, never ones to let facts interfere with good knockabout speeches, roar, fume and posture like bogymen in a horror comic. They talk about savage cuts in the Health Service imperilling the lives and limbs of the populace, especially children. We have been told about that several times.

Opposition Members would all have a good future in Hammer Film productions. Vincent Price need not eat his heart out, but he has some close rivals coming up.

What are the cuts that we keep hearing about? There is a cut of 1 per cent. in manpower—

Mr. Fairbairn

It is only half of 1 per cent.

Mrs. Knight

Let us not over-egg the pudding. We should give a conservative estimate here. Are we really saying that when almost 1 million people are employed in the Health Service, a 1 per cent. cut in personnel will destroy the service? Anyone who really knows the Health Service must be well aware of the overmanning within it. There are scores of examples, such as overstaffing in administration, catering, portering and so on. Such instances have been brought to light many times by people from within the NHS.

Dr. Oonagh McDonald (Thurrock)

Will the hon. Lady give way?

Mrs. Knight

No. I am talking about facts, and as we have had an example of bad manners——

Dr. McDonald

rose——

Mr. Deputy Speaker (Mr. Harold Walker)

Order. The hon. Lady is not giving way.

Dr. McDonald

rose——

Mrs. Knight

This hon. Lady will not give way. I am giving the Opposition a taste of what it is like to have no one give way—[HON. MEMBERS: "What about the Birmingham hospitals?"] I shall tell hon. Members with the greatest of pleasure, because I have spent much time on them. Fairly recently, a constituent told me, "I do not know whether anything can be done, but along with four other ladies I work in an office in a hospital," which she named. She said, "There is enough work for one person in that office. The rest of us have very little to do indeed. One of the clerks was retiring and we told the administrator that there was no need for a replacement as the rest of us could do the work perfectly well." Unfortunately, that person was replaced—[interruption.]——

Mr. Deputy Speaker

Order. Hon. Members must desist from interrupting from sedentary positions. The hon. Lady has a right to be heard.

Mrs. Knight

I am obliged to you, Mr. Deputy Speaker.

Mr. Denis Howell (Birmingham, Small Heath)

Will the hon. Lady give way?

Mrs. Knight

No, I shall not give way. Given the stories from people within the NHS, one wonders whether the 1 per cent. cut is enough. However, there is concern about whether the 1 per cent. cut in personnel is chopping in the right place. The public does not want a cut in the number of doctors and nurses only to be told that wards are closing through lack of medical staff.

My right hon. Friend the Secretary of State is often attacked unfairly. It cannot be said to be his fault if the number of nurses is cut in one hospital or the number of doctors in another. That is surely a matter with which the local health administration must deal, because only the local people on the spot know best where these personnel cuts should fall.

It was put to me yesterday that when personnel cuts are ordered, in some instances that can only mean a cut in the number of doctors and nurses as they are the only personnel with short-term contracts. I hope that my right hon. Friend will consider this as it concerns many people.

Mr. Denis Howell

On a point of order, Mr. Deputy Speaker. The hon. Member for Birmingham, Edgbaston (Mrs. Knight) is making serious allegations about the conduct of the Birmingham central health authority, the chairman of which is her hon. Friend the Member for Derbyshire, South (Mrs. Currie), or at least was during the time about which the hon. Lady is talking. Is it in order for the hon. Lady to attack an hon. Friend over such waste without giving that hon. Member notice, in accordance with normal procedure, so that we can hear both sides of the story?

Mr. Deputy Speaker

I have heard what the right hon. Gentleman said, but I do not think that it is a matter for me.

Mrs. Knight

I am obliged to the right hon. Gentleman for raising that point of order, bogus though it was. It gives me the opportunity to say that the action of which my constituent complained took place six years ago, long before my hon. Friend had anything at all to do with the chairmanship of the area health authority.

There are 45,000 more nurses and 6,500 more doctors and dentists in the service now than there were four years ago. Therefore, what in heaven's name are we talking about? Labour Members must recognise that these are facts, and they can check them wherever they like. That 1 per cent. cut in personnel is the only cut that exists. Regional and district health authorities have their budgets and must keep within them.

The right hon. Member for Islwyn (Mr. Kinnock) suggested that it was dreadful to keep within a budget. Perhaps he never has to, but most of us do. The taxpayers would be extremely concerned if the Government did not keep within their general budget. It is right that local people should be in charge of where the budget is allocated. Some family practitioner committees have overspent, and their parent health authorities have had to alter funding to cover the overspend.

In fact, there has been no cut at all. I do not know what some hon. Members are talking about. My hon. and learned Friend the Member for Perth and Kinross (Mr. Fairbairn) talked about a wife buying many fur coats. I draw a parallel with the household budget of a mum who has blued £50 on a food processor. Readjustments will be needed in that household budget, but it is not a cut. There is no cut in the salaries going in, only that an extra amount has been spent that necessitates readjustments. Similarly, the Government have not cut health spending. It may be argued that they should have, but they have not. I am sick and tired of hearing about Health Service cuts. As I have said, expenditure has more than doubled in the past four years and there is no question but that we must spend the money much more wisely and ensure that there is no waste.

I admit that even if we stop all the waste we shall not get all the money we need to do all the things that we would wish, but we cannot afford the waste that is now taking place. I cite one example from the Moor hospital in Lancaster. Early this month it decided that it would stop issuing two cans of beer a day to its hundreds of patients, resulting in a saving of £10,000 a year. Labour Members may say, "What is £10,000? It is neither here nor there," but it was ridiculous to give those patients two cans of beer a day. That is the sort of waste that the Health Service simply cannot afford.

Recently in the annual Marsden lecture, the BMA secretary, John Havard, highlighted the amount of clinically unnecessary radiography that was carried out in the NHS. Once again, the evidence comes from within the NHS. He said that thousands of pounds were being wasted.

Everyone knows about the over-prescription of drugs. We are all aware of how serious that is. It is perhaps even worse in the family practitioner sector than in our hospitals, but without a doubt an enormous amount of money is spent on unnecessary drugs.

The National Association of Health Authorities in an interesting document recently drew attention to pilfering within the NHS, and earlier this year the conference of security officers within the Health Service estimated that at least £1 million a year was stolen from the kitchens alone. Not only were people taking sides of beef and pounds of butter and sugar, but many others were having meals to which they were not entitled. All this information comes from within the Health Service.

I am bothered about the wait that some patients who need treatment have to face, and all the inquiries that I have made show that frequently that wait could be lessened considerably if the patients were to go to another hospital for their operation. In Birmingham we have examples of people waiting a long time to go to the Dudley road hospital when they can have the same operation at Coleshill Hall hospital more quickly. I do not know why doctors do not direct patients to where the patients can be seen quickly. There are consultants working in St. Chad's hospital who also work in Dudley road hospital, but time and again patients seeing them have to wait many months for an appointment at Dudley road when they could have an appointment within two or three weeks with that same consultant were they to go to St. Chad's. Why can we not be more thinking and caring over the long time people have to face before their consultant's appointment or operation, and switch things around a little?

I welcome the Griffiths report on how to run the NHS with greater efficiency, particularly the part that stresses how, in all its travels, the Griffiths team met with such enthusiastic help from so many sources. It says: We have faced no significant or serious objection to the general line of inquiry we have been pursuing and we have gained general support for our developing ideas … we have been besieged with evidence and points of view during and following all the many meetings we have attended. It is extremely heartening to find that so many people working in, or related to, the NHS care so passionately about the service and the way it should be managed. My final quote comes from the British Medical Journal. I hope that Labour Members will read this magazine in the Library if they do not get it in the post. I shall draw their attention to the leading article in the BMJ on 15 October, in which the writer, a medical man, says: While I strongly deplore arbitrary cuts in the NHS's budget and manpower, I have no doubt that resources can be used more effectively by doctors, nurses, and administrators, and the medical profession would be wise"— so would the Labour party— not to be swept along on a tide of political hysteria that threatens to engulf any practical and commonsense approach to establishing priorities … The reality of life is that individuals and institutions rarely make radical changes in their working practices until faced by a cut in resources. To that extent this government may be—fortuitously or otherwise—doing the NHS a good turn. That should be understood. Criticisms come from the people within the NHS, to whom we should listen. The Labour party has got it wrong again. It wants more and more money for the NHS—far more than people in the NHS are asking for—and it wants less and less supervision on how the money is spent. We can help the sick and elderly to the maximum only if we ensure that every pound in the NHS gives 100p worth of service. It does not at the moment.

7.53 pm

Mr. Ted Leadbitter (Hartlepool)

During the past hour or so it cannot have gone unnoticed that some of the language that has been used in this debate does not reflect the real character and nature of the NHS. I was particularly sad to hear the word, albeit unchallenged, "corruption". The hon. Member who used it has a remarkable linguistic facility, but that does not get him out of the corner. Once he used that word, it marked him in his attitude towards the finest Health Service in the world.

The hon. Member for Birmingham, Edgbaston (Mrs. Knight) spent time talking about a spot of pilfering. More pilfering goes on in the House of Commons than in the NHS. There was a report in the press only recently about someone who is keen on pinching antique clocks from the House. However, let us not be diverted. People outside the House will make a judgment when they see the words that have been used here, because they show a regard for the Health Service that falls far short of what it should be.

My experience is clear. I have visited hospitals in the northern region—in particular, in Hartlepool—on a regular basis. I have a daughter who is a sister in one of the hospitals. I have had a lifelong political association with the National Union of Public Employees, which has a proud record in the NHS.

Dr. Brian Mawhinney (Peterborough)

A quarter of a million added to waiting lists by strikes.

Mr. Leadbitter

Such comments are not worthy of the hon. Gentleman. People go on strike because they have to. The hon. Gentleman and I can afford not to strike. Let me hit that nail on the head straight away.

I have experience of doctors, nurses, surgeons and supporting staff—I do not call them ancillary workers—in the NHS. They are the cream of the working population in this country, in which I am proud to be living. Therefore, it is important that we address ourselves to accepting that description of the people who dedicate their lives to healing, to relieving pain and to producing—this has not been mentioned—a great contribution to our economic prosperity. The notional benefits to the economy are large. We are the richer if we recognise that the efficiency of industry is synonymous with the efficiency of the NHS in terms of its profitability. The aggregate of all that is to the national benefit.

We should spend less time talking about overmanning, as such talk is not justified. I have not been in an overmanned hospital. It is not fair to make a blanket charge of overmanning without some statistical evidence. I have not experienced it. However, I have experienced in-house doctors working atrociously long hours, as do the nurses. No hon. Member would like some of the experiences of the staff in our hospitals dealing with the most difficult of cases. Not the least of these is dealing with drunkenness on a Saturday night, when the drunks are brought slopping into the hospitals and the low-paid nurses are given the job of dealing with them.

It should be a matter of concern to the House that many of our nurses are working in unprotected conditions. Some hospitals are isolated, even in towns and large conurbations, and, because of economies, there is no protection for the nurses at night.

It should be a matter of concern that in some hospital services, the catering facilities for nurses are shocking. What about those nurses who have to work overnight and their supporting staff? Those who work in hospitals should get together. There is a saying, By uniting we stand, by dividing we fall. In the past, Governments have been able to carry out measures in the NHS because of the divisiveness within the service. Those who work in the NHS must be brought together. Some of those who work, for example, on the 9 pm to 8 am shift have no catering facilities, other than perhaps an electric kettle with which to make a cup of tea.

Hon. Members should have some regard for the excellence of those who work in the hospital service, because they are very special people—la crème de la crème.

Mr. John Patten

So far the hon. Gentleman's remarks have concentrated on staff and staff welfare in the NHS, which is, of course, of paramount importance. However, perhaps he will now turn his attention to patients, because the NHS is run for them.

Mr. Leadbitter

If the hon. Gentleman does not mind, I shall make my own speech. With respect to the hon. Gentleman, I have been a Member of Parliament for 20 years and was in public life for 14 years prior to that, and I do not need him to tell me what to say. In this debate, experience lies with me, and inexperience with the Under-Secretary of State.

The National Health Service Act 1977 sets out strict and specific duties for the Secretary of State. Under the title "Services and Administration" part I sets out the Secretary of State's functions. The House should consider them carefully. The Act states: It is the Secretary of State's duty to continue the promotion in England and Wales of a comprehensive health service designed to secure improvement—

1. (a) in the physical and mental health of the people of those countries, and
2. (b) in the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services in accordance with this Act.

The Secretary of State will no doubt say that he is doing just that. However, his view should be put on one side of the balance sheet and compared with the opinion of all the professional bodies involved. How does the right hon. Gentleman's view measure up to the great body of opinion expressed by local, district and regional health authorities? I suggest that the balance sheet is weighted most heavily against him. The professionals cannot all be wrong. It is not true to say that they are defending their corner or empire building. It has been suggested that administrators want first one secretary and then another one and so on. They are not involved in that sort of thing. It is a hard fact of life that the administration of our Health Service is better than the administration found in any other country in the world.

Surely the Secretary of State and the Minister realise that to challenge the judgment of the public and of all the lay bodies associated with hospital interests, such as community health councils and so on, amounts not to a rationale of the situation but to arrogance. It is foolhardy of the Government to sit hack and suggest that that great body of opinion is wrong. As hon. Members have pointed out, there can be no question of the money not being there. If the Government want money, they can stop building the airstrip on the Falklands. Steps have already been taken to negotiate sovereignty of the Falklands, so why in God's name are we spending £2 million or more on the Falklands? Millions of pounds are being spent, yet the Government are being mealy-mouthed about the most important thing in this land—the health of our people.

Mr. Barry Porter (Wirral, South)

As the hon. Gentleman will appreciate, I would not dream of telling him how to make a speech. Indeed, I am following his argument closely. The Secretary of State's balance sheet—as the hon. Gentleman has put it—should perhaps be judged by the amount of money spent compared with the number of people employed. I am a little confused about one point, which the hon. Gentleman may be able to clear up for me. Is not considerably more money being spent in real terms this year than was spent in 1978? I believe that 17.5 per cent. more is being spent in real terms now. Are not more nurses, doctors and dentists employed in the Health Service than in 1978, when the Labour party had control?

Mr. Leadbitter

The same could be said of 1966. In other words, it could be said that we were spending more in 1966 than in 1950. The reason is that the NHS has become a very important element in all our lives, and it must grow. The Government are heading for no growth in the NHS. Indeed, the hon. Member for Edgbaston was talking calmly about a 1 per cent. cut.

Is it not a great waste that thousands of doctors, teachers and nurses should be out of work? I shall cite an example from my constituency. Earlier this month an article was published about student nurses who were training in Hartlepool. The article states: These 17 student nurses at Hartlepool General Hospital are worth nearly £360,000 to the National Health Service. That is the cost of training them for three years. Will it be money down the drain? The third-year students already know they will have no jobs by the end of the year. And the second-year ones don't have much better prospects. The answer is that that training will be money down the drain. Where is the intellect that cannot grasp the elementary conclusion that it is a terrible waste of public money to train nurses, and then to say that we do not want them? It does not make sense for a health authority to be driven to such economies. Nurses are being lost; wards are scarcely manned. I have visited wards in every hospital in my constituency, so I know. Even the management has become daft by complying with the DHSS directives. In my constituency I am ashamed to say that hospitals—and they may be the only ones in the land or in the world—are being manned by nurses who have their caps taken from them to save a piddling £1,000. That is the craziness of it all. Such cuts are silly and irresponsible, and health authorities are not behaving responsibly towards their nurses and those who have given their lives to help the sick. That is a dreadful thing to have happened. One nurse who qualified recently and did manage to find a job said about nurses who could not find jobs: It's a waste of money, it's a waste of knowledge, and it's a waste of us. When the debate is ended people outside the House will assume that there has been a great discussion and that tomorrow we will turn our minds to other matters. While morale in the NHS is bad and pay for the majority of staff is poor, patients are full of praise for the care that they receive. We must not judge the debate on who has made a good speech and whether the leader of one party has made more impact than the leader of another party. The country does not want that. The people want a fair and just Health Service, especially for the young, those raising families and the old.

It is time to accept that politicking is a cancer. There is too much politicking with the NHS. Many hon. Members on both sides of the House love to talk about the NHS. They think that it is politically good to take one stance or another. Yet the majority of hon. Members do not have the knowledge or the facts, and to the outside world most of what they say is hot air. The Government are running a grave risk, because, for once, those in the NHS who are trying to look after the health of our people will not be pushed around to satisfy the dogma of any political party.

8.13 pm

Mr. Christopher Hawkins (High Peak)

I am grateful for this opportunity to make my maiden speech. My predecessor, Spencer Le Marchant, represented High Peak for many years. He was a great character in the House and I know that he was well liked and respected on both sides as well as in his constituency. His contribution to the House was far greater than that recorded in Hansard. He served on numerous Committees and as a Whip for many years. As a result he was prevented from contributing to debate as often as he and the House would have liked. The House is poorer for his departure because of ill-health. I am sure that all hon. Members would want me to wish him a full and speedy recovery. [HON. MEMBERS: "Hear, hear."]

I shall briefly follow the traditions of the House before turning to an issue that I believe to be of great importance. I am greatly honoured to represent High Peak which, though a beautiful constituency, has lately suffered some severe problems. It is my job to fight for them. I know that it is traditional not to be controversial in a maiden speech, so although I feel strongly about the issue that I wish to raise I shall try not to strain the tradition to its limits.

This issue first came to my attention during May when I was a candidate at the general election. People living in Glossop complained that they were finding it difficult to get doctors at night and weekends. They were usually transferred to deputising services and frequently had to wait up to four and a half hours for a doctor, even for serious cases. They claimed that sometimes they were given poor diagnoses, completely at variance with those given by their own general practitioners on the following day.

I raised the matter with my hon. and learned Friend the Minister for Health and he visited my constituency and listened to complaints. I think that he was shocked by what he heard, and he offered to investigate the matter. In June The Sunday Times published reports of similar problems in London, and it became clear that it was a national problem. During June and July I pressed my hon. and learned Friend for action, and in July I asked for an inquiry into the use of deputising services. My hon. and learned Friend said that he would set up an inquiry through the family practitioner committees. I was not entirely happy with that because those committees already monitor and control the deputising services. Unless it was to be merely a first step, it was almost like asking them if they were doing their jobs properly—a question to which we could confidently expect the reply "Yes, Minister".

I pressed my hon. and learned Friend further and asked for an independent body to be established to monitor and control the use of deputising services. I suggested that several laws should be introduced to require doctors in deputising services to have the same qualifications as general practitioners. They should have at least six months' GP training or its equivalent. I felt that the law should limit the number of hours that they worked in view of the allegations that some doctors from deputising services worked excessive hours to the point where no one could be confident that they could do the job properly. My hon. and learned Friend's reply to my requests was, in brief, "No."

Again, I was not happy and during the recess I decided to find out from inside the system what had been happening. I have been much helped by honourable people in the system who have provided me with inside information and papers. I now have extensive evidence covering a conurbation with a population second only to greater London. It includes Manchester, Stockport, Salford, Rochdale, Bury, Oldham, Tameside and also Glossop which is in my constituency.

I have clear evidence of excessive use of deputising services by a significant number of doctors. I have evidence that many group practices are using such services every night and every weekend, contrary to the code of practice. Most alarming, I have evidence that the requirement that professional advisory committees should be present at the interviews of all deputy doctors has not been carried out, other than when specifically requested by the deputising services. All this is contrary to the code of practice. All this evidence I have laid before my hon. and learned Friend the Minister.

I can go so far as to say that in some areas no monitoring has been carried out until recently. In fact, in some areas no system for monitoring exists. The doctors ask for permission to use a deputising service for a few nights a week. Having got that permission they can then phone the deputising service and extend cover to every night and every weekend. No checks of any kind are made.

In one area the family practitioner committee seeks to control the use of deputising services by imposing a limit of not more than 20 calls per month which may be carried out by deputies. I checked up and discovered that, contrary to the belief that people call doctors out for every minor ailment, the average number of night calls is less than one call per doctor, per week, in all the areas that I have mentioned: that is less than four calls a month. The control system allows for 20 per month which enables them, five times over, to use the deputising service every night and every weekend contrary to the code of practice.

In Glossop and other areas I have asked for data on response times—how long doctors from the deputy service take to get to each patient. I was told that the family practitioner committee had asked for the same data but that they had not been forthcoming. What a control system!

I would now like to turn to what needs to be done. I am not saying that deputising services do not have a useful function. I am not saying that there are not many fine doctors doing a good job, working hard and looking after their patients. What I am saying is that some doctors are abusing the system and that the present system of monitoring and control is inadequate. My hon. and learned Friend has ample evidence that the present system of monitoring and control has failed. He has ample evidence to take action now.

The professional bodies that monitor the system are composed almost entirely of doctors and are sometimes composed entirely of doctors. Moreover, they are composed of doctors who themselves make extensive use of the deputising services and, in some cases, have shares in them. Their leisure and sometimes their income must conflict with their duty to monitor and control. We need an independent body, dominated by the public, to monitor and control the use of deputising services. We need a study group to recommend how to monitor and control as it is clear from my evidence that in many areas it is not known how to carry out those functions. We need a standard national system, reporting to an independent body. I am afraid that we also need a new code of practice which gives clear guidelines as the present code is unbelievably vague and woolly. It says that doctors should not make excessive use of deputising services, but it does not define what is regarded as "excessive".

Lastly, we should require by law that all deputies to be employed by deputising services should have the same qualifications required of any GP. They should have at least six months experience as a GP or the equivalent, and we should limit the number of hours that they can work.

I ask my hon. and learned Friend the Minister to consider those proposals so that anyone in Britain who has the misfortune to be ill at night or at a weekend can be sure to receive a speedy visit from a properly qualified doctor. Nothing less will do.

8.22 pm

Mr. Donald Anderson (Swansea, East)

It is my pleasure to congratulate the hon. Member for High Peak (Mr. Hawkins) on his maiden speech, which deserves a clear answer from the Minister. He certainly does not have the grand physical stature of his predecessor but I am sure that if he keeps his speeches as short as he did tonight he will be held in no less affection by all hon. Members.

The debate has centred on the public's expectations of the Health Service against the background of an aging population, new and expensive techniques and an increasing drugs bill. Therefore, the question of priorities has arisen. With that background our main charge against the Government is that now is not the time, if there ever were such a time, to cut that Health Service, which they have done by 0.5 or 1 per cent.

The fault with the Health Service is not one of management—although there are faults and who will gainsay attempts to streamline management? The problem is not caused by privatisation of pilfering but by the need for resources and Government commitment to the Health Service, which its founding father, Aneurin Bevan, stressed is a service where rich and poor are treated alike, where poverty is not a disability nor wealth an advantage. An unfortunate signal was given to our people when the Prime Minister went into a private hospital for eye treatment.

Over the weekend, details were well leaked to the press about the battle that the Secretary of State has said that he has won in the Cabinet Committee on cuts. This battle, we are told, has resulted in unemployment benefit not being reduced in real terms. Is it not a shame that the Government considered cutting unemployment benefit in real terms when they have lengthened the dole queues so massively? That is hardly a great plus for any Minister, especially when in the other part of the Department health services are being cut in real terms as are the allied personal social services of the local authorities. This is causing distress to our population.

Macro questions have been discussed by both Front Benches. I was impressed particularly with the figures given by the right hon. Member for Plymouth, Devonport (Dr. Owen) from his experiences, and they deserve a reply.

I make no apology for discussing the micro element of health services and accepting the Minister's invitation to one of my hon. Friends to discuss the consumer's point of view. Consumers—the patients—are not worried about percentages; they are worried about the services that they and their children receive from the hospitals. I make no apology for quoting from a letter that I have just received from a constituent dealing with the Health Service. My constituent told me about her daughter Tina Wilkinson who died of 'leukaemia' on the 18th July at Morriston Hospital. She was 28 years old and the mother of a nine-year-old girl. Tina died through lack of funds for the vital marrow transplant". This would have saved her life. Her mother thought she was lucky because her younger sister was a perfect match. She had been told she would have to wait until January because of the waiting list and lack of money. Leukaemia is a terrible disease which, unless one has watched someone dying from it, one would not appreciate. She wrote to me as her Member of Parliament so that I could put forward in the House of Commons what has happened to try to help others.

Despite what the hon. Member for Birmingham, Edgbaston (Mrs. Knight) has said, this is not some Hammer horror film production. Is this mother ignorant, as the Minister might have it? Can she not recognise the benefits in what the Government have done for her? How do I explain to this constituent the 0.5 per cent. cut in the NHS, the increasing waiting lists and that the Government are prepared to spend £200 million on constructing an airfield in the Falklands when my constituent's daughter has died because of a lack of funds? I should appreciate the Minister's assistance on this point.

The Under-Secretary of State for Wales (Mr. Wyn Roberts)

The hon. Gentleman has referred to one of his Welsh constituents. I am sure that he will allow me to put the record straight, about the Welsh part of the NHS. Since 1979, there has been a 9 per cent. growth in resources above the increases in pay and prices and after the July reduction. This year, there is an increase in the funds available to the NHS in Wales over last year's increase.

Mr. Anderson

That is even more shameful. There should have been a bigger increase, because the Minister must know that simply to keep pace with the demands of an aging population, the drugs bill and new medical techniques we need far more than that every year. Over the period this Government have been in office there has been a decline in the Health Service in Wales, but not just in Wales. I mentioned the sad and tragic case of that vivacious young mother of 28, but the Minister should go to the Westminster hospital, not far from here, and see the 45 children who are waiting for similar treatment and who may well die because of the Government's inability to find the necessary resources. Those are some of the human statistics that belie the "Never had it so good" complacent view that we have had from the Government Front Bench.

Mr. Roland Boyes (Houghton and Washington)

The guilty men.

Mr. Anderson

They are the guilty men. If the Minister wants me to refer to Wales and the increases that he alleges there have been in the Welsh budget, let me refer him to the West Glamorgan health authority. He knows that West Glamorgan must reduce its expenditure by £500,000 by 31 March next year and by a further £778,000 between March 1984 and March 1985. How will that be achieved? First, by not appointing a badly needed consultant chest physician. The Minister is aware of the incidence of chest diseases in our part of south Wales from industrial causes. It will be achieved by cutting care for geriatrics in an aging community, and the already scarce health provision for the mentally handicapped—[HON. MEMBERS: "Lies".] Is my health authority telling lies about what it must do because of the pressure for cuts from the Government? The cuts being forced on my health authority are replicated in every health authority. Let the Minister deny that.

Mr. Wyn Roberts

rose——

Several Hon. Members

Sit down.

Mr. Anderson

I am not giving way. The Minister will know that, like Scotland, Wales has a high incidence of cardiac diseases and the worst resources. What is the Minister doing? He is sitting on two reports that have been with him for 18 months while people are dying from cardiac disease. People are dying while the bureaucrats push paper and the Minister, subject to the monetarist pressures, pushes decisions further and further into the future. People are dying in the Principality because decisions are not being made about cardiac services.

I was a patient in hospital during August. As a patient, one is fairly captive when doctors, who are more likely to be supporters of the Conservative party than our party, tell people such as me what they see from the front line. The picture I received from two teaching hospitals in London is that there is a freezing of key medical posts and a reduction in beds, and physiotherapists tell me that because of the cut in study leave the quality of their personnel has suffered. Those who want to get on are forced to move to the private sector where they still have study leave. Physiotherapists also tell me that, because only two nurses are often left in large geriatric wards they are being forced to see physiotherapists more regularly for treatment to their backs and necks. That is one effect on nurses.

There is the same pattern in all hospitals and health authorities. That is what is happening in the real world. It is far different from the illusion that the Conservative party seeks to portray. During the election campaign, the Prime Minister said that she would no more dismantle the Health Service than dismantle Britain's defences. But we see the reality in the Health Service around us. It is being slowly strangled by a lack of resources to meet the increased demand while the private sector—there was no criticism of the private sector in the Secretary of State's speech—is increasingly parasitic on the Health Service, in blood services and research, and by stripping the Health Service of trained nurses and other medical personnel.

Our people are still mightily and justifiably proud of our National Health Service. Its management costs, which have been so criticised by Conservative Members, are excellent by comparison with our major competitors. The Secretary of State will know of the report published in July on comparative management costs.

Monetarists in the Cabinet will gloat over public expenditure cuts and reductions in the Health Service, but the people in the field, those employed in the service, the patients and consumers of the service, will not gloat. They will see lengthening queues and a reduction in the quality of the Health Service.

At a time when the Government say that their aim is to reduce direct taxation I believe that to preserve and enhance the quality of our Health Service our people would be prepared to see even an increase in direct taxation. This is borne out by the polls. Unlike the Government, who have no commitment to a free and a National Health Service, as exemplified so tragically by the Prime Minister in her eye operation, it is the task of the Opposition to protect our Health Service, which was proudly established by the Labour party in that great postwar reforming Government. I believe that we shall have public opinion behind us because our people believe deeply in this working model of institutionalised compassion.

Mr. Deputy Speaker (Mr. Paul Dean)

Before I call the next hon. Member, I should inform the House that the winding up speeches are expected to begin at 9 o'clock. Many hon. Members on both sides of the House who have waited a long time still hope to speak. I reiterate Mr. Speaker's appeal for short speeches.

8.37 pm

Mr. Nigel Forman (Carshalton and Wallington)

I shall not follow the hon. Member for Swansea, East (Mr. Anderson) save to agree with his tribute to my hon. Friend the Member for High Peak (Mr. Hawkins) and extend that tribute to my hon. Friends the Members for Oxford, East (Mr. Norris) and for Warwickshire, North (Mr. Maude) for their excellent maiden speeches.

The main thing on which both sides of the House can agree is that we should preserve an efficient National Health Service available to all on the basis of need and largely free at the point of use. It is worth saying also that the Government's record in support of the Health Service over the past four years or so has been good. The figures are well known to the House, but I shall mention just two. There has been a 5.5 per cent. growth in hospital and community services over the past four years and a 4.75 per cent. growth in family practitioner services over the same period.

We now find ourselves in a cold economic climate in which the pressure will inevitably be on all forms of public spending, vital though it may be in certain areas. Because of that, it will become that much more important for us to get the best possible value for money from the Health Service.

The hon. Member for Swansea, East mentioned the comparisons between the cost of administration of our Health Service and those elsewhere. The contrast that the hon. Gentleman made with America, where the cost of administration is about four times greater, is telling. That must have something to do with the fact that the Americans have a largely insurance-based system which is administratively much more expensive. My right hon. and hon. Friends on the Front Bench have done well to remember that in holding the line against a full-blooded insurance-based system in this country.

Because we support the Health Service and wish to see it succeed, we want to see greater efficiency in all areas of the service. Inevitably that means looking critically at manpower efficiency, because staff costs represent more than 70 per cent. of total NHS costs, and more than 70 per cent. of £15.5 billion is a lot of money in anybody's book. I therefore hope that the Minister will give me, when replying tonight or subsequently in correspondence, some answers to some points which bear on the question of efficiency. For example, why has the number of ambulance staff increased when apparently the number of patients carried each year has fallen? There may be good reasons for the increase, but that is the sort of issue we need to consider.

Mr. Boyes

rose——

Mr. Forman

I will not give way, in the interests of time.

Mr. Boyes

The hon. Gentleman should allow me to intervene, because what he said is not true.

Mr. Forman

If that is the case, no doubt the Minister will tell me later.

Why has the number of works and maintenance staff increased at a time when their workload has not noticeably grown? Why has the cost of the so-called hotel services risen in the longer stay hospitals? Why have the Government not had more success in controlling administrative costs in relation to medical costs? There has been some success in that direction, but why not more? Why, above all, has there not been more cost saving investment in the NHS, particularly in such things as energy conservation, which my right hon. Friend mentioned in his opening remarks when he pointed out that about £300 million were spent on energy in our hospitals? The examples I have mentioned are drawn from a Government document entitled "Health Care and its Costs" which drew our attention to them. I think that they are well founded and it is important that we should seek to put them right.

Even if the NHS were managed as efficiently as Sainsbury's there would still be inexorable increases in spending now and in the years ahead. We know the reasons for that—for example, the growth in the elderly proportion of the population and the improvements in medical technology, including scanners, gynaecological cytology, hip joint replacements, kidney transplants, bone marrow tranplants, and so on. Who is to say—in Parliament or anywhere else—that on the basis of the Hippocratic oath doctors cannot do those things if the techniques are available? The difficulty is that there must be some reconciliation of the almost infinite demand for health care and the new forms of health care with the finite resources that are available, and it is there that the political and social difficulty resides.

Then there are the trends in the family practitioner services, which are largely demand determined and which can therefore have an adverse effect on the money available for hospital and community health spending, as we saw following the Chancellor's July package this year. I am particularly concerned about spending on drugs as prescribed by general practitioners. Some of the literature I have read tells me that about £1,156 million was spent on the GP drugs bill in 1981–32. Apparently drug spending represents about 10 per cent. of total NHS spending. I hope that my right hon. Friend and others will he in a position to give more news in the months ahead about, the progress that the Department is making in dealing with the problems of over-prescribing and the problems of expensive "me too" drugs. We have heard of examples—in dealing with, say, arthritis and other such matters—in that context.

I am not sure whether generic prescriptions are necessarily a total answer to that, but no doubt that too needs to be carried forward, as do the consultations, to which my right hon. Friend referred, between his Department and the pharmaceutical companies. The £9 million concession in real terms which the pharmaceutical companies made this year when they were asked to make a contribution to the Health Service was not adequate. If one looks at the size, scale and profitability of many of the companies, many of which are not based in this country but in Switzerland or the United States, one sees that in partnership with the NHS they could have made a better contribution. A step in that direction would be for the sponsorship role of the pharmaceutical companies to be switched to the Department of Trade and Industry and away from the DHSS. It is extremely difficult for the DHSS to act as a monitoring authority as well as a sponsor. There is often a severe conflict of interests, and I hope that the Department will make progress in overcoming it.

All these 'matters are examples of the inexorable pressures that lead to more NHS spending. I fear that the pressures may lead to a need for extra spending up to 1 per cent. or 2 per cent. a year in excess of the present level. In spite of the Government's generosity and good sense in this area, only 0.5 per cent. of extra Government money is going into the NHS each year. That will be the pattern over the coming years. Even when that is combined with the so-called efficiency savings of 0.5 per cent., there is still a disturbing gap left in funding.

I am not quite sure what the long-term policy should be for dealing with these problems, but good, sound management must have an important part to play, as is clear from the Griffiths report. Equally, some abridgement of clinical freedom will be necessary, especially in drug prescription and so-called clinical budgeting. Much more energy should be used on placing greater emphasis on the importance of health prevention and a positive health policy so that the NHS is truly a Health Service rather than a sick service. That, too, would help in the long-term.

I shall be interested to know what success the Department is having in taking the lead in promoting dietary changes among the general population on the lines urged by the National Advisory Committee on Nutrition Education. The committee will come up against strong and entrenched interests, in this instance the interests of the food industry. It seems that if it is not the pharmaceutical industry it is the food industry. We must address ourselves to these matters in the cold economic climate in which we find ourselves. I hope that more positive steps will be taken to discourage smoking. I must declare an interest for I am a non-smoker. I should like to see a complete ban on smoking advertising and increased taxation levied on cigarettes.

Even if greater priority is given to public spending on the NHS and even if we have a recognition on the part of the public that it will be necessary to pay for this spending through the tax system—there is a good deal of evidence from the opinion polls and other sources that there is that recognition—it will be a good thing to concentrate our minds on getting the maximum value for money. Both sides of the House and both sides of the argument should be able to agree that that is common ground.

If there are Labour Members and others elsewhere who think that concern about the future of the Health Service is confined solely to those who occupy the Opposition Benches—it has become clear during the debate that that is not so—I think it right to observe that I have received many letters from constituents on this issue. Many of these letters have been written by Conservative voters and Conservative workers who care about the future of the NHS, who know a great deal about the subject at first hand and who are prepared to write to me to ask me to use what influence I have in acting on their behalf. In the interests of time, I shall not read out salutary excerpts from some of the correspondence. Perhaps it is sufficient for me to say that I can reassure my constituents that the Health Service is safe in the Government's hands provided that they take the necessary short-term and long-term steps at which I have hinted and to which my right hon. and hon. Friends have referred so powerfully in their contributions.

8.49 pm

Mr. Doug Hoyle (Warrington, North)

First, I must declare my interest as a vice-president of ASTMS.

We had to wait a long tine to hear the voice of a Tory wet in this debate. I am pleased that the hon. Member for Carshalton and Wallington (Mr. Forman) was able to contribute to it, but sorry that he spoilt his speech at the end. I do not think that he really believes that the future of the Health Service is safe in the Secretary of State's hands.

The Secretary of State would have one believe that there is life after death. However, I do not want to be too hard on him. After all, he is only the robot who has to pull the switches for the Prime Minister—Mrs. Queue-jumper herself—who takes care of and supports the axeman, the Chancellor of the Exchequer. I was amazed when the Secretary of State had the impertinence to say that Labour Members were responsible for the lengthening of the hospital queues because of the Health Service dispute. The right hon. Gentleman was responsible for not giving Health Service workers a living wage. He bears all the responsibility for what has happened to the Health Service. If he had any decency at all, he would resign. Indeed, it would be far better if he went now. Perhaps we could then have the hon. Member for Carshalton and Wallington in his place.

Mr. Fowler

Who would we have in the hon. Gentleman's place?

Mr. Allan Rogers (Rhondda)

My hon. Friend can speak without his master being here.

Mr. Hoyle

Of course I can.

Mr. Rogers

Like the Governor General, if he can be found.

Mr. Hoyle

He might return. Who knows? He has been kept for 24 hours with the allies. However, I do not want to be too distracted by the Secretary of State.

I should like to have the facts. The Government say that the cut is less than 1 per cent. In fact, it is not 1 per cent.; it is 1.8 per cent. based on the 8 months period also just to stand still, with an aging population and technical developments, the Health Service needs to grow at 1.2 to 1.5 per cent. Therefore, the real cuts are between 1.5 per cent. and 2.5 per cent. Those are the real cuts, and they will have an effect on patients.

Mr. Boyes

Will my hon. Friend give way?

Mr. Hoyle

No, I had better not give way at this stage, much as I should like to have the benefit of my hon. Friend's wisdom.

Mr. Boyes

Two per cent. is 20 per cent. in ambulances in my area.

Mr. Hoyle

I shall come to that matter in a moment.

I want to remind the Secretary of State about the research that was commissioned in his Department in July 1982, because we are hearing a lot of talk about efficiency. That report showed that the NHS was 25 per cent. more productive than the American health service and 10 per cent. better than the Canadian. So when we talk about efficiency, let me remind the Secretary of State that we have the most efficient Health Service in the world. The people who will suffer from these cuts are the patients. Moreover, in relation to GNP, this country spends far less than France, Australia, West Germany or the United States.

What we have not heard about is the way the Health Service is being used as a milch cow by the private sector. In the document "Health Service Management Charges for Private Patients", issued in March 1983, we find that the cost of using operating facilities in the NHS for 10 to 30 minutes is £29.50, and for more than 30 minutes £43.50. How can that be an economic charge? In pathology, a number of tests cost £5, in radiotherapy one treatment a day costs £11.50, and physiotherapy treatment and gymnastics cost £3.50. Those charges are ridiculously low, and in many instances they are not even collected. We know that when Mrs. Queue-jumper went in for her eye operation, if the hospital had not sent for NHS equipment, it could not have carried out the operation. As yet, I do not believe that that has been paid for. What is happening in the Health Service is a disgrace.

We must refer to what is happening on the ground to see that the cuts in Warrington are real. On almost his first day as Minister for Health, the hon. and learned Gentleman received a delegation from Warrington. He agreed that we were underfunded by about £4 million and did something about it. However, there will now be a cut in cash terms of £379,000. That will affect the people of Warrington. Of some 44 trainee nurses 39 will lose their jobs. What effect will that have on the people? The waiting lists are lengthening and we are nowhere near meeting them.

My hon. Friend the Member for Houghton and Washington (Mr. Boyes) referred to the ambulance service. The service in Warrington is a disgrace. We have three motorways, so there is a high risk for the people in the town. In the daytime, five ambulances provide cover. Two of them spend much of the time bringing patients from Liverpool or Manchester or taking patients from Runcorn to Warrington. Another two are on call for outpatients. That leaves one ambulance available in the daytime for emergency cover in an area with three motorways. For a population of 180,000, there are only two locally based ambulances between 8 pm and 8 am. We had the same service when there was only one third of the present population in Warrington. In July there was an accident involving four people. The ambulance broke down and it was 20 minutes before the other ambulance arrived. However, Conservative Members talk of cutting that service, which is already underprovided for in Warrington.

The people in an area, such as Warrington, which has been underfunded for too long, are suffering. The Government's conduct is disgraceful. They keep saying that the Health Service is safe in their hands. It has never been and never will be. The best thing for the people to do is to continue to protest. I hope that an avalanche of letters is reaching the Government. They will not listen to us. The Opposition have repeated themselves time after time, as have our constituents, explaining what the conditions are like in the hospitals, what people have to put up with and how difficult it is to get in, but it all falls on deaf ears. One reason is that Conservative Members do not use the NHS. They use the private sector. Conservative Members neither know nor care about the NHS, and they are reduced to the level of the hon. Member for Birmingham, Edgbaston (Mrs. Knight), who talked about pilfering. The hon. Lady was quoting examples from six years ago. Such was the level of debate from Conservative Members. I do not know what source the hon. Lady was quoting, but it bore no relation to the Health Service.

The cuts should not take place. More money should be spent on the Health Service. The Government's priorities in the Health Service, as in many other areas, are wrong. They will become more and more unpopular because of the way in which they treat the NHS.

8.58 pm

Mr. Charles Morrison (Devizes)

I have just about enough time to make the beginning and end of my speech and leave a large hole in the middle.

The amendment to the Opposition motion invites the House to congratulate the Government on what they have done for the Health Service. I am glad to do so. It is not far short of a miracle, during a world recession and at a time of economic stagnation, that there has been a considerable real increase in expenditure on the NHS. That is not to say that enough is being spent or enough is being done. The truth is that there will never be enough. There cannot be because resources are finite and the demand for health services is infinite. What is more, as we have heard several times in the debate, the demand is bound to grow because of the aging population and the introduction of modern technology.

I shall end my speech by giving two words of warning to the Government. First, they must not assume that vast savings can be made in the cost of administration or at the sharp end of the Health Service. I entirely applaud the Secretary of State's decision on the Griffiths report. I believe, however, that it will not produce many savings but simply a more efficient product.

Secondly, the Secretary of State must not allow the Chancellor of the Exchequer to think that as a result of the changes in management structure Health Service expenditure can be reduced so as to provide tax cuts. That would be extremely unpopular in my constituency and, no doubt, in many others.

Mr. Boyes

On a point of order, Mr. Speaker. May we have a ruling on whether an hon. Member speaking in this debate should declare an interest if he is in a private medical insurance scheme?

Mr. Speaker

I imagine that that sort of information is on the Register of Members' Interests. A great many hon. Members are in private schemes. I am not certain that that information has any relevance to the debate.

9.1 pm

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

It is always interesting to hear maiden speeches. I am very pleased to welcome the three new hon. Members who have spoken in this debate. I particularly welcome the contribution of the hon. Member for High Peak (Mr. Hawkins) because he seems to have done an enormous amount of work on deputising services, a matter of considerable importance to the Health Service which I hope we shall have an opportunity to discuss in detail in the future. The quality of the care that the deputising services gives to patients should be a matter of concern to all hon. Members if we wish to improve any aspect of primary care.

I also found the contribution by the hon. Member for Oxford, East (Mr. Norris) extremely interesting, although I might disagree fundamentally on another occasion with his impression that all was well within his regional health authority. I have not heard a similar view expressed by members of local health authorities in Milton Keynes and other small towns in that part of Oxfordshire.

I am pleased to welcome the hon. Member for Warwickshire, North (Mr. Maude), although I must warn him that if he continues to make good jokes he will have a short parliamentary career.

The last general election was distinguished by the Conservative party suggesting that it was so committed to the Health Service and concerned about what was happening within it that during the Conservatives' period in office there had been an increase in the number of people involved in the service and a real increase in the amount of money given to it. Faint echoes of that suggestion have been heard today. There has been the ritual repetition of statistics which, frankly, I regard as "Fowler's mathematics". The Secretary of State seems to adopt a confetti attitude to statistics. He throws the figures up in the air hoping that with any luck they will not come down. There has been a deliberate attempt to suggest that, during the Conservatives' previous period of office, the Health Service was expanded and that what is now happening is merely a small clipping away of the amount of money involved.

When the Secretary of State spoke at the Tory party conference, he made the type of speech which earns politicians a bad name. He implied that the NHS could easily be made more efficient if the problems of overmanning were dealt with. He insisted that the NHS had too many administrators. Today hon. Members heard about the tail of administration. The Prime Minister likes to call such people "the bureaucrats".

The Secretary of State believes that somewhere lies a magic man management formula. His tenure of office has been distinguished by his having had at least four investigations into how the Health Service ought to run. Only this week we had yet another supposed management investigation which took eight months to conclude that the only people who are qualified to run the NHS are those who have no experience of relevant disciplines or the Civil Service.

The general idea among Conservative Members is that we need only to appoint a new chief executive—a new magic figure—and somehow the NHS will be turned into the equivalent of a nationalised industry. Why should the Health Service be treated as the Government treat nationalised industries? It could be that we are being asked to believe in the wisdom of appointing a new chief executive who will behave just like Mr. Ian MacGregor. Such a person would cut investment, close efficient units and sack as many staff as possible. The parallels with the mismanagement of the past few years are unmistakable.

The deeply held prejudices of the Tory party demand that the NHS be diminished and disoriented in the name of efficiency. That does not, of course, mean efficiency in staff management. Even the worst British manager should be able to work out that manpower targets should not be changed in the middle of a financial year. Nor are we dealing with efficiency in the use of resources as no finance officer who is worthy of that name can plan his cash flow or capital expenditure when every week brings a new instruction from on high which changes his accounting assumptions.

The new efficiency for which Tory Ministers aim consists entirely of an utterly unplanned closure of beds and wards and the unrelated freezing of vital posts such as junior hospital doctors. Moreover, that happens irrespective of the needs of the health regions.

We have also witnessed the beginnings of a direct attack on vital preventative services such as family planning clinics. The short-sightedness of that policy is so manifest that the resultant chaos has worried even Tory regional chairmen. With the exception of the chairman of the Mersey health authority—which is in my constituency—who ingloriously capitulated and accepted all of the cuts without a murmur, all chairmen of regional boards protested vigorously at the arbitrary and asinine quality of the Government's decisions. They knew that, far from improving the service, the latest round of imposed targets will mean worse patient care and staff relations.

The West Midlands regional health authority saved £11 million from its budget because it planned an expansion of badly needed posts in new hospitals and undermanned services. The Government instructed it to forget its plans to take on an extra 2,486 staff—who would have been paid for not by asking for extra cash but by savings which the authority had made. The Government then told the authority that it must reduce its staff by another 140.

The regional health authority's figures show that cuts as a result of the Lawson axe and earlier efficiency cuts have involved the loss of 3,626 jobs. That is not a 0.5 per cent. cut but a 4 per cent. cut. That is not the end of it. The effects of the ruthless squeeze on finance is being felt throughout the region.

It is useful to consider Birmingham, as both Ministers who are present should have some knowledge of what is going on there. Birmingham General Dispensary is a charitable organisation which has provided chiropody treatment for 4,000 patients. In 1983, it received a grant of £45,000 from the NHS and provided more than 21,000 treatments—almost entirely for elderly patients. Ministers know that provision of chiropody services is frequently the difference between keeping elderly people mobile and able to cope on their own in their own homes and having them admitted to extremely expensive geriatric beds. Now the dispensary has been told that its grant will not be renewed after March 1984, which will force closure upon it. The immediate and direct result is to add 4,000 elderly patients to waiting lists for chiropody treatment that are already nine to 12 months long. That area is represented by the Secretary of State. So much for the maintenance and improvement of standards of patient care.

Sometimes the decisions are Kafka-like in their nightmare quality. I was told today about a nurse who suffers from a prolapse and who has been waiting since April to receive treatment. She is off work because she cannot lift patients. Unfortunately for her, she works for an authority which has a policy of sacking staff who are off work for more than six months, so she now faces dismissal because she cannot receive treatment in a hospital that does not have enough staff to deal with the waiting list in order to enable her to return to nursing.

It has become painfully clear that the Tory plan for the revitalisation of the Health Service is a simple formula. During the past four years they have cut the finance available, not by small percentages but by a deliberate attack and by never giving the correct amount of money even to keep up with medical inflation. There has been a deliberate insistence that we must have privatisation irrespective of the real economic cost. That insistence went to the extent of instructing some regional authorities that they should not go ahead with plans for which they had set aside money, but that they should put all the work out to private tender. We have already been told that, in the case of areas such as Calderdale, even the local officials are convinced that the deliberate attack upon their decision is a political one, not an economic one.

However, the Secretary of State did not believe that the dismemberment of the Health Service was proceeding apace, so he decided to impose manpower cuts. It is important to realise that this is different from anything that has happened before. All the way through the reorganisation of the Health Service, Ministers told the House that we needed a much greater local input and that we needed people at the sharp end who could tell hospital authorities how money should be used in their region. However, they did not wish to carry that too far and have elected representatives, because they threw as many elected members as possible off the local representative bodies.

We were told that the point of this enormous, bruising and frightening reorganisation, which took nearly 18 months, and which made an enormous inroad into the confidence of those working in the service, was that at least we would have much greater local involvement. The Secretary of State has decided after four years, and only two years after the reorganisation, that he will not allow the regional authorities to make their own decisions. He has already decided to call in the chairmen from time to time and to limit by cash means as many services as possible, but now he wishes to set up a central organising body to control all the cash limits and all the management targets. He even talks about central manpower targets. That is what he wants—to sit in the middle in London and to dictate throughout the Health Service what its future needs should be.

If we understand the extent of that change, we begin to see that much of the talk that we heard during the general election campaign was cant and hypocrisy. There was no intention to improve the National Health Service. There was a fear of confronting the service head-on, and a desire to make all the cuts by the back door. One means by which the Secretary of State believes that the new efficiency can be brought about is to invite any passing grocer who wishes to play a grown-up game of hospitals to come in and put any idea he wishes into operation. It is pathetic to see such management decision-making from a Secretary of State who should be responsible for a nationwide service.

Ministers intend to sell everything that is not nailed down and to asset-strip every piece of land from every hospital that can be put on the market. Every profit-making enterprise will go almost automatically to the private sector, and the staff will be left with an under-funded service with increasing numbers of patients to deal with.

The Government have handed out fiscal sweeteners, amounting to £4 million a year, to any employer who wants to take up private insurance for his employees. Were that money simply put back into the Health Service, we would at least believe that Ministers were serious. After all, staff are the Health Service. No one has yet invented a robot that will attend to a frightened child in the middle of the night or succour a mentally handicapped patient. If we believed that the Government were serious, we need only look at their financial targets to realise exactly how dishonest they have been with the electorate. They have issued guidelines which mean that for the next 10 years, taking account of the growing number of elderly and the increasing cost of technology, the NHS will suffer a cut of 0.7 per cent. in services every year. By 1988–89, if present trends continue, the Government will have cut £462 million from today's services.

Contrast that with the defence budget. Defence has been promised 3 per cent. more than the rate of inflation—£2,546 million if the present targets are retained. That is a very different set of priorities. The truth is that the NHS has suffered continuously. Last year it lost 10,867 staff before the Chancellor had his £140 million's worth of flesh.

Minister would like all those job losses to come from administration or ancillary staffs. They eternally say, "This is the end that can easily be cut," yet we know that the management costs of providing a comprehensive Health Service are lower in Great Britain than in almost any other developed country. In other words, the policies that they are putting into operation are based not on fact but on prejudice.

We can gauge the Government's view of the Health Service by looking at the way in which the Prime Minister behaves. She is keen on talking about leadership. Therefore, I shall put several questions to her, even though she has not honoured us with her presence this evening, although she was in the Chamber earlier. If she is so keen on giving a lead to the people, why did she not go for her own personal treatment to one of the best centres of excellence to be found anywhere in the world—[HON. MEMBERS: "Freedom of choice."] The Moorfields eye hospital has the best reputation of any comparable unit anywhere. Is it true that initially the Prime Minister was seen in an NHS hospital because she was an emergency? Will she also say whether her second operation depended on the fact that her private hospital had to borrow scalpels and clamps from the King Edward VII NHS hospital? The Government are so determined to run down the Health Service that they want to give people the impression that there is no need for those in the Cabinet to support the basic services.

It is useful to look at some of the things that are happening in the different regions. The Oxford region issues a questionnaire to be used by general practitioners to gain admittance for their patients to the large hospitals. It has suddenly sprouted a new sentence. It says: If you are a member of a private health insurance scheme and wish to avail yourself of private patient facilities, please discuss this with the doctor in the outpatient clinic". The member of the medical staff who raised that matter with me said that this was using those who believed in the NHS in a way that was utterly unacceptable. He said: Those of us who support it will find ourselves advertising for the private sector. This is an intolerable position for us to be placed in". We know that the manpower target factors were carefully aimed at a particular part of the year. Throughout the Health Service debate, and during the election, Ministers told us that the people who mattered in the NHS were not the dreadful ancillary workers who cleaned soiled linen and floors, but the doctors and nurses, but as soon as the manpower targets were published, it became obvious that the entire exercise was based on that point of the year in which there were already vacant posts. There were not only direct cuts, but, because of that factor, the cuts were far larger than anybody has been prepared to admit.

This Government, more than any other, know how to fiddle the figures. They were busy telling us that they had appointed so many extra nurses and had improved standards. They never said that a two and a half hour change had been made in the way that the nurses worked—a change negotiated by the previous Labour Government—which meant that simply changing the nurses' hours, added about 22,400 extra nurses to their figures. I do not know why the Government do not reduce the nurses' hours a great deal further. Without employing one extra nurse, they could double the numbers of people that they say have been employed in the Health Service. That would appeal to them.

The real efficiency improvements in the NHS should come from a number of simple, straightforward things. At long last, the Secretary of State said tonight that he was prepared to do something about the Acheson report. He must have had that report and the Harding report on his desk for at least two years. He must know that there is a great deal more to the reports than suggesting that somehow or other, spending £3 million over three years can bring about an enormous difference in the quality of patient care.

The Secretary of State must know that the closure of many London hospitals and the direct loss of hospital beds is putting enormous pressure on primary care services, which are already unable to cope with the number of patients that they have. About 25 per cent. of Londoners do not have a general practitioner and the small provision of an extra grant for building improvements will not change that. The Secretary of State has done nothing to take up the fundamental suggestions in Acheson and he should be ashamed of pretending that by making a small gesture he will produce a revolutionary change.

There is one part of the NHS in which the Secretary of State could make an immediate, widely welcomed, saving. The drugs industry has a useful golden goose in the NHS. The industry does not need to sell its products, yet it spends 10 per cent. of its budget on advertising. It spends a great deal of money on hospitality, has a vested interest in promoting brand names and is an industry that the Public Accounts Committee found has been grossly overpaid for its products over the past few years. Will the Minister tonight tell us how much money the drug industry is prepared to give back? Will it be £25 million a year? At one point, the Secretary of State appeared to be saying that the repayment would be £25 million over six months, which is a different figure.

What will happen about generic substitutes? Is the Minister prepared to say that he will tell the Health Service that it can have generic substitutes in the future? They could save £117 million on the drugs bill immediately by moving towards the substitutes without restricting the clinical freedom of the doctors. He could make it easier for the patients to get much better value for money. However, we suspect that nothing like that will happen for a simple reason. The drug industry has an extremely powerful lobby in the Conservative party and it will make sure that none of its profits will be cut back.

Why is it that it has suddenly been enunciated that the primary health care services should, in effect be cash limited? Are general practices cash limited, or is it just an accident that Ministers propound the strange theory that because general practice has cost £100 million more than they expected, that extra money must come off the hospital sector? If that is what they are trying to do, why do they not have the decency to say that they are moving towards a fully salaried general practice service in which general practitioners are cash limited? Is it because Ministers are convinced that if they did that they would have to face a very powerful medical lobby? Indeed, it is a lobby that has not yet realised that the proposed changes will limit their clinical freedom far more than ever before.

Let us consider the suggestion of a management board and a board run by the Secretary of State. Who will give the powers to the general managers, who will now be in charge of the separate units? Who will overrule the clinical judgment of the medical establishment? Who will tell the nursing side that its background and views on the staffing of hospitals, wards or theatres do not matter, and that in future it will only be allowed a limited input into the decision-making process, because the general manager of the unit concerned will make the final decision?

There is a hospital in my constituency that is not even 20 years old. Less than 18 months ago Mersey region was so badly understaffed that nurses could not deal with the theatre lists. They told not only the administration but the regional hospital board that if staffing levels continued to be inadequate, they would be unable to provide a decent level of patient care. The administrators made it plain that they believed that the hospital was underfunded by about £2 million, yet less than a year later they face the loss of more than 20 nursing jobs and the closure of gynaecological and other vital beds. Before hon. Members start talking about hospital closures under the Labour Government, they should get one point clear. If a tatty old inadequate Victorian building is closed and replaced by neighbourhood or community or personal social services, that is very different from closing beds and wards in new hospitals.

At present, beds and wards are being closed, and new units and modern hospitals that have just been completed are being mothballed even though people need urgent health care. The reality is that Conservatives regard health care simply as something that requires very strange bookkeeping. To them it is not important that we can demonstrate the need for real improvements for patients. They are worried only about making an improvement in the economic side of the NHS. The hypocrisy of the Conservative party is best demonstrated in its attitude to the NHS. Throughout the general election Conservative candidates said that they were committed to the Health Service and would protect it and care about it, but they could not wait to attack its finances and its jobs, and to close units immediately afterwards. Such hypocrisy will not pass unnoticed and the people of this country will make them pay.

9.29 pm

The Minister for Health (Mr. Kenneth Clarke)

It is my pleasant task to congratulate three maiden speakers. It is an easy task because they made three excellent speeches. My hon. Friend the Member for Oxford, East (Mr. Norris) made a competent and eloquent speech. He chose the right subject because he is an experienced member of the east Berkshire district health authority. He will no doubt contribute frequently to our future debates on the Health Service.

My hon. Friend the Member for Warwickshire, North (Mr. Maude) succeeded in making a successful joke within the first two minutes of his first contribution in the House. As it was a joke about Leslie Huckfield, it united the House behind him. He will obviously carry large numbers of hon. Members behind him in his future contributions to our debates.

My hon. Friend the Member for High Peak (Mr. Hawkins) used his maiden speech to talk about a cause that has already become very much his own—the adequacy of deputising services in the NHS, and the service received by patients in some parts of the country when excessive use is made of such services. I am sure that the whole House appreciated the way in which he brought forward some of the problems with the quality of deputising services. It is largely in response to him that we have asked the family practitioner committees to report on how they are discharging their responsibilities in that area. The reports are almost to hand. We will bear my hon. Friend's recommendations in mind when we move to the next step, which is the evaluation of the response from the committees and also from the public who use the services.

The debate saw a different maiden speech—not from a new Member, but from a new Leader of the Opposition. We all welcome him to his post. We are confident that we will hear that speech again and again. The peroration is much loved by us all but when applied to the NHS does not make a useful contribution to sustained debate outside the House.

One convention when replying to a debate is to say how excellent and useful a debate has been. Because of the contributions from the right hon. Member for Islwyn (Mr. Kinnock) and the hon. Member for Crewe and Nantwich (Mrs. Dunwoody), the debate has not been helpful. Unfortunately, a great deal of the debate across the floor has not addressed itself to the issues that concern the NHS. It has turned on the extraordinary claim that the background to the debate is intended cuts, past cuts and future cuts, and that the Government are somehow reducing expenditure and services in the NHS as a whole.

We do not wish to hear any unparliamentary language. On previous occasions I may have sailed near to that by describing that approach as the "big lie" technique. Today the right hon. Gentleman actually accused the Government of premeditated falsehood and claimed that we were perpetuating that falsehood. We will not respond in kind. We make no attack upon the sincerity of the right hon. Gentleman. His falsehoods were unpremeditated and unintended because he had not carried out enough research into the subject on which he chose to embark. He talked about reductions in the standards of care between 1979 and the present time. My right hon. Friend the Secretary of State in his speech, which immediately followed that of the right hon. Gentleman, gave details of the increased provision of patient care—category by category—that has taken place while we have been in office.

The right hon. Gentleman spoke about the lengthening waiting lists, which he had the nerve to say have grown while the Conservative Government have been in office. The record-breaking level of waiting lists was reached in March 1979. when the figure stood at 752,000. In March 1983 the figure had been reduced to 726,000. What determines waiting lists is, in part, the pace of medical advance. There are all those who are now able to wait for hip replacement operations that were not possible a few years ago. Waiting lists are always with us, but contrary to assertions, they have been declining and continue to decline, except during periods of industrial action backed by the Labour party.

The underlying fallacy in the Labour party's claim is the continued assertion that we have made cuts in spending over the past four years. Many argue about the use of statistics, and I agree with all those hon. Members who say that all that the public want to hear about are patients—that was a word that the hon. Member for Crewe and Nantwich mentioned, I think, only once in half an hour—and that they do not want to get lost in the miasma of statistics.

There are four straightforward statistics which no hon. Member has been able to challenge in this debate or any other. Cash spending has doubled since June 1979. The economic cost to the country, for which purpose one makes a comparison with the retail price index, has increased by 17.5 per cent. If one makes an allowance for the increased cost of medical services there has been a planned growth in service of 7.5 per cent. and capital expenditure is up 14 per cent. It requires a curious use of the English language to continue to use the word "cut" to describe any of that financial provision over the past four years.

There have been even more fanciful attacks on manpower. The hon. Member for Bradford, West (Mr. Madden), in a speech which, although I welcome his return, made me think at one point that he had brought his soap box with him, got carried away when talking about sacked doctors and nurses. I have not yet met a doctor or a nurse who has been sacked as a result of any measures taken by the Government. I shall meet one if the hon. Gentleman can find one. He would not give way during his speech when he saw me trying to rise and challenge him to produce any such individual.

The hon. Member for Fife, Central (Mr. Hamilton) launched in with figures of 20,000 unemployed nurses and 3,000 unemployed doctors. I can only say that those figures are the highest that I have yet heard in the usual fictional accounts that are given about the number of unemployed professionals in Britain and I do not have the slightest idea of his source. The best estimate of unemployed doctors that we have is about 1,000, most of whom are employed for short periods between jobs. If we did not have that many registered unemployed doctors people would be complaining about a shortage because there would be no mobility to enable movement from job to job.

Mrs. Dunwoody

Why is it that the British Medical Association's junior hospital doctors committee has estimated that on the basis of its survey there are 3,500 unemployed?

Mr. Clarke

I look forward to the BMA junior hospital doctors committee producing the slightest evidence for that figure which I have heard it use. The best estimate that we can make is the one that I have given. Any occupation is bound to have a number of unemployed at any set time.

The right hon. Member for Plymouth, Devonport (Dr. Owen) tried, on behalf of the Social Democrats, to focus without too many statistics on the issue that we should be looking at—the level of provision, not cut provision, and how it matches demand. At least he dismissed the Labour party's case. He said that it would be a fool who sought to deny that there had been an increase in resources between 1979 and 1983 and that resources had failed to keep up with demographic demand. I share that judgment with him; and those to whom the description attaches should wear the cap that fits them.

The right hon. Gentleman went on to concentrate not on challenging the Government's record before the election, which cannot be attacked on the grounds assumed by the Labour party, but on what had occurred since the election which, he tried to claim, showed some change of course by the Government incompatible with what we then said. First, he talked about manpower targets. I shall dismiss one or two of the other unpremeditated falsehoods. It is been said that we made no announcement before the election, but we did that back in July 1982. The claim has just been made that we changed the manpower targets in mid-year, but we did no such thing. We produced the first indicative targets in July because we did not then have the figures that were supposed to be forthcoming and we have not changed them.

The right hon. Gentleman said that he accepted that savings had to be made in some staff posts and that there were savings to be made in the Health Service. He claimed that the savings should be part of a transfer of staff from those places where they could be saved to where they could be better deployed. He re-attacked our targets, claiming that they are somehow affecting key posts in areas catering for the elderly and other priority groups. That is not the case. While we were carrying out the manpower target exercise this year and negotiating with health authorities, we discovered from their returns and their estimates before the targets were set that although most health authorities were fairly level spenders they were proposing to increase their staff by about 7,000 primarily in administrative, clerical and work areas, not in the frontline areas. In negotiating with the regions—this is now being carried through to the districts—we aimed to re-examine the system to ascertain the scope for the elimination of unnecessary posts so that money could be saved and devoted to developments, new hospitals, wards and services.

We concluded that this year's developments would save a little under 5,000 posts in a service that employs 820,000 people. Our examination showed also that better efficiency in manpower use—this will be achieved by authorities—would produce £40 million which could be spent elsewhere in the service on development by those health authorities.

Mr. Pavitt

rose——

Mr. Clarke

I shall not give way; a number of hon. Members failed to give way to me.

The right hon. Gentleman and others referred to the Acheson report and the statement by the Secretary of State about improving services in inner cities. No one has challenged the desirability of improving the level of primary care in inner cities. We have described the way in which money will be expended on nurse training, group practice and grants for the improvement of substandard premises in which doctors must operate.

Mr. Andrew F. Bennett (Denton and Reddish)

Where will the money come from?

Mr. Clarke

I am helpfully reminded of the question. This money is new. It is not being taken from the budgets of the health authorities or the family practitioner service. We made provision for this money in this year's White Paper. Earlier this year, we announced an increase of £3 million. The Secretary of State announced that the full programme would cost £9 million. I am sorry that the hon. Gentleman does not seem pleased with his answer that we are devoting more money to primary inner city care.

The right hon. Member for Devonport asked me why we were not expanding the joint finance system which is useful in promoting co-operation between health and local authorities and in promoting a caring community policy. I am sorry that there was no announcement today of more money for joint finance. Since the Government came into power, joint finance has increased from £31 million in 1978–79 to £90 million this year—an increase in real terms of no less than 80 per cent. in that desirable part of the service.

The right hon. Member for Devonport and others talked about the effect of the July measures on overall expenditure this year. Those who say that there is a contrast between what we are doing and spending now and what we did and spent when we made our speeches during the election are using a false premise and only a part of the statistics. The right hon. Gentleman tried to demonstrate that this year there was a 0.2 per cent. reduction in real terms in the budget of the NHS. I point out that he was taking only the figures for the health authorities providing the hospital services; he was ignoring the general practitioners, the family practitioners and total spending on the NHS.

Our position is unchanged from what the Prime Minister said at Edinburgh and during the Election. The July measures have had a neutral effect on spending on the NHS as a whole. They keep us at the planned levels, of which we were proud during the Election. The reduction in the cash limit of programmes took £89 million from hospital health authorities' budgets. Forecasts for expenditure on the family practitioner services showed an increase of £108 million. Those who wish to criticise the increased spending on the family practitioner services per se are making a mistake. The House knows that the family doctor system in this country is one of the better features of the NHS vis-à-vis services provided in other countries. Extra expenditure upon it is of benefit to the National Health Service but it has to be paid for like any other expenditure and has to be accommodated between planned levels and what the economy can afford.

There are those who would query whether over the years the balance of spending——

Mr. Clement Freud (Cambridgeshire, North-East)

rose——

Mr. Clarke

I am sorry that the hon. Gentleman has not been here throughout the debate, but it is too late to give way—between the hospital services and the family practitioner services—they have sometimes taken more money from the hospital services—has always been good.

In so far as the increased expenditure reflects an increase in the drugs bill, I can assure the hon. Lady for Crewe and Nantwich and those who raised the subject, that we are no more sparing the drugs bill from the search for economies to release resources for patient care than any other area. In so far as this year's increased expenditure was partly the result of the drugs bill, for the remaining part of the financial year we have already obtained £25 million from the planned drugs bill by freezing prices until the end of this year.

We are negotiating reductions in the anticipated drugs bill with the pharmaceutical industry by renegotiating that system of payment for drugs that the Labour party introduced in the late 70s when the right hon. Member for Devonport, who mentioned the point, was Minister for Health.

I assure those who are worried about the drugs bill that we will make savings, but when the hon. Member for Crewe and Nantwich says that by generic substitution alone we can save £170 million, I would point out that the best estimate of the total profitability of the industry from the National Health Service is £250 million. On top of all the other things that she believes that she can obtain from the drugs bill, she will put 70,000 people out of work and turn away a great deal of inward investment—[Interruption]—in a valuable industry. Her estimate of potential savings from generic substitution, at which we are looking, is a grotesque exaggeration compared with any estimates that we have.

Mr. Pavitt

rose——

Mr. Clarke

The best illustration of the impact of what we have done this year was given by the two maiden speakers with experience of health authorities. My hon. Friend the Member for Oxford, East (Mr. Norris), the vice-chairman of east Berkshire health authority, gave an incontrovertible description of the effect upon his authority. He said that the 51 staff post cuts being asked for will have no effect upon his authority and the cash cuts would also have no effect because the authority did not reach the level of estimated underspend.

I assure my hon. Friend, and others who are worried, that the suggestion that manpower targets might be set for different categories of staff does not arise. We did not prescribe any cuts for doctors or nurses or any other group of staff. District health authorities are left entirely free to decide where unnecessary staff posts can be saved. There is no injunction upon them to reduce staff posts in any particular area.

My hon. Friend the Member for Warwickshire, North and my hon. Friend the Member for Oxford, East said that one of the difficulties in estimating the effects of our manpower target this year is the number of authorities who could not say how many people they employed. The target exercise enabled them to concentrate on searching for efficiency and that will benefit the authorities.

The record must be set against the rising demand for services. My hon. Friends the Members for Eastleigh (Sir D. Price) for Devizes (Mr. Morrison) and for Birmingham, Edgbaston (Mrs. Knight) in the most informed speeches on the Health Service all acknowledged—[Interruption.]—the rising demand for health care and the potential danger, as my hon. Friend the Member for Eastleigh said, of expectations of health care going ahead of resources as they always have done since 1948. The problem to which the debate should address itself is how to get as near to those expectations as one can from the resources one can reasonably expect the economy and the taxpayer to provide.

The answer, as I understand it from the Opposition, is that the taxpayer should pay more for the service that he already gets or will get. The taxpayer already has that pleasure because the priority that the Government are giving to the National Health Service and the cost upon the tax he pays for the National Health Service has steadily increased since we came to power.

When we came to office in 1979 the cost of the National Health Service per head of the population was £143. In 1983 it has risen to £268. The proportion of the gross domestic product had risen from 4.7 per cent. expenditure on the Health Service that the Labour Government left us when their concern was a little less sharp than it is now to the present 5.5 per cent.

The right hon. Member for Devonport did not try out in the House today the only way in which outside he tried to address this problem. I have seen reports in The Times of an article in which he floated the idea of a new local health tax to finance—presumably over and above general taxation—extra health care in this country. That tax might be a little more popular than rates, but nevertheless it would be an addition to the total level of local taxation, whether levied by rates or income tax. The experience of people being asked to take added burdens for health is not always as good as it might be in general. The experience of raising prescription charges never brings out in the Opposition a sudden desire to see more revenue spent on health. But such a tax would also be a new impost on the economy of this country. Whatever it was called and however it was raised, it would be new taxation and would inevitably have an impact on the proportion of GDP being spent on health care and or the amount left available for economic development.

I remind the right hon. Gentleman of his thoughts in November 1975 when he was Minister of State. He did not look for new taxation as a way out of the problem. During the period of office of which he was so proud, he said: It will be difficult to persuade and to explain to people why we need to cut back in some of our social services, which most of us hold very dear, in order to increase industrial development and earn our living in the markets of the world."—[Official Report, 21 November 1975; Vol. 901, c. 445.] I am not surprised that the right hon. Gentleman said that because he was in the middle of a pay dispute with junior doctors caused by pay policy. He was trying to rein back his then Secretary of State who was devoting all his efforts to trying to phase out pay beds. They were on the eve of the 1976 clash when his Government had to cut back capital spending on the National Health Service to a degree which we never have.

We believe that our record in making demands on the taxpayer and spending on the service is a good one, but these extra demands can be avoided and are not a real need if on top of increased spending we can achieve ever better value for money and ever more efficiency and performance for the benefit of the patient, who will derive more care if we can reduce to a minimum the cost of administration, laundries, support and so on. On that point I do not understand how the Opposition face up to the issues—if they face up to the real issues at all. The problem of efficiency is not new. The theme has been recurrent during debates on the Health Service in recent years but at the moment the Labour party appears to have abdicated all responsibility for contributing to debate and has resisted any attempts we make to change matters and to improve the performance of the Health Service.

We are criticised for talking about the administrative tail of the Health Service. I can find quotations from Lord Ennals when he was Secretary of State acknowledging that there was too much administration in the service and pledging himself to try to reduce it. He actually started what he called a management cost exercise. The difference between what they did and what we are doing is that they were unsuccessful in restraining the administration of the service. When they were in office the number of administrative and clerical staff rose from 82,700 in 1974 to 100,300 in 1979, yet their Ministers were asserting that they wished to cut down unnecessary administration

Since then we have abolished a whole tier of authorities so as to cut down unnecessary waste and we have embarked on our manpower targets policy so as to release £40 million this year, concentrating in particular on administration. We have produced the Griffiths report, which also addresses itself to the style of management and the performance of administration. There are some excellent managers and administrators in the service. We require the right structure of administration to get the best out of them so that they can make their contribution to decision-making and patient care.

The Griffiths report has had a good reception from those in the service, particularly consultants and administrators, who see the need for change. Indeed, as the Griffiths report team went round it received hardly any representations from people saying that nothing needed to be done to the present structure.

Mr. Pavitt

What about the Royal College of Nursing?

Mr. Clarke

The Guardian, which is not renowned for giving my right hon. Friend and myself an easy ride on Health Service projects, said in a leader about what it called "the Sainsbury prescription": In short, this report deserves to be taken seriously as a contribution to the debate about the National Health Service. It would ill serve either the NHS as dedicated employers or its patients to fail to take advantage of what can be learnt from better management techniques or to fail to ask why the same operation may take three times as long in parts of London as in Kingston or twice as long as in Chelmsford. The medical professions are better able to make explicit choices as a result of such information and management; so much the better for clinical freedom, too. There has been that and much other serious editorial comment, yet what we got from the hon. Member for Crewe and Nantwich were snide jokes about grocers and a mish-mash of an analysis of the Griffiths report. She did not even address herself to the redistribution of resources among different parts of the country.

We are following the principles of the Resource Allocation Working Party, the RAWP system, set up by the Labour Government. The difference is that we are following it through consistently and are looking for the biggest savings in those parts of the country which are plainly comparatively over-resourced and where the biggest savings can be made.

But what do Labour Members do? They support the activities of Brent district health authority in its resistance to further savings this year. That authority is 25 per cent. over the target laid down for spending by the Labour Party's own RAWP system. It is one of the most high-spending district health authorities in Britain. When it had its key meeting earlier this year it was informed by its treasurer that it was heading for an underspend of about £500,000 this year, but what was its reaction to the suggestion that £250,000 might go back to the region? The authority then embarked on a spending programme which included refurbishing the staff kitchens and new equipment for the telephone switchboard, all in an attempt to get through the cash limits. Its levels of financial control are probably not good enough to enable it to spend the money quickly enough to do that.

That gets support from the Labour Party, yet that money, if spent in that way, will be spent at the expense of other parts of the region, such as Luton and Dunstable, and other parts of the country, such as Warrington, which on any RAWP formula are underfinanced. I will not go further into matters which the Labour Party resists whenever——

Mr. Boyes

rose——

Mr. Clarke

I cannot see what is wrong with testing the costs of laundry, cleaning and catering if one can maintain the same standard of care by laying down the right levels of care and allowing the savings to come back to the patients.

Calderdale has been cited throughout the debate and the right hon. Member for Islwyn said that the spending of £2 million on a new hospital in Calderdale was justified to make a saving of £18,000 each year—£2 million out of a capital programme which could otherwise be spent on hospitals—all to protect Calderdale against having to put its costs out to tender.

My hon. Friend the Member for Carshalton and Wallington (Mr. Forman) reaffirmed the Government's commitment to the NHS. I too, reaffirm that commitment on behalf of the Government. We propose to change and improve the Health Service whereas the right hon. Member for Islwyn is wedded to 1948 and Nye Bevan. He resists change in a way that is entirely contrary to the true interests of the NHS.

Question put, That the original words stand part of the Question:—

The House divided: Ayes 205, Noes 338.

Division No. 52]	[10 pm
AYES
Abse, Leo	Dixon, Donald
Adams, Allen (Paisley N)	Dobson, Frank
Alton, David	Dormand, Jack
Anderson, Donald	Douglas, Dick
Archer, Rt Hon Peter	Dubs, Alfred
Atkinson, N. (Tottenham)	Duffy, A. E. P.
Bagier, Gordon A. T.	Dunwoody, Hon Mrs G.
Banks, Tony (Newham NW)	Eadie, Alex
Barron, Kevin	Eastham, Ken
Beckett, Mrs Margaret	Edwards, R. (W'hampt'n SE)
Beith, A. J.	Ellis, Raymond
Bell, Stuart	Evans, Ioan (Cynon Valley)
Bennett, A. (Dent'n & Red'sh)	Evans, John (St. Helens N)
Bermingham, Gerald	Ewing, Harry
Bidwell, Sydney	Fatchett, Derek
Blair, Anthony	Faulds, Andrew
Boyes, Roland	Field, Frank (Birkenhead)
Bray, Dr Jeremy	Fields, T. (L'pool Broad Gn)
Brown, Gordon (D'f'mline E)	Fisher, Mark
Brown, Hugh D. (Provan)	Flannery, Martin
Brown, N. (N'c'tle-u-Tyne E)	Foot, Rt Hon Michael
Brown, Ron (E'burgh, Leith)	Forrester, John
Bruce, Malcolm	Foulkes, George
Caborn, Richard	Fraser, J. (Norwood)
Callaghan, Rt Hon J.	Freeson, Rt Hon Reginald
Callaghan, Jim (Heyw'd & M)	Freud, Clement
Campbell, Ian	Garrett, W. E.
Canavan, Dennis	George, Bruce
Carlile, Alexander (Montg'y)	Godman, Dr Norman
Cartwright, John	Golding, John
Clark, Dr David (S Shields)	Gould, Bryan
Clarke, Thomas	Gourlay, Harry
Clay, Robert	Hamilton, James (M'well N)
Cocks, Rt Hon M. (Bristol S.)	Hamilton, W. W. (Central Fife)
Cohen, Harry	Hardy, Peter
Coleman, Donald	Harman, Ms Harriet
Concannon, Rt Hon J. D.	Harrison, Rt Hon Walter
Cook, Robin F. (Livingston)	Hart, Rt Hon Dame Judith
Corbett, Robin	Hattersley, Rt Hon Roy
Corbyn, Jeremy	Healey, Rt Hon Denis
Cowans, Harry	Holland, Stuart (Vauxhall)
Craigen, J. M.	Home Robertson, John
Crowther, Stan	Howell, Rt Hon D. (S'heath)
Cunliffe, Lawrence	Howells, Geraint
Cunningham, Dr John	Hoyle, Douglas
Dalyell, Tam	Hughes, Mark (Durham)
Davies, Rt Hon Denzil (L'lli)	Hughes, Robert (Aberdeen N)
Davies, Ronald (Caerphilly)	Hughes, Roy (Newport East)
Davis, Terry (B'ham, H'ge H'l)	Hughes, Sean (Knowsley S)
Deakins, Eric	Hughes, Simon (Southwark)
Dewar, Donald	Jenkins, Rt Hon Roy (Hillh'd)

John, Brynmor	Powell, Raymond (Ogmore)
Jones, Barry (Alyn & Deeside)	Prescott, John
Kaufman, Rt Hon Gerald	Radice, Giles
Kennedy, Charles	Randall, Stuart
Kilfedder, James A.	Redmond, M.
Kilroy-Silk, Robert	Richardson, Ms Jo
Kinnock, Rt Hon Neil	Roberts, Ernest (Hackney N)
Lambie, David	Robertson, George
Lamond, James	Robinson, G. (Coventry NW)
Leadbitter, Ted	Rogers, Allan
Leighton, Ronald	Rooker, J. W.
Lewis, Ron (Carlisle)	Ross, Ernest (Dundee W)
Lewis, Terence (Worsley)	Ross, Stephen (Isle of Wight)
Litherland, Robert	Rowlands, Ted
Lloyd, Tony (Stretford)	Ryman, John
Lofthouse, Geoffrey	Sedgemore, Brian
Loyden, Edward	Sheerman, Barry
McCartney, Hugh	Sheldon, Rt Hon R.
McDonald, Dr Oonagh	Shore, Rt Hon Peter
McGuire, Michael	Silkin, Rt Hon J.
McKay, Allen (Penistone)	Skinner, Dennis
McKelvey, William	Smith, C. (Isl'ton S & F'bury)
Mackenzie, Rt Hon Gregor	Smith, Rt Hon J. (M'kl'ds E)
Maclennan, Robert	Snape, Peter
McNamara, Kevin	Spearing, Nigel
McTaggart, Robert	Steel, Rt Hon David
McWilliam, John	Stewart, Rt Hon D. (W Isles)
Madden, Max	Stott, Roger
Marek, Dr John	Strang, Gavin
Marshall, David (Shettleston)	Straw, Jack
Martin, Michael	Thompson, J. (Wansbeck)
Mason, Rt Hon Roy	Thorne, Stan (Preston)
Maxton, John	Tinn, James
Meacher, Michael	Varley, Rt Hon Eric G.
Meadowcroft, Michael	Wainwright, R.
Michie, William	Walden, George
Mikardo, Ian	Wallace, James
Millan, Rt Hon Bruce	Wardell, Gareth (Gower)
Miller, Dr M. S. (E Kilbride)	Wareing, Robert
Morris, Rt Hon A. (W'shawe)	Weetch, Ken
Morris, Rt Hon J. (Aberavon)	Welsh, Michael
Nellist, David	White, James
Oakes, Rt Hon Gordon	Wigley, Dafydd
O'Brien, William	Williams, Rt Hon A.
O'Neill, Martin	Wilson, Gordon
Orme, Rt Hon Stanley	Winnick, David
Owen, Rt Hon Dr David	Woodall, Alec
Park, George	Wrigglesworth, Ian
Parry, Robert	Young, David (Bolton SE)
Patchett, Terry
Pavitt, Laurie	Tellers for the Ayes:
Pendry, Tom	Mr. Austin Mitchell and Mr. Norman Hogg.
Penhaligon, David
Pike, Peter

NOES
Adley, Robert	Biffen, Rt Hon John
Alexander, Richard	Biggs-Davison, Sir John
Alison, Rt Hon Michael	Blaker, Rt Hon Sir Peter
Amery, Rt Hon Julian	Body, Richard
Amess, David	Bonsor, Sir Nicholas
Ancram, Michael	Bottomley, Peter
Arnold, Tom	Bowden, A. (Brighton K'to'n)
Ashby, David	Bowden, Gerald (Dulwich)
Aspinwall, Jack	Boyson, Dr Rhodes
Atkins, Rt Hon Sir H.	Braine, Sir Bernard
Atkins, Robert (South Ribble)	Brandon-Bravo, Martin
Atkinson, David (B'm'th E)	Bright, Graham
Baker, Kenneth (Mole Valley)	Brinton, Tim
Baker, Nicholas (N Dorset)	Brittan, Rt Hon Leon
Baldry, Anthony	Brooke, Hon Peter
Banks, Robert (Harrogate)	Brown, M. (Brigg & Cl'thpes)
Batiste, Spencer	Browne, John
Bellingham, Henry	Bruinvels, Peter
Bendall, Vivian	Bryan, Sir Paul
Bennett, Sir Frederic (T'bay)	Buchanan-Smith, Rt Hon A.
Benyon, William	Buck, Sir Antony
Berry, Sir Anthony	Budgen, Nick
Best, Keith	Bulmer, Esmond
Bevan, David Gilroy	Burt, Alistair

Butcher, John	Hayes, J.
Butler, Hon Adam	Hayhoe, Barney
Butterfill, John	Hayward, Robert
Carlisle, Kenneth (Lincoln)	Heathcoat-Amory, David
Carttiss, Michael	Heddle, John
Chalker, Mrs Lynda	Henderson, Barry
Channon, Rt Hon Paul	Hickmet, Richard
Chapman, Sydney	Hicks, Robert
Chope, Christopher	Higgins, Rt Hon Terence L.
Churchill, W. S.	Hill, James
Clark, Hon A. (Plym'th S'n)	Hind, Kenneth
Clark, Dr Michael (Rochford)	Hirst, Michael
Clark, Sir W. (Croydon S)	Hogg, Hon Douglas (Gr'th'm)
Clarke Kenneth (Rushcliffe)	Holland, Sir Philip (Gedling)
Clegg, Sir Walter	Holt, Richard
Colvin, Michael	Hooson, Tom
Coombs, Simon	Howard, Michael
Cope, John	Howarth, Alan (Stratf'd-on-A)
Cormack, Patrick	Howarth, Gerald (Cannock)
Couchman, James	Howell, Rt Hon D. (G'ldford)
Critchley, Julian	Hubbard-Miles, Peter
Crouch, David	Hunt, David (Wirral)
Currie, Mrs Edwina	Hunt, John (Ravensbourne)
Dickens, Geoffrey	Hunter, Andrew
Dicks, T.	Hurd, Rt Hon Douglas
Dorrell, Stephen	Irving, Charles
Douglas-Hamilton, Lord J.	Jackson, Robert
Dover, Denshore	Jenkin, Rt Hon Patrick
du Cann, Rt Hon Edward	Jessel, Toby
Dunn, Robert	Johnson-Smith, Sir Geoffrey
Dykes, Hugh	Jones, Gwilym (Cardiff N)
Eggar, Tim	Jones, Robert (W Herts)
Emery, Sir Peter	Jopling, Rt Hon Michael
Evennett, David	Joseph, Rt Hon Sir Keith
Eyre, Reginald	Kershaw, Sir Anthony
Fairbairn, Nicholas	Key, Robert
Fallon, Michael	King, Roger (B'ham N'field)
Farr, John	King, Rt Hon Tom
Favell, Anthony	Knight, Gregory (Derby N)
Fenner, Mrs Peggy	Knight, Mrs Jill (Edgbaston)
Finsberg, Geoffrey	Knowles, Michael
Fletcher, Alexander	Knox, David
Fookes, Miss Janet	Lang, Ian
Forman, Nigel	Latham, Michael
Forsyth, Michael (Stirling)	Lawler, Geoffrey
Fowler, Rt Hon Norman	Lawrence, Ivan
Fox, Marcus	Lawson, Rt Hon Nigel
Franks, Cecil	Lee, John (Pendle)
Fraser, Rt Hon Sir Hugh	Leigh, Edward (Gainsbor'gh)
Fraser, Peter (Angus East)	Lennox-Boyd, Hon Mark
Freeman, Roger	Lester, Jim
Fry, Peter	Lewis, Sir Kenneth (Stamf'd)
Gale, Roger	Lightbown, David
Galley, Roy	Lilley, Peter
Gardiner, George (Reigate)	Lloyd, Ian (Havant)
Gardner, Sir Edward (Fylde)	Lloyd, Peter, (Fareham)
Garel-Jones, Tristan	Lord, Michael
Gilmour, Rt Hon Sir Ian	Lyell, Nicholas
Glyn, Dr Alan	McCurley, Mrs Anna
Goodlad, Alastair	Macfarlane, Neil
Gorst, John	MacGregor, John
Gow, Ian	MacKay, Andrew (Berkshire)
Gower, Sir Raymond	MacKay, John (Argyll & Bute)
Grant, Sir Anthony	Maclean, David John.
Gregory, Conal	Macmillan, Rt Hon M.
Griffiths, E. (B'y St Edm'ds)	McNair-Wilson, M. (N'bury)
Griffiths, Peter (Portsm'th N)	McNair-Wilson, P. (New F'st)
Grist, Ian	McQuarrie, Albert
Ground, Patrick	Madel, David
Grylls, Michael	Major, John
Gummer, John Selwyn	Malins, Humfrey
Hamilton, Hon A. (Epsom)	Malone, Gerald
Hamilton, Neil (Tatton)	Maples, John
Hampson, Dr Keith	Marland, Paul
Hanley, Jeremy	Maude, Francis
Hannam,John	Mawhinney, Dr Brian
Hargreaves, Kenneth	Maxwell-Hyslop, Robin
Harvey, Robert	Mayhew, Sir Patrick
Haselhurst, Alan	Mellor, David
Hawkins, C. (High Peak)	Merchant, Piers

Miller, Hal (B'grove)	Soames, Hon Nicholas
Mills, Iain (Meriden)	Speed, Keith
Mills, Sir Peter (West Devon)	Speller, Tony
Moate, Roger	Spence, John
Monro, Sir Hector	Spencer, D.
Montgomery, Fergus	Spicer, Jim (W Dorset)
Moore, John	Spicer, Michael (S Worcs)
Morris, M. (N'hampton, S)	Squire, Robin
Morrison, Hon C. (Devizes)	Stanbrook, Ivor
Moynihan, Hon C.	Stanley, John
Murphy, Christopher	Steen, Anthony
Neale, Gerrard	Stern, Michael
Needham, Richard	Stevens, Lewis (Nuneaton)
Neubert, Michael	Stevens, Martin (Fulham)
Newton, Tony	Stewart, Allan (Eastwood)
Nicholls, Patrick	Stewart, Andrew (Sherwood)
Norris, Steven	Stewart, Ian (N Hertf'dshire)
Onslow, Cranley	Stokes, John
Oppenheim, Philip	Stradling Thomas, J.
Oppenheim, Rt Hon Mrs S.	Sumberg, David
Osborn, Sir John	Tapsell, Peter
Ottaway, Richard	Taylor, John (Solihull)
Page, Richard (Herts SW)	Taylor, Teddy (S'end E)
Parris, Matthew	Tebbit, Rt Hon Norman
Patten, Christopher (Bath)	Terlezki, Stefan
Patten, John (Oxford)	Thatcher, Rt Hon Mrs M.
Pattie, Geoffrey	Thomas, Rt Hon Peter
Peacock, Mrs Elizabeth	Thompson, Donald (Calder V)
Percival, Rt Hon Sir Ian	Thompson, Patrick (N'ich N)
Pink, R. Bonner	Thorne, Neil (Ilford S)
Porter, Barry	Thornton, Malcolm
Powell, William (Corby)	Thurnham, Peter
Powley, John	Townend, John (Bridlington)
Prentice, Rt Hon Reg	Townsend, Cyril D. (B'heath)
Price, Sir David	Tracey, Richard
Proctor, K. Harvey	Trippier, David
Raffan, Keith	Twinn, Dr Ian
Raison, Rt Hon Timothy	van Straubenzee, Sir W.
Rathbone, Tim	Vaughan, Dr Gerard
Rees, Rt Hon Peter (Dover)	Viggers, Peter
Rhodes James, Robert	Wakeham, Rt Hon John
Rhys Williams, Sir Brandon	Waldegrave, Hon William
Ridsdale, Sir Julian	Walker, Bill (T'side N)
Rifkind, Malcolm	Walker, Rt Hon P. (W'cester)
Rippon, Rt Hon Geoffrey	Wall, Sir Patrick
Roberts, Wyn (Conwy)	Waller, Gary
Robinson, Mark (N'port W)	Walters, Dennis
Roe, Mrs Marion	Ward, John
Rossi, Sir Hugh	Wardle, C. (Bexhill)
Rost, Peter	Warren, Kenneth
Rumbold, Mrs Angela	Watson, John
Ryder, Richard	Watts, John
Sackville, Hon Thomas	Wells, John (Maidstone)
Sainsbury, Hon Timothy	Wheeler, John
St. John-Stevas, Rt Hon N.	Whitfield, John
Sayeed, Jonathan	Wiggin, Jerry
Scott, Nicholas	Winterton, Mrs Ann
Shaw, Sir Michael (Scarb')	Winterton, Nicholas
Shelton, William (Streatham)	Wolfson, Mark
Shepherd, Colin (Hereford)	Wood, Timothy
Shepherd, Richard (Aldridge)	Woodcock, Michael
Shersby, Michael	Yeo, Tim
Silvester, Fred	Young, Sir George (Acton)
Sims, Roger
Skeet, T. H. H.	Tellers for the Noes:
Smith, Sir Dudley (Warwick)	Mr. Carol Mather and Mr. Robert Boscawen.
Smith, Tim (Beaconsfield)

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 33 (Questions on amendments):—

The House divided: Ayes 331, Noes 204.

Division No. 53]	[10.14 pm
AYES
Adley, Robert	Alison, Rt Hon Michael
Alexander, Richard	Amery, Rt Hon Julian

Amess, David	Finsberg, Geoffrey
Ancram, Michael	Fletcher, Alexander
Arnold, Tom	Fookes, Miss Janet
Ashby, David	Forman, Nigel
Aspinwall, Jack	Forsyth, Michael (Stirling)
Atkins, Rt Hon Sir H.	Fowler, Rt Hon Norman
Atkins, Robert (South Ribble)	Fox, Marcus
Atkinson, David (B'm'th E)	Franks, Cecil
Baker, Kenneth (Mole Valley)	Fraser, Rt Hon Sir Hugh
Baker, Nicholas (N Dorset)	Fraser, Peter (Angus East)
Baldry, Anthony	Freeman, Roger
Banks, Robert (Harrogate)	Fry, Peter
Batiste, Spencer	Gale, Roger
Bellingham, Henry	Galley, Roy
Bendall, Vivian	Gardner, Sir Edward (Fylde)
Bennett, Sir Frederic (T'bay)	Garel-Jones, Tristan
Benyon, William	Gilmour, Rt Hon Sir Ian
Berry, Sir Anthony	Glyn, Dr Alan
Best, Keith	Goodlad, Alastair
Bevan, David Gilroy	Gorst, John
Biffen, Rt Hon John	Gow, Ian
Biggs-Davison, Sir John	Gower, Sir Raymond
Blaker, Rt Hon Sir Peter	Grant, Sir Anthony
Body, Richard	Gregory, Conal
Bonsor, Sir Nicholas	Griffiths, E. (B'y St Edm'ds)
Bottomley, Peter	Griffiths, Peter (Portsm'th N)
Bowden, A. (Brighton K'to'n)	Grist, Ian
Bowden, Gerald (Dulwich)	Ground, Patrick
Boyson, Dr Rhodes	Gummer, John Selwyn
Braine, Sir Bernard	Hamilton, Hon A. (Epsom)
Brandon-Bravo, Martin	Hamilton, Neil (Tatton)
Bright, Graham	Hampson, Dr Keith
Brinton, Tim	Hanley, Jeremy
Brittan, Rt Hon Leon	Hannam, John
Brooke, Hon Peter	Hargreaves, Kenneth
Brown, M. (Brigg & Cl'thpes)	Harvey, Robert
Browne, John	Haselhurst, Alan
Bruinvels, Peter	Hawkins, C. (High Peak)
Bryan, Sir Paul	Hayes, J.
Buchanan-Smith, Rt Hon A.	Hayhoe, Barney
Buck, Sir Antony	Hayward, Robert
Budgen, Nick	Heathcoat-Amory, David
Burt, Alistair	Heddle, John
Butcher, John	Henderson, Barry
Butler, Hon Adam	Hickmet, Richard
Butterfill, John	Hicks, Robert
Carlisle, Kenneth (Lincoln)	Higgins, Rt Hon Terence L.
Carttiss, Michael	Hill, James
Chalker, Mrs Lynda	Hind, Kenneth
Channon, Rt Hon Paul	Hirst, Michael
Chapman, Sydney	Hogg, Hon Douglas (Gr'th'm)
Chope, Christopher	Holland, Sir Philip (Gedling)
Churchill, W. S.	Holt, Richard
Clark, Dr Michael (Rochford)	Hooson, Tom
Clark, Sir W. (Croydon S)	Howard, Michael
Clarke Kenneth (Rushcliffe)	Howarth, Alan (Stratf'd-on-A)
Clegg, Sir Walter	Howarth, Gerald (Cannock)
Colvin, Michael	Howell, Rt Hon D. (G'ldford)
Coombs, Simon	Hubbard-Miles, Peter
Cope, John	Hunt, David (Wirral)
Cormack, Patrick	Hunt, John (Ravensbourne)
Couchman, James	Hunter, Andrew
Crouch, David	Hurd, Rt Hon Douglas
Currie, Mrs Edwina	Irving, Charles
Dickens, Geoffrey	Jackson, Robert
Dicks, T.	Jenkin, Rt Hon Patrick
Dorrell, Stephen	Jessel, Toby
Douglas-Hamilton, Lord J.	Johnson-Smith, Sir Geoffrey
du Cann, Rt Hon Edward	Jones, Gwilym (Cardiff N)
Dunn, Robert	Jones, Robert (W Herts)
Dykes, Hugh	Jopling, Rt Hon Michael
Eggar, Tim	Joseph, Rt Hon Sir Keith
Emery, Sir Peter	Kershaw, Sir Anthony
Evennett, David	Key, Robert
Eyre, Reginald	King, Roger (B'ham N'field)
Fairbairn, Nicholas	King, Rt Hon Tom
Fallon, Michael	Knight, Gregory (Derby N)
Farr, John	Knight, Mrs Jill (Edgbaston)
Favell, Anthony	Knowles, Michael
Fenner, Mrs Peggy	Knox, David

Lang, Ian	Ridsdale, Sir Julian
Latham, Michael	Rifkind, Malcolm
Lawler, Geoffrey	Rippon, Rt Hon Geoffrey
Lawrence, Ivan	Roberts, Wyn (Conwy)
Lawson, Rt Hon Nigel	Robinson, Mark (N'port W)
Lee, John (Pendle)	Roe, Mrs Marion
Leigh. Edward (Gainsbor'gh)	Rossi, Sir Hugh
Lennox-Boyd, Hon Mark	Rost, Peter
Lester, Jim	Rumbold, Mrs Angela
Lewis. Sir Kenneth (Stamf'd)	Ryder, Richard
Lightbown, David	Sackville, Hon Thomas
Lilley, Peter	Sainsbury, Hon Timothy
Lloyd, Ian (Havant)	St. John-Stevas, Rt Hon N.
Lloyd, Peter, (Fareham)	Sayeed, Jonathan
Lord, Michael	Shaw, Sir Michael (Scarb')
Lyell, Nicholas	Shelton, William (Streatham)
McCurley, Mrs Anna	Shepherd, Colin (Hereford)
Macfarlane, Neil	Shepherd, Richard (Aldridge)
MacGregor, John	Shersby, Michael
MacKay, Andrew (Berkshire)	Silvester, Fred
MacKay, John (Argyll & Bute)	Sims, Roger
Maclean, David John.	Skeet, T. H. H.
Macmillan, Rt Hon M.	Smith, Sir Dudley (Warwick)
McNair-Wilson, M. (N'bury)	Smith, Tim (Beaconsfield)
McNair-Wilson, P. (New F'st)	Soames, Hon Nicholas
McQuarrie, Albert	Speed, Keith
Madel, David	Speller, Tony
Major, John	Spence, John
Malins, Humfrey	Spencer, D.
Malone, Gerald	Spicer, Jim (W Dorset)
Maples, John	Spicer, Michael (S Worcs)
Marland, Paul	Squire, Robin
Maude, Francis	Stanbrook, Ivor
Mawhinney, Dr Brian	Stanley, John
Maxwell-Hyslop, Robin	Steen, Anthony
Mayhew, Sir Patrick	Stern, Michael
Mellor, David	Stevens, Lewis (Nuneaton)
Merchant, Piers	Stevens, Martin (Fulham)
Miller, Hal (B grove)	Stewart, Allan (Eastwood)
Mills, Iain (Meriden)	Stewart, Andrew (Sherwood)
Mills, Sir Peter (West Devon)	Stewart, Ian (N Hertf'dshire)
Moate, Roger	Stokes, John
Monro, Sir Hector	Stradling Thomas, J.
Montgomery, Fergus	Sumberg, David
Moore, John	Tapsell, Peter
Morris, M. (N'hampton, S)	Taylor, John (Solihull)
Morrison, Hon C. (Devizes)	Taylor, Teddy (S'end E)
Moynihan, Hon C.	Tebbit, Rt Hon Norman
Murphy, Christopher	Terlezki, Stefan
Neale, Gerrard	Thatcher, Rt Hon Mrs M.
Needham, Richard	Thomas, Rt Hon Peter
Neubert, Michael	Thompson, Donald (Calder V)
Newton, Tony	Thompson, Patrick (N'ich N)
Nicholls, Patrick	Thorne, Neil (Ilford S)
Norris, Steven	Thornton, Malcolm
Onslow, Cranley	Thurnham, Peter
Oppenheim, Philip	Townend, John (Bridlington)
Oppenheim, Rt Hon Mrs S.	Townsend, Cyril D. (B'heath)
Osborn, Sir John	Tracey, Richard
Ottaway, Richard	Trippier, David
Page, Richard (Herts SW)	Twinn, Dr Ian
Parris, Matthew	van Straubenzee, Sir W.
Patten, Christopher (Bath)	Vaughan, Dr Gerard
Patten, John (Oxford)	Viggers, Peter
Pattie, Geoffrey	Wakeham, Rt Hon John
Peacock, Mrs Elizabeth	Waldegrave, Hon William
Percival, Rt Hon Sir Ian	Walden, George
Pink, R. Bonner	Walker, Bill (T'side N)
Porter, Barry	Walker, Rt Hon P. (W'cester)
Powell, William (Corby)	Wall, Sir Patrick
Powley, John	Waller, Gary
Prentice, Rt Hon Reg	Ward, John
Price, Sir David	Wardle, C. (Bexhill)
Proctor, K. Harvey	Warren, Kenneth
Raffan, Keith	Watson, John
Raison, Rt Hon Timothy	Watts, John
Rathbone, Tim	Wells, John (Maidstone)
Rees, Rt Hon Peter (Dover)	Wheeler, John
Rhodes James, Robert	Whitfield, John
Rhys Williams, Sir Brandon	Wiggin, Jerry

Winterton, Mrs Ann	Young, Sir George (Acton)
Winterton, Nicholas
Wolfson, Mark	Tellers for the Ayes:
Wood, Timothy	Mr. Carol Mather and Mr. Robert Boscawen.
Woodcock, Michael
Yeo, Tim

NOES
Abse, Leo	Forrester, John
Adams, Allen (Paisley N)	Foulkes, George
Alton, David	Fraser, J. (Norwood)
Anderson, Donald	Freeson, Rt Hon Reginald
Archer, Rt Hon Peter	Freud, Clement
Atkinson, N, (Tottenham)	Garrett, W. E.
Bagier, Gordon A. T.	George, Bruce
Banks, Tony (Newham NW)	Godman, Dr Norman
Barron, Kevin	Golding, John
Beckett, Mrs Margaret	Gould, Bryan
Beith, A. J.	Gourlay, Harry
Bell, Stuart	Hamilton, James (M'well N)
Bennett, A. (Dent'n & Red'sh)	Hamilton, W. W. (Central Fife)
Bermingham, Gerald	Hardy, Peter
Bidwell, Sydney	Harman, Ms Harriet
Blair, Anthony	Harrison, Rt Hon Walter
Boyes, Roland	Hart, Rt Hon Dame Judith
Bray, Dr Jeremy	Hattersley, Rt Hon Roy
Brown, Gordon (D'f'mline E)	Healey, Rt Hon Denis
Brown, Hugh D. (Provan)	Holland, Stuart (Vauxhall)
Brown, N. (N'c'tle-u-Tyne E)	Home Robertson, John
Brown, Ron (E'burgh, Leith)	Howell, Rt Hon D. (S heath)
Bruce, Malcolm	Howells, Geraint
Caborn, Richard	Hoyle, Douglas
Callaghan, Rt Hon J.	Hughes, Mark (Durham)
Callaghan, Jim (Heyw'd & M)	Hughes, Robert (Aberdeen N)
Campbell, Ian	Hughes, Roy (Newport East)
Canavan, Dennis	Hughes, Sean (Knowsley S)
Carlile, Alexander (Montg'y)	Hughes, Simon (Southwark)
Cartwright, John	Jenkins, Rt Hon Roy (Hillh'd)
Clark, Dr David (S Shields)	John, Brynmor
Clarke, Thomas	Jones, Barry (Alyn & Deeside)
Clay, Robert	Kaufman, Rt Hon Gerald
Cocks, Rt Hon M. (Bristol S.)	Kennedy, Charles
Cohen, Harry	Kilfedder, James A.
Coleman, Donald	Kilroy-Silk, Robert
Concannon, Rt Hon J. D.	Kinnock, Rt Hon Neil
Cook, Robin F. (Livingston)	Lambie, David
Corbett, Robin	Lamond, James
Corbyn, Jeremy	Leadbitter, Ted
Cowans, Harry	Leighton, Ronald
Craigen, J. M.	Lewis, Ron (Carlisle)
Crowther, Stan	Lewis, Terence (Worsley)
Cunliffe, Lawrence	Litherland, Robert
Cunningham, Dr John	Lloyd, Tony (Stretford)
Dalyell, Tam	Lofthouse, Geoffrey
Davies, Rt Hon Denzil (L'lli)	Loyden, Edward
Davies, Ronald (Caerphilly)	McCartney, Hugh
Davis, Terry (B'ham, Hge H'l)	McDonald, Dr Oonagh
Deakins, Eric	McGuire, Michael
Dewar, Donald	McKay, Allen (Penistone)
Dixon, Donald	McKelvey, William
Dobson, Frank	Mackenzie, Rt Hon Gregor
Dormand, Jack	Maclennan, Robert
Douglas, Dick	McNamara, Kevin
Dubs, Alfred	McTaggart, Robert
Duffy, A. E. P.	McWilliam, John
Dunwoody, Hon Mrs G.	Madden, Max
Eadie, Alex	Marek, Dr John
Eastham, Ken	Marshall, David (Shettleston)
Edwards, R. (Whampt'n SE)	Martin, Michael
Ellis, Raymond	Mason, Rt Hon Roy
Evans, Ioan (Cynon Valley)	Maxton, John
Evans, John (St. Helens N)	Meacher, Michael
Ewing, Harry	Meadowcroft, Michael
Fatchett, Derek	Michie, William
Faulds, Andrew	Mikardo, Ian
Field, Frank (Birkenhead)	Millan, Rt Hon Bruce
Fields, T. (L'pool Broad Gn)	Miller, Dr M. S. (E Kilbride)
Fisher, Mark	Morris, Rt Hon A. (W'shawe)
Flannery, Martin	Morris, Rt Hon J. (Aberavon)
Foot, Rt Hon Michael	Nellist, David

Oakes, Rt Hon Gordon	Skinner, Dennis
O'Brien, William	Smith, C.(Isl'ton S & F'bury)
O'Neill, Martin	Smith, Rt Hon J. (M'kl'ds E)
Orme, Rt Hon Stanley	Snape, Peter
Owen, Rt Hon Dr David	Spearing, Nigel
Park, George	Steel, Rt Hon David
Parry, Robert	Stewart, Rt Hon D. (W Isles)
Patchett, Terry	Stott, Roger
Pavitt, Laurie	Strang, Gavin
Pendry, Tom	Straw, Jack
Penhaligon, David	Thompson, J. (Wansbeck)
Pike, Peter	Thorne, Stan (Preston)
Powell, Raymond (Ogmore)	Tinn, James
Prescott, John	Varley, Rt Hon Eric G.
Radice, Giles	Wainwright, R.
Randall, Stuart	Wallace, James
Redmond, M.	Wardell, Gareth (Gower)
Richardson, Ms Jo	Wareing, Robert
Roberts, Ernest (Hackney N)	Weetch, Ken
Robertson, George	Welsh, Michael
Robinson, G. (Coventry NW)	White, James
Rogers, Allan	Wigley, Dafydd
Rooker, J. W.	Williams, Rt Hon A.
Ross, Ernest (Dundee W)	Wilson, Gordon
Ross, Stephen (Isle of Wight)	Winnick, David
Rowlands, Ted	Woodall, Alec
Ryman, John	Wrigglesworth, Ian
Sedgemore, Brian	Young, David (Bolton SE)
Sheerman, Barry
Sheldon, Rt Hon R.	Tellers for the Noes:
Shore, Rt Hon Peter	Mr. Austin Mitchell and Mr. Norman Hogg.
Silkin, Rt Hon J.

Question accordingly agreed to.

Mr. Speaker

forthwith declared the main Question, as amended, to be agreed to.

Resolved, That this House reaffirms its commitment to the National Health Service and to the maintenance and improvement of standards of patient care; congratulates Her Majesty's Government on the progress made over the last four years; and endorses its efforts to ensure the best value for money spent on patient care.

Mr. David Alton (Liverpool, Mossley Hill)

On a point of order, Mr. Speaker. While I accept that many right hon. and hon. Members tried to catch your eye during the previous debate, would the Chair be prepared to look into the problem of Liberal Members not being called today? I know that my hon. Friend the Member for Leeds, West (Mr. Meadowcroft) tried to catch your eye.

Mr. Speaker

Order. If the hon. Gentleman reflects on it, he will realise that that is not the sort of question that he should put to me now. I explained to the House that more than 40 right hon. and hon. Members wished to speak. The shorter the speeches, the more hon. Members I would have been able to call. Unfortunately, some of the speeches were not all that short.