National Health Service

HC Deb 19 January 1988 vol 125 cc824-916

Mr. Speaker

Before the debate on the National Health Service, I must announce that I have selected the amendment in the name of the Prime Minister. I should repeat what I said earlier in answer to a point of order: no fewer than 58 right hon. and hon. Members have written to express their interest in speaking in the debate, and there may be others. Many of them are Privy Councillors, so I make a special plea for brief contributions.

The House has not given the Chair authority to limit speeches to 10 minutes, but it would be helpful if all Back-Bench speeches could be limited to 10 minutes on this motion.

3.43 pm

Mr. Robin Cook (Livingston)

I beg to move, That this House notes that two out of three health authorities anticipate a deficit at the end of the current financial year and that attempts to balance their accounts have produced closures of hospital wards and cancellation of operations; affirms its commitment to the principle of a National Health Service providing comprehensive, free treatment to all citizens on the basis of need, not payment; further notes that current Treasury revenue substantially exceeds expenditure; and therefore calls upon Her Majesty's Government to release additional funds to end the financial crisis in the Health Service, and to drop proposals for new charges for dental examinations and for eyesight tests. This is the second occasion on which the Opposition have named health for their Supply debate within the past two months. I wish to advance three reasons why we took the view that it was not only appropriate but essential that the House should have an opportunity to return to this vital matter today.

The first reason is the evidence, accumulating since we last debated the issue only two months ago, that the NHS is currently in financial crisis. Indeed, the weight of evidence pointing to that financial crisis is now so massive that even the Law Officers of this Government must be considering advising their client to plead guilty. May I produce the witnesses who have come forward in the past two months since we debated the issue to confirm the state of crisis in which they have to operate?

The first witness is the chairman of the consultants' committee of the British Medical Association. Last month he announced that that committee was setting up a survey of the acute specialties and he said: The acute sector is falling apart at the seams. The director of the Association of Community Health Councils published its survey only this month. That survey showed that 56 out of 113 health authorities proposed to close wards — some of them entire hospitals — in this financial year. The director stated: Unless there is action now, some parts of the NHS, already on the brink of collapse, will simply fall apart during 1988. In Oxfordshire, 296 general practitioners signed an advertisement opposing the closure of 140 beds. That advertisement said: These cuts will cause considerable suffering and very possibly hasten death in some patients. Consultants at St. Mary's hospital, Paddington wrote to the press saying: We have a duty to inform the public that the fabric of the NHS is crumbling about us. Consultants at the Birmingham children's hospital wrote to the press stating that they now turn away 30 acute cases every week, and added: We no longer accept that this service is safe in the Government's hands. Most damning of all was a statement, not by any doctor or any nurse or even by Brian Redhead of the BBC, but by the hospital manager of the Manchester royal infirmary last week. He wrote to the 2,500 employees of that hospital advising them that he could no longer pay for drugs and that, by the end of the financial year, he may no longer be able to pay for their wages. He added: To all intents and purposes we are bankrupt. If we were a commercial organisation we would have gone into voluntary liquidation". The Government pride themselves on introducing a commercial ethos into the NHS. They have now achieved a new first — they have introduced the concept of bankruptcy into the NHS. Looking at the amendment in the name of the Prime Minister and her colleagues, I am astonished that it has the nerve to express their support for the dedicated staff of the NHS. If the Government have such respect for the staff of the NHS, they should listen to what those staff are saying to them day after day.

In truth, in the past two months, the Government have sought to pin the blame on the very staff who work in the NHS. Last month, it was the fault of the consultants. Bernard Ingham, the true voice of the Government, briefed the press on the basis that too many consultants were nipping off to do private practice. I find it breathtaking that the Government, who have done everything possible to encourage consultants to do more and more private practice, should now identify that as their excuse. In 1980, the Government even changed the consultants' contracts so that those full-time NHS consultants might carry out private practice in the time when they are paid a full-time salary by the NHS. However, I welcome the Government's repentance and their belated recognition of the fact that, if one extends private medicine, the people who are neglected are the patients on the NHS waiting lists.

Such private practice by consultants is not the major source of the current crisis. At present, all round Britain, health authority managers are telling consultants to slow down and to cut their output. They are being told to go off to the golf course, do a spot of gardening, do anything but increase the rate at which they operate on their waiting list. Indeed, at the Queen Elizabeth hospital in Birmingham some surgeons have been instructed to carry out 10 per cent. fewer operations next year than this year.

Last week a new culprit was discovered. The right hon. Member for Chingford (Mr. Tebbit), who is to grace us with a speech in this debate, discovered that it was not the consultants but the nurses who were to blame—with a little help from the BBC. The right hon. Gentleman informed us that too many nurses were moonlighting. There is a fat lot of support for the dedicated staff of the NHS in that statement. I am not entirely sure that I follow the right hon. Gentleman's logic. Presumably, if those nurses stopped moonlighting, the staffing crisis in our hospitals would be even worse. However, I bow to the right hon. Gentleman's superior knowledge of moonlighting.

Mr. Norman Tebbit (Chingford)

If the hon. Gentleman had listened to what I said, he might have perceived—although it is doubtful, as his abilities in that respect are limited—that my objection was to the crazy system in the Health Service which frequently precludes nurses from working overtime in their own hospitals but allows them to work overtime as agency nurses in another hospital. While a nurse is doing that, a girl from a second hospital is busy working overtime as an agency nurse in her hospital. That is my objection.

On moonlighting, Opposition Members might benefit from doing a little themselves. It might add to the debate if we had a bit more moonlighting and a little less moonshine.

Mr. Cook

I would acquit the right hon. Gentleman of the charge of merely having moonlighted. Since he retired as chairman of the Conservative party, he has gone through the whole galaxy of night-time work. On the explanation that he has offered of his speech on Friday, I am bound to say that if that was what the right hon. Gentleman intended to convey to the press, he signally failed to choose the correct words to put his message across.

Furthermore, NHS nurses do not fail to do overtime in their own hospitals. If the right hon. Gentleman had followed the documents that have been cascading from the professional bodies for the past two months, he would have seen the survey carried out at the request of the Royal College of Nursing by independent surveyors, who discovered that 60 per cent. of nurses did an average of five hours a week unpaid overtime in their own hospitals. Those are the people whom the right hon. Gentleman maligns.

At the weekend, the nurses were superseded by a new culprit. I was distressed to read that my opposite number, the Secretary of State, is now being fingered as the culprit. I feel a personal sense of involvement in seeking to acquit the Secretary of State. I am glad to see him back at the Dispatch Box and looking so well. It is as well that I should put that on the record, because it is not immediately apparent that all his colleagues feel the same. The charge being made in the alcoves of the Westminster bars is that he has created chaos out of order single-handedly and in seven months—taking two months off for illness the while. Think what he could have achieved had he remained in good health throughout the seven months. It is a ludicrous charge. The crisis that has erupted in the past few months has been years in the brewing.

Yesterday, I took part in a radio package in which the hon. Member for Reading, East (Sir G. Vaughan) also participated. The hon. Gentleman was Minister for Health during the first three years of this Government's period in office. I praise him for his refreshing candour and honesty. On "The World at One" yesterday the hon. Gentleman said: We have known this would be crisis year since 1981. They knew it was coming. They did nothing to avert it. They deliberately planned the financial squeeze that gave rise to the current crisis.

I have no doubt that we shall again hear figures showing the growth in the NHS budget. I invite right hon. and hon. Members to bear in mind that one third of that increase took place before 1981 and was almost entirely attributable to the Clegg awards. Most of the increase since 1981 has taken place outside the hospital sector, among the family practitioner services, which are, of course, demand-led. We can see what would have happened to expenditure on those services had they been cash-limited by looking at what did happen to the hospital sector during the same period. In 1986, the Select Committee on Social Services reviewed the hospital budget between 1981 and 1986 and concluded that, in volume terms, the increase was 3.1 per cent. over the entire five years.

The Minister for Health has answered a question pointing out the demographic pressures on the hospital budget and quantifying it in percentage terms. During those same years, when the hospital budget increased by 3.1 per cent., on the Minister's own figures, demographic change added a 4.3 per cent. burden to the hospital sector alone. We do not have a report from the Select Committee for 1987, but it is possible to update those figures. Indeed, the King's Fund has done so and has identified a 3.4 per cent. increase in volume terms over the six years 1981–87 and a 5.4 per cent. increase in the pressure from demographic change during the same period.

Demographic change is racing ahead by two thirds of the increase in the budget of our hospitals. That is why they are now in crisis. That is why wards are closing and patients are being turned away. However, these are statistics that the Prime Minister has chosen not to use in her weekly exchanges with my right hon. Friend the Leader of the Opposition.

Mr. Eric Forth (Mid-Worcestershire)

Will the hon. Gentleman give an undertaking that, if the Labour party is elected to government in the future, it is prepared to commit sufficient funds to the National Health Service to eliminate waiting lists totally? If he is prepared to give that undertaking, which flows from the logic of his argument, will he estimate the cost of that? If he is not prepared to give that undertaking, will he tell us which elements of the waiting lists he is prepared to live with and which he would prefer to eliminate?

Mr. Cook

Only last week, my right hon. Friend made a clear statement of the five points that we are putting forward as our commitment to the NHS. Those commitments have been costed. They mean making good the reduction in expenditure in the hospital sector during the past six years. They involve a planned and controlled expenditure increase to reduce waiting lists, rather than the ad hoc, one-off cosmetic gestures that we get from the Government.

There are other statistics which the Prime Minister chooses not to use, which shed a different light on the record of her Government. However, those statistics occasionally slip out when the guard is down. My hon. Friend the Member for Huddersfield (Mr. Sheerman) obtained an interesting answer last week, which showed that expenditure on nurse training has decreased from £479 million in 1979 to £439 million in 1986. That is one reason for the staffing crisis in our hospitals.

There are also the accelerating figures on bed closures in acute specialties. During the Government's first three years, we lost 5,000 beds for acute specialties. I concede straight away to the Secretary of State that that was more or less on trend with the long-term decline in the number of beds for acute specialties.

Mr. Tony Marlow (Northampton, North)

Will the hon. Gentleman give way?

Mr. Cook

No, I shall continue my speech.

During the next four years, we lost over 10,000 beds for acute specialties and last year we lost 5,000 acute specialty beds. That is three times the rate for the figure for only eight years earlier —[Interruption.] I am asked about waiting lists. Well, the waiting list for March 1987 was 15,000 higher than for the year before. We do not yet have the figure for September 1987 but, so far, every waiting list figure for September under this Government has been higher than any September figure under the previous Labour Government.

We also have the figures for infant mortality. Last year, alone among Western nations and for the first time since 1970, infant mortality increased in Britain. When the Prime Minister was taxed about that a fortnight ago, she was so shocked by the increase that for once she lost her confidence in statistics and said: It may well be that it is a statistical error."—[Official Report, 12 January 1988; Vol. 125, c. 141.] I am afraid that there is no statistical error. However, I can say that the Prime Minister was absolutely right to point out that the increase did not take place in the first four weeks after birth—which is the period of intensive medical care — but in the subsequent 11 months, between the first and the 12th month of life: the post-neonatal period. I have before me a press statement by Peter Pharoah, professor of community health at Liverpool university, who said: Post-neonatal deaths are much more affected by social factors such as unemployment, housing conditions, low income". That brings us to another set of statistics about the present Government. Survey after survey shows that unemployment makes people ill. The unemployed are 40 per cent. more likely to suffer from cancer, and 200 per cent. more likely to commit suicide. Even the wives of unemployed men have a higher mortality rate, and their children have a higher infant mortality rate. The current rate of unemployment, in the calculation of the British Medical Journal, causes an additional 3,000 deaths a year.

If the Government wish to trade statistics, there are plenty with which we can cap any that they produce. Ultimately, however, the trading of statistics is an exercise as sterile as any operating theatre in the National Health Service. Whether the position is better or worse than in 1979 is an argument of obsessional interest to professional politicians, and to just about no one else. People outside this Chamber see their wards closing and their operating theatres being shut down. They see a real problem, and they want to hear a solution to it. They may well have the wit to work out for themselves that those wards and operating theatres stayed open throughout the period of the last Labour Government. However, they are not interested in comparisions with the past; they want to know what plans have been made for the future.

That brings me to the second reason for returning to the issue. It is now clear that the Government are planning on the expectation that the coming year will be even worse than the one that we have just been through. On 18 November, the two junior Health Ministers met the regional health chairmen in Cambridge. One of the chairmen said afterwards: The chairmen went in to hang the table and make sure ministers understood just how bad things are out there There wasn't any need. The two Ministers just acknowledged it and said in effect it was going to get worse". I have with me the letter that the Minister for Health subsequently sent to the chairmen of the regional health authorities. I do not believe that he has yet placed it in the Library; perhaps he will do so after the debate. The letter is, of course, beautifully crafted by some civil servant and written in coded terms, but it is not difficult to break the code and decipher what is meant by the "need for realism" or more rational use of resources". Paragraph 3 of the letter makes it clear that there will not be a penny more for 1988–89, while paragraph 6 states that there will be the same pressure for cost improvement programmes in the next year. The Minister accepts that some of the more obvious things have now been done and that attention will increasingly need to be given to the cost effective use of clinical resources. In other words, cost improvement programmes will shift this year from ancillary services to patient care.

Paragraph 8 makes it clear that the health authorities must plan on the expectation that pay increases will not be fully funded this year: Authorities will therefore need to plan flexibly and recognise that they may well be called on to meet some pay and price pressures in 1988/89. For "may well", we may read that they can bet their bottom nurse that that will happen.

I have a letter from the North-West regional health authority, which was sent out following that circular, instructing every district health authority in the north-west to cut its real budget by 1.5 per cent. next year. That of course includes Manchester royal infirmary. All the chairmen in the Yorkshire health authority area were summoned to a meeting with the regional chairmen on Friday, and instructed to cut their budgets by 1 per cent. in the next financial year. I have before me the papers put before Bloomsbury district health authority last week, which show that, in the coming financial year, there will be an additional shortfall of nearly £3 million.

Mr. Max Madden (Bradford, West)

My hon. Friend referred to Yorkshire. Is he aware that Bradford health authority, in a document that was leaked this week, is shown to be planning to cut health services by more than £3 million over the next two years. The infant mortality rate in the city is twice the national average, and the authority plans to close a maternity unit. Heart illness is way above the national average, and it plans to cancel the appointment of a second cardiac specialist.

The overwhelming majority of people would forgo tax cuts to improve and defend their local health services. What message has my hon. Friend for the people who want a better Health Service, and not more tax cuts? How will he persuade the Government to take that message on board?

Mr. Cook

When my hon. Friend allows me to resume, I shall try to ram that message home. The point that he makes underlines the statement by the British Cardiac Society only last week that 10 million people are living in district health authorities with no cardiac specialists in the hospitals. We are told that the response to the problem—

Mr. Tony Favell (Stockport)

Will the hon. Gentleman give way?

Mr. Cook

No, I shall proceed with my speech if I may.

Mr. Favell

I want to take up a point that the hon. Gentleman has just made.

Mr. Cook

If the hon. Gentleman will bear with me, I am sure that he can aspire to catch your eye, Mr. Speaker.

We are told that the response to the problem is that expenditure must be more cost-effective, but the way in which we are managing our hospitals at present is ludicrously cost-ineffective. Whole operating theatres are standing idle because they cannot afford the marginal cost of operations. These may be cuts, but they are not savings. They represent waste on an extravagant scale: wasted investment, wasted technology and wasted skills. If we are going to bring those skills and investment back into use, we need extra resources.

Mr. Favell

Will the hon. Gentleman give way?

Mr. Cook

No, I shall not give way to the hon. Gentleman: I have made that perfectly clear to him. He is plainly not interested in hearing what I wish to say to him, and I therefore doubt very much whether he will listen to my reply.

For a moment last week, a light flickered. The Secretary of State met the three presidents, who emerged to say that he had discussed with them extra resources for the NHS. The very next day, the Chief Secretary puffed out that light: the Government would not budge from the commitment that they had made in the Autumn Statement.

The Secretary of State will know that, when he replies to this address, he will have to explain who has got it right. Was the Chief Secretary folded up in a corner of the office keeping notes while he met the three presidents, or were the three presidents right when they emerged to say that their fears had been allayed?

There is, of course, a weasel way out. The statement claims that there was a recognition of the need for extra resources. Perhaps the Secretary of State proposes to take the line that he recognises the need for extra resources, as long as they do not come from the Chancellor of the Exchequer. Let the money come from alternative funding, from income generation or from lotteries — anywhere but from the Government.

We now come to the interesting rhetorical body swerve that Conservative Members keep practising. Whenever they are pushed into a corner to admit the inadequacies of public funding, they start talking rapidly about private funding. But private funding of the NHS has nothing to do with value for money. The Government's handling of private pay beds has been a first-rate commercial disaster. They have increased private pay beds in our hospitals by a quarter, and, during the same period, the number of patients in those beds has fallen by one fifth. The total bad debts of the NHS from private patients has escalated every year, and now stands at £11 million—more than the Government anticipate that they will gain from income generation. In the light of that experience, only a Government who had smashed the learning curve could persist in the delusion that a financial problem can be solved with more pay beds.

Mr. Edward Leigh (Gainsborough and Horncastle)

Will the hon. Gentleman confirm that it is Labour party policy to end pay beds at a cost of some £60 million and, incidentally, to end competitive tendering at a cost of £100 million? Does he agree that such dogma resulted in the pay of nurses falling for three years out of four under the Labour Government?

Mr. Cook

If the hon. Gentleman wishes to talk about dogma, let us consider dogma. Let us look at the instruction from the Minister of State to the West Midlands regional health authority that it can have £250,000 to buy private operations in private hospitals, but only to buy private operations and not to spend in its own hospitals. It is a sort of Health Service parallel to the assisted places scheme. On inquiring of BUPA, the health authority discovered that a hip replacement operation in a private hospital would cost £700 more than in its own hospitals and that a hysterectomy would cost £400 more.

Meanwhile, in Wolverhampton the regional health authority has so starved the district that it has closed the operating theatre for the orthopaedic ward. All hip replacements in Wolverhampton have ceased. To save what? To save a sum that is actually less than the amount that the Minister of State offered to the west midlands, earmarked for the purchase of orthopaedic operations in the private sector.

If the hon. Gentleman wants a little dogma, I can think of no clearer and finer illustration than paying over the odds to subsidise the private sector while forcing the closure of identical facilities in the NHS. That has nothing to do with cost-effectiveness but it has everything to do with political dogma.

That brings us to the heart of the debate between ourselves and those on the Government Benches. In truth, this is not a debate about public spending priorities; it is a debate about political values. The reason the NHS is under siege is that the Government's vision of a private enterprise society cannot tolerate the contradiction of a public health system that is more efficient and more comprehensive than its private sector competitor.

Those who sit on this side of the Chamber have the advantage of being able to see the Prime Minister's face, so we notice a revealing feature that may be lost on those who sit behind her. Whenever the Prime Minister recites the extra spending on the NHS under her Government, she does not do it with pride, satisfaction or relish; she does it with self-evident resentment. In her eyes, the NHS commits two fatal offences. The first is that everyone is equal, regardless of ability to pay. The second is even worse than the first: the service is actually popular because of that.

I do not know whether the right hon. Member for Brent, North (Sir R. Boyson) is with us today. The right hon. Gentleman has participated in exchanges on this subject outside the House. I particularly relished his speech on the fringe of the Conservative party conference last autumn, when he advocated an insurance system, with the Church of England catering for those who could not afford insurance. That does not seem an adequate solution for those who live in Scotland.

The right hon. Gentleman expressed the difference between our parties very well, I thought. He is on record as saying: The problem with the National Health Service is that there is no link between what people pay and what they receive, and no way of influencing what they receive by what they are prepared to pay. The right hon. Gentleman sees that as a problem. We see it as a strength of the NHS. Having glimpsed that gulf of political values between us, I think we can understand why the NHS is in financial crisis and why it will be kept in financial crisis. What we see as a crisis of the NHS some Conservative Members see as an opportunity to claim that the NHS cannot deliver and as an excuse to dismantle a service that they never liked. How else can we explain the persistent refusal to give it more funds, when we all know that the Chancellor's wallets are as ample as his presence?

That brings me to the third reason why it is important that the House debate the matter again. It is more than ever transparent that the Government can afford to fund the NHS. I note that The Times today quotes a Whitehall source as saying that the Secretary of State's argument will be If you haven't got it, you cannot spend it. Possibly the Whitehall source, who may be with us, would stand up and disclose himself so that we may see who is responsible for that wonderful observation.

The fact is that, in terms of financial resources, the Government have got the necessary funds. The Chancellor would need a JCB to cart the current Treasury surplus around Whitehall. Only today the Treasury, with impeccable timing, released the public sector borrowing requirement figures, which show that the PSBR is now a minus figure; that is Treasury language for being in surplus. There is a surplus of £400 million rather than a planned deficit of £4,000 million. Greenwell Montagu estimates that next year the surplus could be £11,000 million.

Perhaps I may dampen the enthusiasm of hon. Members on the Government Benches. Greenwell Montagu might not be spot on. Suppose it is wildly wrong. Suppose it is only half right. Suppose the surplus is only £5,000 million. That would still be enough to cut tax by the 2p beloved by the Chancellor and to give £2,000 million more to hospitals.

We saw on "Weekend World" that the Harris poll discovered that 68 per cent. of Conservative Back Benchers would rather see tax cuts than increased spending on the NHS. Those hon. Members need agonise no more. They can have both their passion for tax cuts, without any nagging doubts as to whether they are being faithful to the wards back home, and more expenditure o n the NHS. If Greenwell Montagu is more wrong and if there is only a quarter of that sum, there can be no serious doubt that if the Government have to choose, this year the priority must be not tax handouts but rescuing the NHS.

Mr. Robert McCrindle (Brentwood and Ongar)

rose—

Mr. Cook

No; I am moving to my conclusion.

If there is any doubt, may I conclude by reflecting on the people whose health and hopes are in our hands when we vote tonight? The most remarkable feature of the past year has been that tens of thousands of operations have been cancelled. No one knows how many, because no statistics are collected nationally. No one ever cancelled operations en masse before. We know that all districts have been postponing non-emergency operations until the next financial year. One district alone has cancelled 3,500 non-emergency operations.

Who are the patients who are non-emergency cases? They are patients in pain from hernias, patients going immobile from arthritis, patients who know that their hips will deteriorate and that the operation will be more difficult when they get it, patients going blind—like the lady I met at the weekend who waited six months for the first examination for cataract, only to be told that she had another nine months to wait for the operation. They are patients with cancer, consumed with anxiety by the knowledge that the longer the operation is delayed, the less chance that it will be in time to be successful. There are also the parents whom my right hon. Friend the Leader of the Opposition and I met yesterday, driven to distraction by worry that the next time their child is called for operation it may be cancelled as it was last time.

Time after time in the last few months, consultants have said that it was not reasonable, fair or just that they be asked to decide who gets an operation and who does not, who dies and who lives. Ultimately we decide whether those patients will get their operations. It is our responsibility. This year the Chancellor of the Exchequer has the money to ensure that we get a National Health Service that can deliver to its patients. Tonight the House will have the opportunity to instruct him to make those patients his top priority.

4.20 pm

The Secretary of State for Social Services (Mr. John Moore)

I beg to move, to leave out from "House" to the end of the Question and add instead thereof: applauds the achievement of the National Health Service in providing a record level of patient care; recognises that this achievement rests on the substantial additional funds from the taxpayer which a strong economy has made possible and which has supported the dedicated work of the National Health Service staff; and welcomes the Government's continued commitment to the most effective use of all the Service's growing resources to bring about a further rise in the standard of health care, both in hospitals and in the community". May I start by genuinely thanking the hon. Member for Livingston (Mr. Cook), my "shadow", for his kind remarks with regard to my illness. He and I have known each other for many years and I am always conscious of his continuing courtesy and personal politeness, and I do appreciate it.

Having said that, I know that the House, as I think both I and the hon. Gentleman would wish it to, will treat a subject of this importance in the 40th anniversary year of the National Health Service with the serious, rational and thoughtful tone that it clearly needs. Health—or illness, as I certainly know to my personal cost—arouses deep emotion, but we will not find long-term solutions in emotion alone. It will require clear thinking. And above all—and I stress this in the light of the remarks that the hon. Gentleman finished with — it will require a successful economy.

May I start, therefore, with the fundamental point that good health needs and must have a successful economy. That has been the essence of the argument of the hon. Member for Livingston and of his right hon. and hon. Friends in the past few weeks. They have argued that the only answer—and they have put it in the motion in terms of a "financial crisis" — is essentially to spend more public money. They want more, that is, than the increases that we have provided and more than the increases we have promised. It is the only answer that they have offered. The awful, fascinating and terrifying thing for them is that that is the only offer we know they cannot deliver if, ever again, we have the tragedy of having them in office.

I know full well and accept entirely, because they are not dishonourable men and women, that they do not mean to hurt the Health Service, and never intended to do so when they were last in office. But when the economy collapsed in their period of office, let me first remind the House of the priority they put on health care, and their attitude towards staff. I will come to the contrast with our attitude afterwards. Let me remind the House of the way in which they handled future investment in the NHS and their responsibilities when in office. First, public spending on the Health Service fell from 5 to 4.7 per cent. of GDP while they were in office.

Miss Marjorie Mowlam (Redcar)

Will the Minister clarify that health expenditure next year will fall as a percentage of GDP under this Government?

Mr. Moore

No, I will not. In a little while I shall explain precisely the increases, as the hon. Member for Livingston asked me to do. I shall also go beyond the GDP decline and specify them for the Leader of the Opposition when I come to comparisons with the Government's period of office. I shall specify the actual amount of money we are talking about, and deal with the way in which Labour treated Health Service staff. Opposition Members are concerned quite rightly about staff, because they are a key ingredient in the success of the Health Service.

Ancillary staff had their incomes reduced in real terms in the five years that Labour were in office by 4.8 per cent. Administrative and clerical staff had their incomes reduced in real terms by 14.4 per cent. For doctors and dentists, the decline was 22.4 per cent. in real terms. Nurses had their pay cut in real terms for three years running, and in 1976–77 by no less than 10 per cent. in real terms. In the five years to 1979, nurses had a reduction in pay of 21 per cent.

I shall come to the comparisons with our record in a moment. I said that there were three pillars on which I wanted to compare the record before going on to deal with patient care. The third of those is investment in the future. I and many of my right hon. and hon. Friends have sat in the House when investment in the capital of the National Health Service was slashed by 30 per cent. in real terms. Is this a record of which the Opposition are proud?

What is the contrast to that appalling record that they have the temerity to criticise in this Chamber? I stress again that because of our successful management of the economy we have a bigger GDP to help finance our health services. Let us examine our priorities, because that is the key question. First I shall deal with the percentage of GDP we have spent. I shall come then to the specific questions fairly asked by the hon. Member for Livingston in relation to his comments in the newspapers.

I remind the House that the GDP percentage declined from 5 to 4.7 under Socialism. What has happened since? It has increased from 4.7 per cent. and not to 5 per cent. but to 5.4 per cent. of GDP, so the percentage of a greater GDP has increased. That is why we are able to spend such enormous additional amounts of money. I am not yet dealing with the points made about pressures, but with the actual amounts of money, quoted time and again, the increase of 33 per cent. in real terms.

Just suppose for a moment that we had had the tragedy, with or without North sea oil, of having the Opposition in office for the past eight and a half years, with the same increase in the size of the economy that we have achieved and 4.7 per cent. growth in GDP, which is the Opposition's chosen priority as a percentage. How much less would have been spent today, or in this year or last year? Spending would not have been £21 billion, but £18.1 billion. They would have spent £2.9 billion less, even with their own sense of priorities.

What about staff, who are treated so appallingly? I did say, Mr. Speaker, that before I dealt with staff I would cover the specific points made by the hon. Member for Livingston about what he thought was the difference between my views and those of my right hon. Friend the Chief Secretary to the Treasury. There is no difference at all; quite the reverse. People are able to do even basic calculations and consider matters post my party conference speech. Even though we now have the listening party sitting opposite, they do not necessarily spend their time listening to Conservative party conference speeches; but in my speech I made it quite clear that resources for the Health Service must increase.

What has happened since then? In the public expenditure round that was recently announced, there were the increases that had been planned before the general election, with £1.1 billion of further increases, which is £700 million more than had been planned. There were those increases, which I referred to in my meeting with the presidents of the royal colleges, and which were referred to by my right hon. Friend the Chief Secretary, and rightly, as the hon. Member for Livingston says, moneys that will come from the cost improvement programme and additional moneys that we hope will come from an increase in resources from the private sector.

Those figures have been tabulated, and we can consider the totals and calculate what has been spent in the past and what will go into health care next year. It might be of help to the House to know what they are. The total gross increase for 1988–89 in real terms will be 2.1 per cent. If we add to that the extra resources expected to come from CIP, that will be 3 per cent., which is far more than most of the Opposition have argued for. I am assuming those additions on the simple basis of the very good experience of the past few years.

Ms. Joan Ruddock (Lewisham, Deptford)

I should like to ask the Minister, despite what he is saying about increases, whether he can explain the paradox of my own local district health authority? As a result of the extra moneys that were given to maintain services, which I suggest is an admission of gross under-funding, those sums of money will enable us at the end of this month in theory to open closed wards. But we cannot employ the nurses to staff those wards and, indeed, we shall be forced to close wards again at the end of the financial year. Even the increases that the Secretary of State has announced for next year will not enable us to keep those services in existence.

Mr. Moore

Before I comment on the specific point, the hon. Member for Livingston would not, I know, want me simply to talk about the increases within the National Health Service as a whole, because he rightly tried to distinguish between the acute care hospital sector and the National Health Service, while acknowledging that there had been massive increases in real terms in the primary health care services. If one just looks at the HCHS and at the total gross increase in the coming year, excluding the CIP programme expected yield, that will be an increase in real terms next year of 2.2 per cent., including the cost improvement programme at 3.4 per cent.

To be specific, the hon. Member for Lewisharn, Deptford (Ms. Ruddock) shares the dilemma of the RAWP disadvantage that many of us, including myself, who live within a Thames region have faced since 1977. Hon. Members who had experience and responsibility at the time will recognise the nature of the change, the reduction in the population and the problems associated with the Metropolis with regard to the attraction of' staff.

Several Hon. Members

rose—

Mr. Moore

I know that a very large number of Members wish to speak. I have given way so far and I would like to get on as I have quite a few things to say.

Mr. Favell

Is it not also the case that within the acute sector the performance of hospitals varies enormously? I draw my hon. Friend's attention to some figures recently published by the North-West regional health authority, which show that last year the cost of an in-patient case at Stepping Hill general hospital was £605.28, yet at north Manchester general hospital, where NUPE had recently been on strike, the cost per in-patient case was £1,107.33.

Mr. Moore

I am very grateful to my hon. Friend. I was planning to tackle that particular point later.

I was comparing the percentage of gross domestic product spent on health care. I then wanted to compare the appalling record of the Labour Government with my own Government's record in regard to improving the remuneration of staff. We have heard many times in the House, and I will not burden hon. Members by repeating them, the figures of staff increases, but I think it especially important to remind the House how those dealing directly with patients have increased as a proportion from 59 to 65 per cent.

In particular, I think that the record on the pay of nurses merits attention compared with the appalling record of the Opposition when in office. We have not simply established the proper pay arrangements through the pay review body; we are seeking to establish a pay arid grading structure for nurses and midwives which recognises the particular individual's skills and responsibilities. I know that all hon. Members will be particularly pleased that the Nursing and Midwifery Staffs Negotiating Council has reached agreement on the new grading definition, which has been sent to the review body.

The third point that I said I wanted to touch on was investment in the future of the National Health Service. The building of the new NHS from the appalling slashing of programmes that existed when we took office has been proceeding massively in the last eight years. As opposed to a reduction of 30 per cent., we have seen an increase, in real terms, of 40 per cent. We are now running a programme where we are spending £1,000 million a year on building the new NHS in the United Kingdom. All of this shows what can be achieved with a successful economy under our Government in contrast to the failure of the economy under Socialism.

I now want to illustrate, because I think that this is what many hon. Members would want me to do, what, at the end of the day, this means to patients. This, surely. is what we are all talking about. What these resources and the enormous efforts that the National Health Service staff have put into improved efficiency, which must be recognised, have meant in terms of patient care is quite staggering. To describe the service as being on the point of collapse, in the light of these figures, is really appalling.

The achievements of the service, as my right hon. Friend the Prime Minister said last week—[Interruption.] I seem to have heard an interruption from a sedentary source asking why I did not use it. Happily, throughout my adult life, I have been able to benefit from the NHS, whether in Whittingham hospital, University College hospital or St. Thomas' hospital, and I am not sensitive in any way. I would assume that the listening party would like to listen to the end of these remarks.

Every member of my family has used and continues to use the NHS. I shall never forget the debt that I owe to the St. Helier hospital, where my mother died of cancer. I shall never forget the treatment that the doctors and nurses gave. But it is a bizarre feature of the world in which we now live that, because, as a consequence of my experience and knowledge, I was willing for many years, along with my wife, to pay less than I paid when I used to smoke as a modest contribution to the premiums of a non-profit-making organisation, when I chose this time not to burden the Health Service, not to force myself upon it, somehow it is regarded as wrong. That is one of the reasons why this country will never again elect the present Opposition to office.

Our great National Health Service deals with six inpatients for every five in 1978, 11 out-patients for every 10 in 1978—these are the realities for the constituents of Opposition Members—and nearly two day cases for every one in 1978. Those are the patients who are now receiving treatment in our acute care hospitals.

Mr. Robin Cook

rose—

Mr. Moore

I will continue for a little while, if I may.

There is not just more treatment, but better and more complex treatment. For example, many of us know that the first coronary heart bypass operation took place in the United Kingdom in the mid-60s. Three such operations are now being done for every one in 1978. Members of the Opposition do not want to hear the facts.

Mr. Cook

rose—

Mr. Moore

I will give way in a minute, when I have completed these figures because these are the figures of real patient care—[Interruption.]

Mr. Speaker

Order. Let us get back to the debate and the arguments, not personalise it.

Mr. Moore

Five treatments are being given for chronic renal failure for every two in 1978. Four hip replacements are being done compared with three in 1978. We are doing not only double the kidney transplants that we were doing in 1978, but more than any other European country. There were 30 bone marrow transplants in 1978; there is nearly one a day now. It is the Opposition, in the face of the reality of the great achievements of the National Health Service, who have lost their way. Finally, there were three heart transplants in 1979—in the whole year—but 176 in 1986, as well as 51 heart-lung transplants. Those are the figures of our NHS today.

Mr. Cook

If the Secretary of State is resting his case on the situation in our hospitals being so much better than it was under the Labour Government, can he explain to the House why during that Labour Government it was never necessary for the presidents of the royal colleges to go and see the then Secretary of State; it was never necessary for 1,000 consultants to go and see the Prime Minister; it was never necessary for general practitioners to pay for advertisements warning their patients what was happening to them; and it was never necessary for the BMA to set up a survey of acute specialties?

Mr. Moore

I will, of course, come to the way forward and the points on demography in a second but, since memories seem to be failing here, I will remind the hon. Member of what happened in 1978. On page 115 of Lord Donaghue's book, he said — and I believe that it is relevant—that in 1978 Mr. Callaghan again sought ways to justify providing extra funds to the National Health Service and asked David Ennals to produce a paper on the NHS crisis. Beyond that, morale in the NHS was falling in March 1978. I can give chapter and verse and quote after quote. The British Medical Association chairman said that a big injection of money was necessary to resuscitate the NHS. Nurses said that Lack of money prevents patient care and that it led to the NHS crisis in August 1978. It is almost beyond belief for the Opposition to have the temerity not to remember the winter of discontent in 1978–79.

The statistics are not just bald statistics. They affect millions of families who have benefited each year from our hospitals and many patients whose quality of life has been improved by operations scarcely possible a decade ago. The hon. Member for Livingston asked why, despite this success story, the service is still under such pressure.

Mr. Kevin Barron (Rother Valley)

rose—

Mr. Moore

I wish to deal with this point. It is a legitimate matter to address.

Despite the increased efficiency and the increases that we have promised for the future, we must consider three factors before we can consider the way forward. We must see these factors as opportunities rather than problems. They relate to demography, to medical technology and its changes and to what some of my hon. Friends have been calling from a sedentary position the legitimate rising expectations of a more affluent society.

The picture is not unknown to most hon. Members who consider seriously the dilemmas that we face in western society. Happily, we are living longer. The over-75s have doubled since 1951. The over-80s will double by 2011. The implications for the National Health Service are enormous. As we grow older, demands on the Health Service increase disproportionately. When we realise that 54.6 per cent. of NHS beds are used by the over-65s the dimensions of the problem are better understood. Technology is not a problem, but an opportunity. I fully accept that point. The reality of increased patient care is a reflection of that.

The second feature of the inter-relationship of that change in demography is the total and wonderful change in medical technology which has enabled us to investigate, diagnose and treat conditions that would have been ignored or left dormant in the recent past. In addition to that new technology, there are rising expectations about what the NHS can provide and legitimate changes in the consumerist attitude of an affluent Britain.

Mr. Barron

rose—

Mr. Moore

In an affluent Britain, consumers want more choice and expect to get the kind of choices that we are seeking to provide.

What, then, is the way forward? We must remember that the key to our policy must be a successful economy generating the wealth that allows us to continue the increases in resources that we have provided and promised, if we are to satisfy the legitimate public expectations of health care. I wish to concentrate on six matters beyond the basic improvement of the economy.

Mr. Barron

rose—

Mr. Moore

We must improve and enhance the service in the face of technology, demography and rising expectations. We must press on for greater efficiency. This is not simply a matter of being a good accountant. It is a matter of trying to use valuable resources in health care and nobody should want anything different.

We must acknowledge and give great credit to the Health Service for what it has already done in this matter. The cost improvement programmes have radically improved the way in which it can add money to health care. As a consequence of the cost improvement programme, £1.3 billion is now the cumulative addition to health care. We have streamlined the service by abolishing area health authorities and we have introduced general management which is beginning to produce major improvements. We have introduced competitive tendering which is saving £100 million a year, which will go into better patient care.

Mrs. Ann Clwyd (Cynon Valley)

I notice that there is one comparison that the Minister has not made. Does he agree that every year, apart from one since the Government came to office in 1979, there has been a decrease in the amount of money spent on nurse training? It is the lack of quality nursing care which affects those who are waiting for hole in the heart operations. Can he explain why the Government have spent less money on nurse training since 1979?

Mr. Moore

It is critical that we address the point raised by the hon. Lady and the nature of the change in demography which has given us a smaller and different pool. It is part and parcel of the way in which we have approached the clinical grading review, about which I am delighted, and of the way in which we consider Project 2000. This is an area of critical training and is a key to the future. I know that the hon. Lady will be helping in this.

I wish to explain what has been achieved beyond the improvements in competitive tendering. There has been a better use of beds. I hate to use the terminology of the accountant—

Mr. Matthew Taylor (Truro)

rose—

Mr. Moore

—but it is important to see the way in which the throughput of beds used has increased by 36 per cent. There has been a dramatic increase in day care. A vital part of this will be the provision of more and better information to doctors about the cost of the treatment that they provide and about the basis of our current resource management initiative.

Mention has already been made of the differences between authorities. When we are discussing the efficient use of resources, we must consider published indicators much more carefully. We now have 450 indicators. The system was established by my predecessor the Secretary of State for Employment in 1983–84 and was first published in the latter part of 1985. We are beginning to see clear benefits from it.

Mr. Matthew Taylor

rose—

Mr. Moore

If we consider the nature of the use of beds, the length of stay and the cost per case, the variations are still enormous. Even when we take into account the differences in the size of districts, geography, population and activity, these figures will help hon. Members to understand the nature of the efficiency gains. When we consider general surgery and the annual number of inpatient cases, the lowest figure of bed use given by one health authority runs at 27·8 per cent. and the highest figure runs at 70 per cent., so there is an enormous difference.

Mr. Matthew Taylor

rose—

Mr. Moore

Equally, the average length of stay of an in-patient in general surgery varies between three and a half days and 11 days.—[Interruption.] Unless we can secure the most efficient use of valuable resources, it is no good putting more resources into health care.

Mr. Nigel Spearing (Newham, South)

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

Mr. Moore

I know that hon. Members will be interested in the facts.

The cost per case — the third level — the annual revenue in-patient expenditure on major acute hospitals in the average district varies between a low of £467 and a high of £1,231. Those figures show the enormous opportunity for improvements.

Mr. Matthew Taylor

The right hon. Gentleman has well illustrated the increased throughput in beds and used it as an example of efficiency, but why have not we had the crucial statistic on the readmission of patients who have been pushed out of hospital and who have had to be readmitted? For example, only a few days ago a constituent of mine, having rescued people from a burning house and been admitted to hospital after he collapsed, was discharged at 3.30 am and had to walk 20 miles home.

Mr. Moore

I shall ask my right hon. Friend the Minister for Health to pursue that constituency case, but at the end of the day in every case the removal of people from hospital is a matter for clinical judgment, not for the Government.

Mr. Michael Morris (Northampton, South)

My right hon. Friend has rightly given some conclusive statistics. Will he take heart from the fact that year in, year out the Public Accounts Committee looks at the NHS and reports that there is further work to be done in those areas?

Mr. Moore

I thank my hon. Friend who has given many years of distinguished service on the Public Accounts Committee.

I said that there were six areas I wanted to pursue as part of the way forward. The second, beyond trying to achieve major efficiency gains, is to encourage health authorities to take full advantage of the income generation powers contained in the Health and Medicines Bill which is now being discussed in Committee. Those are not insignificant amounts of money. At least £70 million a year could be generated and my Department will shortly set up a special unit to encourage and help health authorities to pursue this initiative.

Thirdly, I want to encourage health authorities to use — this is critical and I know that many of my hon. Friends share our view — spare capacity in other authorities whenever it is sensible and cost-effective to do so. That is already happening in part under the waiting list initiative. I want to encourage it, to improve the accounting information systems and to give patients a better knowledge of the system through giving better information to general practitioners.

Mr. Barron

rose—

Mr. Moore

I have given way frequently and I think that it would assist the House if I were to move forward.

Fourthly— this is important—I want to seek to increase the total resources going into health care by encouraging further co-operation with the private sector. I shall not allow narow-minded dogma to stop resources being used for patient care. One of the great weaknesses of Britain's Health Service is the small contribution made by the private sector compared with that in other countries.

Mr. Barron

rose—

Mr. Moore

In France, 2.7 per cent. of GDP goes into health care from the private sector, in Germany 1.8 per cent., in Canada 2.1 per cent., and in Holland 1.9 per cent., compared with only 0.5 per cent. in the United Kingdom. There is a clear gap there. We must seek to encourage such contributions.

Mr. Barron

rose—

Mr. Moore

Fifthly, we shall improve the primary care services. The hon. Member for Livingston has recognised the major increases in real resources in those in the past eight years. They are critical to our acute care hospital service because they are the gateway to the expensive hospital sector. The announcements in our White Paper about the way in which we are seeking to amend general practitioners' terms of service to clarify their role in the provision of health promotion services and the prevention of ill health are critical. Equally, we want to introduce a range of incentives through general practitioners' pay to encourage them to carry out specific activities such as attaining target levels of vaccination and screening. That has been welcomed by most hon. Members.

Sixthly — this is also important and surrounds the debate outside as well as inside the House—I want us to focus much more on the overall objective of our health care policies. Our aim is clear—better health for the nation. So much of today's debate has been trapped on inputs—money, staff and beds. I accept that those are important, but we look too little at the outcome or the outputs. We need better indicators and targets to help us to judge good health against which we can judge our inputs and objectives.

Dr. David Owen (Plymouth, Devonport)

I, like other hon. Members, have listened for a sign of any new policy or hope. Will the Secretary of State at least say that, if the independent review body on nurses' pay makes, as everyone hopes, a substantial recommendation over and above that allowed for in the Government's public expenditure White Paper, that settlement will be met in full by the Government, as happened in election year? That reassurance is genuinely needed.

Mr. Moore

It is the height of cheek for a right hon. Member who supported a Government with an appalling record on nurses' pay to make such a comment. The Government's record on the nurses, the setting up of the pay review body and the way in which its reports have been implemented is second to none.

Mr. Neil Kinnock (Islwyn)

Will the Secretary of State now answer the question posed by the right hon. Member for Plymouth, Devonport (Dr. Owen) which I have addressed before? Will the Government fully fund the next pay increase for the nurses? If they do, it will be the first time.

Mr. Moore

First, that is factually inaccurate. The Government fully funded —[Interruption.] Not all. The Government's record on the nurses, as the right hon. Gentleman knows to his discomfort, is outstanding. [HON. MEMBERS: "Answer the question."] I am trying to do so, despite the sedentary interruptions.

If the right hon. Gentleman ever stood on this side of the Dispatch Box —I hope that that will never occur —I am sure that he would not submit to the pay review body not only recommendations but the assumption in advance that full funding would automatically occur. That would not be a recipe for serious debate about serious work and serious attempts to achieve proper incentives to efficiency within the service. It would be foolish to do so.

Mr. Kinnock

The word that the right hon. Gentleman is groping for is "no".

Mr. Moore

No, I am groping for one thing only—the Government's responsibility and record.

Mr. Barron

rose—

Mr. Speaker

Order. The hon. Gentleman must not keep rising. The Minister has already given way to the Leader of the Opposition.

Mr. Moore

All the measures that I have outlined are sensible and deserve the support of everyone who cares about the nation's health. I am glad that we are having this debate today and I welcome the wider debate that is taking place in the country on the future of the NHS. It is right that the whole nation should be involved in constructive discussion about health care. What is wrong is when the discussion degenerates into destructive attacks upon the Health Service.

The National Health Service enters its 40th year with a proud record. It is wilfully blind not to recognise its splendid achievements—in particular, those of the past eight years. Worse than that, attacks on the service damage the morale of workers in it and undermine the confidence of the public. However, the NHS also enters its 40th year facing unprecedented demands. That is why it is so crucial that our debates are informed and rational. Fevered attacks will not help the National Health Service. We stand firmly — I think the hon. Member for Livingston wanted me to say this, and I shall be delighted to do so—as we always have, behind the principle of the NHS, which is that adequate health care should be available to everyone no matter what his means. At the same time, the dramatic changes in demography, technology and expectations that I have outlined today mean that we must constantly reconsider how that principle can best be implemented.

The Government have increased the resources that are available to the National Health Service every single year since they came to office. Those increases will continue, but, in the light of the accelerating and unending demand for health care, we must consider even more carefully how resources can best be used and how, like other western countries, we can encourage a greater private sector contribution to enhance and add to the increasing resources that the Government have already committed.

Today, thanks to the Government's excellent record, health care in this country is being provided for more people by more skilled staff in better facilities than at any time in our history. We shall build on these achievements in meeting the challenges of tomorrow. It is in that spirit that I look forward to the contributions of hon. Members to the debate, and in that spirit that I urge the House to reject the Opposition motion.

5.1 pm

Mr. Stanley Orme (Salford, East)

The Secretary of State has not answered the central question why the National Health Service is in the biggest crisis since its creation in 1948. Why are hospital beds and wards closing? Why are people having to wait longer for treatment? Why is there a shortage of nurses now?

The Secretary of State referred to the period of the Labour Government. In Salford, part of which I have represented for the past 23 years, we have never known such a crisis. Under the Labour Government we were building a hospital; under this Government we are closing hospitals. Why has the whole country suddenly reached this crisis? It is to be found not only in the inner cities, but everywhere. The basic problem is that since 1981 health authorities have had to face the cuts that the Government have imposed. If there was any fat to cut out before, there is none now, so the authorities are up against it.

Let me discuss my inner-city area. We heard much from the Government after the election. We heard from the Prime Minister that priority was going to be given to inner-city areas. Some of my hon. Friends, like myself, represent inner-city areas. Salford has a large elderly population suffering from chronic medical problems. As a result, my health authority will have to cut £2 million a year right into the 1990s. If the Government make that happen, it will mean that four wards will have to close in one hospital; in another, a children's hospital, two will have to close. Salford royal hospital, a nationally known hospital with a great reputation in the medical world, is now threatened with closure.

Dame Elaine Kellett-Bowman (Lancaster)

Does the right hon. Gentleman know that his authority has the second highest administrative costs in the country? Will it now save something in administration rather than close wards?

Mr. Orme

Our costs are high because demand is high in our city. We are very efficient, and I want to quote to the hon. Lady what professor Galasko, operating at the Hope hospital in Salford, has to say: The service we give is not ideal, but it is of such a standard that complex cases continue to be referred to our Department in ever increasing numbers. For example, the numbers of patients on my own Waiting List have increased from 219 in April 1986 to 291 now. The waiting time for surgery has also increased. The waiting time for adults on my Waiting List has increased from 51 weeks in April 1986 to 107 now, whereas the waiting time for children with complex orthopaedic problems has increased from 82 weeks in April 1986 to 102 weeks now. That is the position in my health authority. The Ladywell unit, a special unit for young disabled people, of which we are proud, is threatened with closure. What does the Secretary of State have to say about that? What does he have to say to the young people I have seen there, for whom it is a lifeline? They are seriously disabled young people in their teens and early twenties and thirties. What chance have they when the unit is threatened with closure?

Only last week, a nurse from the Royal Manchester children's hospital made a statement. Sister Margaret Rickard said: No one else will say this. I have been waiting too long for it to be said—now I am going to say it. A lot of these children arc desperately ill. I am sure very ill kids are going to die because there is nowhere for them to be seen. That is what is happening in a hospital in the constituency of my hon. Friend the Member for Eccles (Miss Lestor).

Throughout the country, from one area health authority to another, the story is the same. The Government must answer these charges. But what do we get from the Secretary of State today? He is making no promises of new resources, nothing concrete for the nurses and no method of dealing with the problem. He talked about 1978 and 1979, but I have never known the medical profession so united and agitated as it is now. Doctors, local medical committees, surgeons, orthopaedic surgeons, nurses and nursing ancillaries are all saying the same thing. They are talking not about what might happen, but about what is happening now. Wards are closing and people cannot obtain services. From the consultants to the trade unionists, the message is the same.

Prestwich hospital is under threat, and the unions are fighting that. What proposal has been put forward to assist with that? Bio-Plan Holdings Ltd. has come forward to say that it will put some tin-pot private development on a National Health Service property. It says that it may treat National Health Service patients at cost plus 10 per cent.

There is no answer to the problem of the National Health Service. The National Health Service was created so that people could use it at a time of need and pay for it throughout their working lives. That is the basic philosophy. If we move away from that, we shall go clown the American road of different standards between those who can afford to pay and those who cannot. We shall have National Health Service hospitals, but people will have to wait 12 months, 18 months, or two years before they get any service at all.

Mr. Terry Lewis (Worsley)

My right hon. Friend spoke about possible ward closures at Pendlebury children's hospital. Is he aware that on the other side of my constituency the Astley hospital is under threat of closure? This morning, I learnt that two ambulance stations are threatened with closure. The area has already had cuts in the number of ambulances, but now there is the possible closure not only of emergency services, but of ambulance stations.

Mr. Orme

It is all cumulative. Wards are being closed. Waiting lists are increasing and hospitals are under threat. I am talking not about Britain, but about Salford. Many of my hon. Friends can give similar examples; and if Conservative Members had had the honesty to do so, they, too, could give similar examples.

The National Health Service needs to be rescued. The money is there. As my hon. Friend the Member for Livingston (Mr. Cook) said, money can be injected. Instead of money coming from the contingency fund on a one-off basis, which might suit the right hon. Member for Chingford (Mr. Tebbit), Opposition Members want the funding which is available now to be used for tax cuts to be given instead to the National Health Service in order to give it a new lease of life. We could then consider the matters about which the Secretary of State was speaking.

First and foremost, we must save the National Health Service. That is the battle in which we are engaged. For the first time in my political life, all the forces in the National Health Service are united in that battle. That is the message that we give to the House and to the Secretary of State. The British people want action, and they will demand it.

5.12 pm

Mr. Norman Tebbit (Chingford)

I hope to be brief to allow other hon. Members to speak. First, I should declare an interest in that at least one of the companies in which I am involved may in future act as a contractor to the National Health Service. I am glad about that, as I believe that it will benefit the company and the Health Service.

The speeches of the right hon. Member for Salford, East (Mr. Orme) and of the hon. Member for Livingston (Mr. Cook) were interesting in that they were extremely long on complaints but short on cures. The hon. Member for Livingston was short on answers. He certainly could not answer the crisp and pointed question put to him by my hon. Friend the Member for Mid-Worcestershire (Mr. Forth).

Implicit throughout the debate has been the acknowledgment that, because of the success of the Government's policies which had always been opposed by Opposition Members, the Chancellor can make available, they say, extra resources which no Labour Government could have provided. It was not a lack of North sea oil that forced Chancellor Healey to go to the IMF with his troubled economy and to slash the Health Service, cut nurses' wages in real terms, close hospitals and lead us into the winter of discontent when almost every hospital in the country was closed.

I welcome the opportunity for a debate —[Interruption.] I see that the hon. Member for Liverpool, Walton (Mr. Heifer) is debating in his usual style with loud remarks made from a sedentary position.

Mr. Eric S. Heffer (Liverpool, Walton)

rose—

Madam Deputy Speaker (Miss Betty Boothroyd)

Order. I do not believe that the right hon. Gentleman is giving way. Is that the case?

Mr. Tebbit

That is quite correct.

Mr. Heffer

rose—

Madam Deputy Speaker

Order The right hon. Gentleman is not giving way.

Mr. Heffer

The right hon. Gentleman referred to me.

Madam Deputy Speaker

Order. Is the right hon. Gentleman giving way?

Mr. Tebbit

No. [Interruption.] All those who know the hon. Member will know the truth about that.

I should like to express my great thanks to Mr. Maxwell and to the Daily Mirror for all that they have done to precipitate the debate. But for the Daily Mirror and others, we might have drifted on without having a proper debate on these issues. Now, if we are to have a debate, let us have an open debate and try to reach some conclusions.

Last Friday, I posed some questions about the National Health Service, and I should like to enlarge a little on those questions. Some of them were inherent in the question put by my hon. Friend the Member for Mid-Worcestershire, which the hon. Member for Livingston could not answer. The House should turn its mind to the question whether there should be any limit on National Health Service expenditure. The hon. Member for Livingston looks puzzled, but he must understand the question—I hope that he understands the question.

Should expenditure be entirely demand-led? We must think of the implications of allowing the Health Service the privilege of demand-led expenditure, which would give the Health Service the right either to unlimited taxation or to require unlimited cuts in other expenditure programmes. [Interruption.] My hon. Friend the Member for Birmingham, Selly Oak (Mr. Beaumont-Dark) says that nobody has asked for that. But it was implied in the speech of the hon. Member for Livingston that the Opposition would deliver it.

I should like to know whether the Opposition favour an absolute limit on Health Service expenditure, or whether they favour a demand-led expenditure. When we have an answer to that question, it would be wise to ask what that limit should be and how it should be expressed. Should we continue to express it as we do now, in public expenditure White Paper money terms, after the Star Chamber and all the trials which Ministers have to go through, or should we express it as a percentage of GDP?

My right hon. Friend rightly took pride in the fact that we have increased the share of GDP going into the National Health Service. Should we set a target or a limit in those terms? That would be a buoyant limit of revenue — unless we had a Labour Government, when GDP would fall and there would be the usual cuts. Should it be a slice of revenue or a percentage of income tax, the product of 15p off the standard rate of income tax which it currently requires, or the product of a rate of VAT, recollecting that the Health Service costs just about all the revenue at present achieved from VAT? Those questions are worth asking and worth answering.

Then we should go on to ask how that cash should he raised.

Mr. Tony Lloyd (Stretford)

I follow the drift of the right hon. Gentleman's questions, which will strike a chord with Conservative Members. If he is seeking a more rational way to distribute health care, he would not support the local authority in central Manchester which is talking about voluntary or compulsory redundancies. That is irrational.

Mr. Tebbit

It is clear that I was unwise to give way to the hon. Member for Stretford (Mr. Lloyd), who wanted to make a complaint instead of contributing to the debate.

We should then ask how that cash should be raised. Should it continue to be raised almost exclusively from the general burden of taxation out of the Consolidated Fund, or should we look for other methods of raising money? Should we look to the example of West Germany where the service is funded by a payroll tax—

Ms. Harriet Harman (Peckham)

No.

Mr. Tebbit

The hon. Lady immediately says no, but she has not even thought about it before reacting. The listening party is leaping to conclusions.

Should we give consideration to a payroll tax for health purposes, as in West Germany, where the current payroll tax is 12 per cent. and has been judged to be too high? Efforts are being made to reduce it because the burden is too heavy. Should we go down that path, or should we denominate some part of income tax? The Chancellor would never agree to a hypothecated tax, but a quasi-tax such as a payroll tax or a slice of VAT may be possible. We should be debating those questions, instead of the shroud-waving exercise which has been going on exclusively for the local press of Opposition Members.

We should look at how we provide the service. We cannot doubt all the statistics, but I will come now to some that I do doubt. The increase of almost one third in real terms, which has been put into the Health Service in cash, the 64,000 more nurses, the 13,000 more doctors and dentists—where are they? When my right hon. Friend the Minister referred to resources, Opposition Members posed an important question, which the hon. Member for Livingston (Mr. Cook) has not really thought about yet: "Then where has it all gone?" That is a very good question.

Are those nurses standing beside beds and are the doctors standing alongside them, or have they gone into a vast administrative black hole? We hear much about the cancellation of health care due to a lack of nurses or medical equipment, but I have never heard of a committee being cancelled because of a lack of photocopiers, paper or clerks to push the paper around. I sometimes wonder who sets the priorities within the great bureaucracy of the National Health Service.

Mr. Nigel Griffiths (Edinburgh, South)

The right hon. Gentleman implies that nothing has been done for the past eight or nine years. What have his Government been doing about it?

Mr. Tebbit

The hon. Gentleman asks a fair question. We have had Health Service reorganisations under various Governments, all within the context of the nationalised provision of service, and none of them has been outstandingly unsuccessful, perhaps because of the very nature of the provision. The listening party, in a leaflet distributed over the signature of the Leader of the Opposition, asks that question. The Leader of the Opposition says that we should ask whether the way we provide health care is the best way. I do not know whether that is a genuine question or he has already closed his mind on the issue, but we should have open minds on it. I hope that the hon. Gentleman will join me in having an open mind on it and will consider it on its merits.

I dealt earlier with the point raised by the hon. Member for Livingston about my remarks on nurses who work extra time for extra money. I recognise that many nurses work overtime without being paid, but if they work overtime they ought to be paid. My criticism of the system is that it precludes them from being paid for working overtime in their own hospitals, but provides for them to work overtime in other hospitals. That seems to be administrative nonsense.

As a London Member, I recognise that the differential between the pay of nurses and others, and between the London rate and the rate in areas where the cost of living is much lower, is too narrow. If I recollect rightly, that was part of the burden of the Government's evidence to the pay review body, which unfortunately was not accepted or acted upon by that body. It is no wonder that medical staff, particularly junior nurses in London, look for other sources of pay, because they find it extremely difficult to afford accommodation unless they can increase their pay. My criticism is overwhelmingly of management and the system.

The Health Service is not just people, although people are the most important part of it. Capital—cash, money —is another part of it. I take issue with the reliance that is sometimes put on some statistics, as to which hospital is cheaper or more expensive than another for an operation because, typical of a nationalised system, there is no balance sheet and capital comes free. Nobody accounts for the cost of capital. Once the investment is made, it is written off. Nobody thinks of putting a cost on the money which must be provided so that the comparisons may be not about the efficient way a hospital is managed but about which hospital has had a huge injection of capital and which has not. The nationalised system has inherent defects, which mean that capital is not properly allocated. All too often it goes in not on the basis of need but on the basis of decibels of squeal, and we have no real idea whether the capital is being effectively and efficiently used.

That leads me to the question posed by the hon. Member for Edinburgh, South (Mr. Griffiths) and by the Leader of the Opposition—although he is not seriously interested in the answer—has hospital nationalisation been a success? We would be unwise to leap to the conclusion that it has. Is the present system likely to use scarce resources of cash or staff effectively? We should not leap to conclusions; there is time for mature consideration and to do a proper job. We must do our figures carefully, taking into account the cost of capital.

The right hon. Member for Salford, East compared the cost of the public and private sectors in his city. Is the public sector expected to remunerate its capital? Of course not, but the private sector is, so we are not comparing like with like. If capital is free, it is likely to be badly used, and if we do not account efficiently for the cost of it, how can the people in the Health Service know whether they are doing well or badly?

I end with two points: the essence of the Health Service, as my right hon. Friend the Minister said, is that treatment should be available regardless of ability to pay. It is not essential to the Health Service that provision should be made exclusively through either the public or private sector, or that the funds to finance it should come exclusively through the tax system, or exclusively or partially through charges for service at the time of provision.

I have supported the huge increases in national health spending under this Government, and I am glad that expenditure will continue to increase, but I say to my right hon. and hon. Friends that I would strongly object to a policy of drip-feeding £100 million by £100 million, or even £1 billion by £1 billion, to those who complain the loudest.

No doubt if my right hon. Friend the Chancellor were to decide that there are to be no tax cuts, no attempt to reduce public sector borrowing, which he should do—preferably he should have a negative PSBR next year—if he spent the whole amount available on the Health Service, it would not be many years before the demand would rise again, with people saying, "We want more." The more money that is drip-fed in response to complaints which are not always—I emphasis not always—quite rational, the worse the service will become, because it is not an efficient allocation and use of resources. We should seize our chance and re-examine the whole funding and provision of the Health Service and should make that searching review a condition of any more funding. The best comment yet was the sedentary question posed from the Opposition Benches: "Where has it all gone then?" That is what we ought to know before we decide to put any more into the same system.

5.29 pm

Mrs. Rosie Barnes (Greenwich)

We have heard much in recent weeks, and today in the House and in the country at large, about the crisis in the Health Service. We have heard continually from the Government that there is no crisis. Today has been no different.

There is nothing new and no hope or enlightenment for people on waiting lists. Statistical answers bring little comfort to people who do not know whether their children will live long enough to have vital operations.

I agree with some of the sentiments that have been expressed by Conservative Members. We must reconsider this problem and open a debate on the state of the Health Service, what it will provide and how we shall fund it.

The Government cannot continue to pretend that there is no crisis, when the country is screaming that there is. Short-term and panic-stricken cash injections and mindless repetition of statistics are not the answer. Equally, it is quite wrong to pretend that an infinite demand for health care can be instantly financed out of the public purse.

There is an important issue that we must face as a country. We should be looking for a consensus and we should put party politics behind us. We must acknowledge the changing circumstances in which the National Health Service makes its decisions. We must acknowledge the increase in the number of elderly people and the demands that they will put on the Health Service. We must acknowledge the fact that technical advances, in many respects, are making the Health Service a victim of its own success.

There is no point in developing new technology if ordinary people do not have access to it. We need longterm answers on which we can all agree. There is no greater sector of need for a national consensus than funding of the National Health Service. Yes, we need a debate, but not only on the expenditure involved or the limits of expenditure; society must make decisions on what level of health service will be provided and how it will be paid for.

What criterion of assessment should we use? It is simple: if it is available, I want it for my family. The rest of the community feels the same. There should be a guarantee of treatment, if it is available, within a reasonable period of time. Patients have rights. Desperate recourse to courts by distraught parents is an indictment of our society.

Mr. Tebbit

What the hon. Lady is saying is in slight conflict with what she said earlier. If she is saying that a treatment—that is, if it exists—should be available when people want it and that they should have it regardless, she is saying that there should be a demand-led service with no financial limit. Which side of the question does she come down on?

Mrs. Barnes

I am saying that society must consider this question and come up with the answer. If treatment is available, I would apply the criterion that people expect their family to be treated; if it is available privately, it should be available on the National Health Service. We must look, as a society, at how we shall pay for this service, and we must take that question very seriously.

Dame Elaine Kellett-Bowman

The hon. Lady's exact words—she can check them in Hansard—were: There should be a guarantee of treatment … within a reasonable period of time. That rather answers the question that my right hon. Friend the Member for Chingford (Mr. Tebbit) asked.

Mrs. Barnes

I believe that there should be a guarantee of treatment within a reasonable time.

What is needed is a consensus and answers that will last for some time to come. That consensus should be based on three elements.

Mr. Keith Raffan (Delyn)

Will the hon. Lady give way?

Mrs. Barnes

No, I shall not give way.

First, there should be increased Government spending in line with growth in GDP. Earlier, the Minister spoke of the importance of the economy and its relationship to the nation's health. There is no direct relationship, but a significant link can be made if a specific portion of the national economic cake is allocated to the Health Service.

Secondly, we must find ways in which to encourage people, individually, to spend more on health care without abandoning the principles of the National Health Service — for example, through rededicating premium bonds and through local health lotteries. There is considerable evidence that people are prepared to spend more indirectly if they know that the money that they are giving is going straight to the Health Service and not being absorbed in general income.

Thirdly, we must realise that we can use existing resources even more efficiently by creating an internal market that matches the internal supply and demand of individual health authorities in a much more effective way. Clearly, if people needing treatment would receive it far more quickly in a different health authority there is no reason why they should not be given the right to take advantage of that authority's facilities and their own health authority should have to pay the bill.

I should like to highlight one less-emphasised but equally important crisis in the Health Service—the crisis caused by the implementation, not the principle, of the Resource Allocation Working Party proposals. The problem is the lack of funding caused by the implementation of those proposals in certain parts of the country.

Ms. Joan Walley (Stoke-on-Trent, North)

I should like to point out to the House that there is a myth in this country and in the Chamber that other parts of the country are benefiting from RAWP. In my constituency, the North Staffordshire district health authority is not receiving the benefits of the special deprivation programme. It has been suspended by the Government because of their failure to meet the nurses' pay increase in full.

Mrs. Barnes

I shall refer to the shortfall in some areas in that regard—but in some areas only.

I am completely committed to the principle of reallocating resources from richer health authorities to poorer ones. It is of great concern to us all that people's chances of avoiding serious illness or premature death depend far more than in comparable countries on the social class to which they belong or the area in which they live or were born.

I am concerned about the way in which the RAWP formula is being implemented. It does not take adequate account of social deprivation at regional or sub-regional level. By and large, RAWP overlooks what can be substantial pockets of deprivation in large regions such as the south-east, which generally is wealthier and better provided for than other areas. The result is that many inner-city areas, such as Greenwich, which have a high need for health care because of considerable social deprivation, do not receive the resources they need because RAWP, in terms of South East Thames regional health authority, and sub-regional RAWP, in terms of Greenwich, do not take adequate account of social deprivation, poor housing and low income, which undoubtedly contribute substantially to poor health. The assumption was that, in such areas, there would be substantial cuts in provision.

In my area, it was expected that the demand for acute hospital beds would fall, so the health authority made provision for such a reduction. The exact opposite has occurred, and demand for those beds has substantially risen. The assumptions contained in RAWP may have been true across the board, but in significant patches those assumptions have proved false. That has caused significant hardship to health authorities, and especially for patients in those areas.

I want a RAWP formula that accurately reflects the need for health care at regional and sub-regional level. What matters is how many people in a given area suffer from ill-health and therefore require care. Some of the evidence used to assess health care has been inaccurate. There has been a tendency to rely heavily on standard mortality rates. There is also a clear suggestion that, in areas of social deprivation, chronic illness is far more persistent and far more widespread. Such illness may not be fatal, but it needs treatment.

To rely solely on standard mortality rates is not enough. There are measures afoot to try to reconsider the RAWP allocations to take account of social deprivation. It has been suggested that the ACORN technique should be used to take account of such deprivation. However, that technique has aroused considerable anxieties because it was intended as a marketing tool and not as a measure of the need for health care. ACORN also uses information based on the 1981 census and, in the inner-city areas, that census material is considerably out of date and does not reflect the current position.

The practical effects of the loss of income in certain areas as a result of RAWP have been severe. In my area, we have lost three hospitals and are faced with the prospect of losing two more. Indeed, many of the areas affected by RAWP were not designed to cater for the medical needs of the 1980s and 1990s. Such areas have many small cottage hospitals — perhaps one large hospital— but do not have adequate facilities to cater for the needs of the community. The closure of five hospitals will entail substantial expensive changes. Such changes can be ill afforded and, in the light of severe cash shortages, are poorly carried out. The problems connected with RAWP allocation are the clearest illustration of the paucity of the Government's approach in specific areas.

The Secretary of State constantly tell us that the NHS has never had so much money devoted to it and that all is well, but people are feeling the pinch. They are experiencing hospital and ward closures and long waiting lists. They know that it is a very different story. The perception gap between the people and their Government is breathtaking.

District health authorities' problems have been compounded by the Government's refusal to fund nurses' pay awards in full. The Government cannot continue to evade their responsibilities by only partly funding pay awards and expecting health authorities to make savings to achieve these awards. Such authorities are already under considerable financial pressure.

It is clear that there is no room to make further cost savings. Perhaps there was some fat to be trimmed, but now we are down to the bone. Any further pay increases must be funded in full by the Government. It is clear that some RAWP money that had been reallocated and money that was intended to prioritise certain areas of health care is now used as basic revenue. There is little point in the Government encouraging health authorities to prioritise certain areas of health care or to reallocate resources to areas of greater need if the money provided to achieve those aims is used to provide the basic facilities.

I believe that we should have a national debate and a review of what we expect from our Health Service and how we are to fund it. We also need to consider the subsidiary issues of how we can be sure that the aims of RAWP are fairly realised so that broadly economically successful health authorities, which contain within their larger areas pockets of social deprivation, are not penalised.

5.45 pm

Sir Barney Hayhoe (Brentford and Isleworth)

In the November debate I began my speech by regretting the absence of my right hon. Friend the Secretary of State and I hoped that he would soon be fully restored to health. I am delighted that he is now back and that he will be participating in our continuing debates.

I welcome this wide-ranging debate about the NHS and health care. The debate has been raging with great intensity since we last spoke about these matters in the House. However, I deeply deplore the sharply personalised turn that has been taken in the public expression of this debate in the past few days. My right hon. Friend the Secretary of State has been targeted as some sort of fall guy. It would be wholly inappropriate for my right hon. Friend the Secretary of State for Employment to claim credit for the steady and welcome reduction in the numbers of unemployed that he is now able to announce to the country each month. Equally it would be wrong for my right hon. Friend the Secretary of State for Social Services to be blamed or held responsible for the financial difficulties now facing the hospitals and community health service.

I agree with my right hon. Friend that there are serious problems deserving rational and well-informed debate. It is right to state — as my right hon. Friend did on a number of occasions during his speech — that a successful economy and sensible economic policies that provide national wealth are absolute requisites to provide money that can be spent on the Health Service and other desirable social objectives and to improve the general standard of living. However, highly emotive questions traded for repeated, well-used statistics — however impressive the statistics — make little contribution to solving the problems.

In November I said that the statistics must be considered carefully. My right hon. Friend the Member for Chingford (Mr. Tebbit) has referred to the number of nurses and asked where they have all gone. What is interesting is to consider when those nurses arrived. The annual report on the Health Service in England published a few days ago shows that there are some 403,000 whole-time equivalent people in nursing and midwifery in England. Since 1979 the number employed has increased substantially, by 44,000. It is clear from the figures that an increase of 38,700 took place before the 1983 general election.

At that election we rightly took great credit for those extra nurses and midwives. However, in the four years since then the increase has been only 5,600. The increase has flattened off. Equally, while substantial extra sums have been spent on the Health Service, the really sharp increases took place in the early years of the Conservative Government and were largely used to restore the pay of National Health Service staff to some sort of reasonable standard from the low level to which it has sunk, leading in part to the winter of discontent of 1978–79.

Mr. Robert B. Jones (Hertfordshire, West)

I am most interested in the points that my right hon. Friend makes. However, is it not fair to note that comparable countries can manage with half as many nurses per bed or per head of the population and that our nurses are doing jobs that might well be done by far less well qualified people in other countries? Is not that point worthy of attention?

Sir Barney Hayhoe

My hon. Friend assumes that nurses in this country have the same qualifications as those abroad. They do not. In other countries, nursing is largely a graduate profession. We may be moving towards a graduate profession, but the process will not be completed for many years to come. Over-simplified international comparisons do not really help the debate. One needs to be sure that one is comparing like with like. I certainly do not believe that we are getting particularly poor value for the money that we spend on the National Health Service.

Let me deal with two or three of the major events that have taken place since our debate last November. First, the Government have come forward with an extra £100 million to meet specific urgent requirements in the present financial year. I welcome the decision to add that extra money from the contingency fund.

We have also witnessed a series of strikes and disruptive action by some nurses—not by the Royal College of Nursing, I hasten to add, but by other unions. I do not know all the facts, but I question the Government's reaction to those strikes or at least the way in which it has been perceived by the press. The phrase "Government climbdown" is often used. That seems to me to be a highly dangerous message. It is dangerous for it to be thought that the Government are responding in that way to militant and sometimes irresponsible action by the trade unions responsible for some National Health Service staff. Certainly, the anti-privatisation strikes in Scotland are wholly unjustified. Of course there should be competitive tendering and the money available should be used in the best possible way.

The £100 million extra is very welcome, but it seems to have been dragged out of a reluctant Treasury. How different the scene would have been if that sum had been announced in the wind-up of the debate on 26 November. One of our problems as a Government is that we have spent this additional money in such a way as to get little praise for it. Delay has strengthened the arm of the Treasury, which will say to the spending Ministers, "Look. We agreed to that extra money but instead of plaudits we are attacked." And this because the announcement had been so long delayed. For heaven's sake, when we make extra resources available—and I believe that we must continue to do so—let us draw credit from it and ensure that it is to the Government's advantage.

The bulk of that extra money will help with the serious over-spending problems that confront so many district health authorities, which stem largely from the underfunding of pay increases made as a result of pay review body awards, or negotiations through the Whitley system in the case of non-pay review body staff. Tremendous difficulties are caused when pay increases exceed the budgeted provision in cash-limited services. The case of the National Health Service illustrates that vividly. The review body awards apply both to the hospital and community health service and to family practitoner service. In the case of the family practitoner services no problems of implementation arise, apart from complaints from doctors when implementation is staged and delayed or when the award is not paid in full. The real problems arise in the hospital and community health service because it is cash-limited.

What on earth can be done? If the cash limit is to be maintained the pay increases have to be staged and applied for only part of the year so that the budgeted provision for increased pay is absorbed over seven or eight months rather than spread over the whole year. That end-loads the system. I remember from my involvement with Civil Service pay some years ago the strictures laid down by the Treasury and Civil Service Committee about end-loading because it raises the base line for the following year. Such staging pushes the problem forward into the following year.

Alternatively the cash limit can be increased with extra money coming from the contingency reserve, as, for example, in 1987 when the Government decided to implement the pay review body awards in full. It was an election year and the Government were not wholly unmindful of these important considerations. Even then, the Treasury did not agree fully to fund the awards. In his evidence to the Treasury and Civil Service Committee the Chancellor said: £30 million— I think that he was wrong and that the sum was £24 million— had to be found by the health authorities from their cost improvement programmes. Those self-same cost improvement programmes were also expected to meet non-budgeted pay increases for non-pay review body staff and other additional expenditure that exceeded the budgeted amount. Fine, so that extra spending was being met out of the cost improvement programmes. However, the cost improvement programmes had already been taken fully into account in establishing the public expenditure figures for the hospital and community health service for 1987–88. The House will not think for one moment that when the Secretary of State goes along to see the Chief Secretary or to the Star Chamber those cost improvement programmes are ignored. They are brought into the argument. The Treasury says, "You are to get £150 million a year"— the figure announced by the Secretary of State for the current year and for next year—"and we shall take that into account in arriving at the overall figure." As my right hon. Friend the Secretary of State said, the cumulative total sum arising from cost improvement programmes over the past four or five years is £1.3 billion. In the current financial year the programmes are running cumulatively at about £600 million. If those sums had not been taken into account by the Treasury in determining the overall finances for the hospital and community health service, we should largely have overcome the funding problems that are besetting so many of our district health authorities at the moment.

My right hon. Friend the Secretary of State rightly praised and commended the NHS managers and staff concerned for achieving these substantial efficiency savings. However, their motivation to find even more savings in future years must be damaged by their increasing awareness that the Treasury is taking full account of these savings in determining the cash limits for the hospital and community health service.

My hon. Friends and others who are calling for greater efficiency in the Health Service are right to do so. However, they should not be misled into thinking that as a result of that greater efficiency more money will necessarily be available for patient care because what happens is that in the arguments during the public expenditure round between the spending Department—the DHSS—and the Chief Secretary, the Treasury and others, account will be taken of those efficiency savings.

I now look more widely at the general financing of the National Health Service. I am delighted that the Select Committee on Social Services has made that its priority subject. I hope that it will get ahead with the work and produce an authoritative and useful report. I welcome the present wide-ranging public debate, with inquiries by the King's Fund, the Institute of Health Service Management, and the Public Finance Foundation and the flurry of activity from Right-wing pressure groups such as the Centre for Policy Studies, the Institute of Economic Affairs and the Adam Smith Institute. There are many new ideas, or at least re-worked ideas because there has been an awful lot of literature on this subject in the past.

Insurance funding has often been suggested as a way out of the present difficulties. It was investigated by the Government between 1980 and 1982. However, my right hon. Friend the then Secretary of State for Social Services, now the Secretary of State for Employment, announced in a written answer in July 1982 that the Government have no plans to change the present system of financing the National Health Service largely from taxation".—[Official Report, 30 July 1982; Vol. 28, c. 860.] That was following the internal review of the insurance system.

It is also suggested that increased charges would bring more money into the Health Service and would also discourage use of particular services. I am often surprised that sometimes those of my hon. Friends who give a greater importance to market considerations than perhaps I do in the general run of things seem to ignore the fact that by their very nature increased charges discourage use. Perhaps, for some, that is even a positive merit. But on considering the Government's proposals for charges for sight testing and dental inspection, one is not encouraged to think that there is much advantage to be gained in pursuing increased charges as a way out of the present financial difficulties.

It is also suggested that lotteries could make a contribution. I ask instantly, "Why not?" Many years ago, Ireland used to have the hospital sweepstake. I gather that it now has a much more modern system which churns in a great deal of money and which follows similar systems used in California, Australia and many other areas. We should look at that suggestion and if it will produce substantial amounts of extra money, why on earth should we not adopt it?

Of course, at the same time we must search for increased efficiency. I remain a firm supporter of the National Health Service. I welcome increased cooperation with the private sector and am totally opposed to those who, for dogmatic reasons, regard any cooperation with the private sector as a betrayal of the cause of the National Health Service.

I am attracted by ideas for developing an internal market within the National Health Service to begin to deal with some of the problems of the enormous difference between the apparent costs of particular operations when carried out in different areas and regions. I should like the internal market concept to be developed.

I am also convinced that clinical budgeting, along the lines suggested by Professor Alan Maynard, will inevitably exert a growing influence on the way in which resources, which will always be scarce whatever arrangements are made, are best used in the interests of patient care.

Although I envisaged that all those suggestions are more likely to take place in the future, within a largely tax-financed service, alternative sources of funds deserve careful consideration. However, I must challenge the naive assumption that runs through much of the present debate about NHS financing — that new money means extra money — because everything that I know about the Treasury goes against it. As soon as new money is found and begins to come in, it will figure in the public expenditure discussions. The Treasury side of the table would, for example, say, "You are getting £200 million to £300 million from the lottery. We shall take that into account, which means that £200 million to £300 million less needs to come out of the tax-borne expenditure than would otherwise be the case." Those who argue that new sources of finance mean extra money for the service must somehow overcome the Treasury's long tradition of taking account of that money. That fact changes many of the arguments.

I am not enunciating a new doctrine. The Royal Commission on the National Health Service reported in 1979. Paragraph 21(13) states: It must be understood that there is no escaping government supervision of health service expenditure whatever system of raising funds is adopted. Some advocates of an insurance system evidently see it as a mechanism for automatically increasing expenditure on the NHS as costs rise. They delude themselves if they do. The rising cost of health care is a major concern in most developed countries, and measures to control it may be, and are, introduced whatever the method of financing health services. The Government will always look at the overall total amount of money going in to the service. So long as there remains a tax-borne element in that overall spending, the Treasury will take account of it. If the Treasury is to change its attitudes to new sources of funding, it might be much simpler and less administratively expensive if that change of attitude occurs under the existing system. However, perhaps that opens up wider considerations.

The fundamental requirements of the National Health Service that face us in this House and in the Government relate to the way in which we can introduce more taxpayers' money—there is no other money available in the short term—into the Health Service in the coming months. I am not suggesting a great deal more money, as have some hon. Members, but there must be more money for 1988–89 to meet the full unbudgeted costs of the 1988 pay increases plus, perhaps, up to £500 million — I certainly would not put the figure any higher—to relieve the mounting pressure on so many health authorities. The generous provision that has been made and the £700 million more that will be given to the health authorities for the coming year, 1988–89, represents a cash increase for next year of 6.3 per cent. according to a DHSS press release.

Inflation is estimated to be 4.5 per cent., and 75 per cent. of overall spending goes in pay. Does anyone think that the pay increases for doctors, nurses and midwives in 1988.89 will be 4.5 per cent. or less? Anyone who thinks that that will be recommended by the pay review body, or that, if it awards more, the Government will stick to their figure, is living in a dream world. Money is washing out, not from the second floor of the Treasury, but from the attics. In such circumstances, it is totally unrealistic to try to hold down nurses' pay to the budgeted level of 4.5 per cent.

The Secretary of State was right to point to the need for extra resources when he met the presidents of the royal colleges. The headlines read: Moore accepts NHS cash need … Doctors' fear on future of health service allayed … Minister pledges action on funds". The stories in the papers last Thursday morning were very different from what my right hon. Friend the Chief Secretary said that evening. My right hon. Friend the Secretary of State very properly and loyally tried today to equate the message that came out of his meeting with the presidents of the royal colleges with what the Chief Secretary said when he wound up the debate on the Autumn Statement on Thursday. But I think that the earlier simple message from my right hon. Friend the Secretary of State was right: more funds are required in the coming year.

Of course, that does not prejudge the wider questions, many of them posed by my right hon. Friend the Member for Chingford (Mr. Tebbit). However, there is an urgent, present need, and the sooner that the Government meet that need, the better. The longer that they delay doing what I believe is now virtually certain to be done—that is, provide extra money for 1988–89—the more they will dissipate the political advantages that should flow from such action, and the more they will damage morale within the National Health Service.

Several Hon. Members

rose—

Mr. Speaker

Before I call the next Back Bencher, let me remind the House that at the beginning of the debate I appealed for short contributions. The right hon. Member for Salford, East (Mr. Orme) set an admirable example. Since then, however, we have had a 27-minute speech and two lasting for 117 minutes. May I appeal again for brief contributions.

6.12 pm

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

Normally, when the House debates the National Health Service, it does so by arguing about how best to provide a service that is useful to everyone. Such debates are usually marked by contributions from both sides of the House that pay at least lip service to the idea that the NHS is there to provide good health care for everyone, irrespective of income.

That is not an accident. Although the Conservative party opposed the creation of the National Health Service originally, it realised very rapidly that it was not just popular, but essential. We do not need examinations of whether the system of payment out of taxation is the right one for the NHS. Never was a service more surveyed, reported on and generally commented on. The Royal Commission on the National Health Service did probably the best survey, ever, and it remains so, but we have also had the Black report—which told us what is happening to the population as a whole when the privileged decide what kind of income and housing we shall have—and a number of other surveys, from the King's Fund and other interested groups.

We know, therefore, that a service funded out of taxation, and free at the point of use, is not only the best way of providing health care, but one of the most efficient. Yet, week after week in the House, we hear the Prime Minister recite numerous statistics — most of them meaningless — suggesting that the NHS is not only improving all the time, but that a large injection of cash is understood by the population as a whole to be producing the most wonderful results throughout the country.

What is really happening in the NHS is obvious to the population, and it is fundamentally different. In my constituency, we rely very much on a large district hospital. That started closing wards, went on to close whole sections and finally changed the way in which it operated. Occasionally, it has received a great injection of cash from the Mersey authority, because it is so grossly underfunded that it has had considerable problems. Nevertheless, health care has gone on declining, and waiting lists have continued to get longer.

That is because the Government, since they first took office, have chosen to cash-limit the hospital service. They never say, when they are talking about the money available, that it is in the non-cash-limited family practitioner service that much of the money has been spent. The hospital services have tended to suffer most. For example, in the constituency of the right hon. Member for Shropshire, North (Mr. Biffen), there is a specialised hospital—a fully equipped orthopaedic hospital—whose theatres are to be kept empty for three months. What contempt would be shown by Conservative Members if it were suggested that a fully equipped manufacturing unit, with high standards and expensive equipment, should be kept empty for three months, while retaining its staff and equipment. My goodness, we should hear about something like that. In the NHS, however, such action is regarded as perfectly acceptable.

We have problems in Oswestry with the district general hospital and with the family practitioner services, which are increasingly finding it impossible to obtain the back-up staff that they require. There is also a growing and frightening habit of suggesting that the reality can be changed with words. Nowadays, when people discuss decanting mentally handicapped patients into the community, they talk about "fast-track" and "slow-track" decanting, as if those patients were Norfolk turkeys being shoved through on a production line. We are talking about people, not turkeys. That means that we do not say, "How much of this land can we sell off? Where can we get a nice section to put money back into the Health Service? We will not use it to provide better services for people who were in institutions before. Oh, no; we shall simply put the money back into the Treasury." That is what is consistently happening, and happening consistently. It is mildly hypocritical for Conservative Members to come here and say, "Of course, we should be looking at other means of funding and improving the service", when what they really mean is, "In my constituency, I want you to spend more money, but elsewhere I want you to cut back."

Many of the smoke-screens relate to things that do not matter a damn in relation to overall finance. We can alter the administration as much as we like. Really the organisation was a disaster, and, although there have been larger cuts in administration than in other services, it still costs less to administer the NHS than it would to administer any comparable insurance-based scheme. We can alter the general way in which patients are moved from one list to another, and suggest that the provision of computer waiting lists will make a difference; but it will make no difference if the staff and funding for those specialised units are not there.

We should be asking one question of the Secretary of State tonight: what undertakings did he give to the august gentlemen who came to him, the presidents of the royal colleges, about funding? Why did the Chief Secretary make it clear the next day that in no circumstances was he prepared to support even the suggestion that the NHS was lacking in money? That is a question that the Secretary of State somehow did not find time to answer today, but it is relevant to this whole debate.

There is no better way of funding the National Health Service than by direct taxation. We know that because we have considered it time and again. There is no better way of providing health care than when people need it and letting them pay for it out of taxation. We do not solve the problems, as suggested in my district general hospital, by building a private unit of 12 beds which is supposed to produce a mythical answer that will encourage consultants to stay on the site, as if they were for ever running off. If consultants are not doing their job, machinery exists for disciplining them and it is time the people in charge did something about it.

The real truth is that the NHS needs large amounts of money now. It needs proper back-up for the staff now. Anything that detracts from that is hypocritical, mealy-mouthed and uncaring. Those are the points that should be made time and again until the electorate understand what the Government really mean by health care.

6.20 pm

Sir David Price (Eastleigh)

I am glad to take up the general challenge made by my right hon. Friend the Member for Chingford (Mr. Tebbit) and by the hon. Member for Greenwich (Mrs. Barnes) to consider the long-term funding problems of the National Health Service. I was interested in the arguments put forward by the hon. Member for Crewe and Nantwich (Mrs. Dunwoody), but she will forgive me for not commenting on the immediate position. As she knows, and as my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe) pointed out, we who are on the Select Committee are examining the immediate funding problem. Indeed, tomorrow, if the hon. Lady would like to come to the Committee, we will be meeting the three august presidents; I do not wish to anticipate their replies.

The long term is a much more serious problem. I believe that there are solutions to the immediate problem, some of which have been suggested by my right hon. Friend the Member for Brentford and Isleworth. The long term problem is getting increasingly difficult intellectually, let alone politically. I put it in these terms. It is the exponential nature of our expectations of the Health Service. The demand consequences of those exponential expectations are likely to run increasingly ahead of available resources, even if the resources put into the National Health Service expand at the same growth rate as the economy.

The chairman of Wessex regional health authority, the distinguished mathematician who is known to some hon. Members, Sir Bryan Thwaites, demonstrated in a telling lecture at Southampton university that the demands on the NHS, projected over the next 20 years, are likely to grow at an annual rate of 5 per cent. I think I carry hon. Members with me when I say that it is equally likely that available resources will not increase by 5 per cent. a year. Indeed, I argued, when I spoke in the debate on the Loyal Address, that we should commit ourselves to a growth rate in resources from public funds to the NHS equivalent to the growth rate in our gross domestic product. Experience shows that 2.5 per cent. is the most that one can reasonably assume. That has been achieved by this Government. I do not see any alternative Government sustaining over a decade more than a 2.5 per cent. economic growth rate. Anyone who suggests more can point to no historical experience to support his hopes. Of course it would be nice to have a higher economic growth rate, but I do not see that happening.

Therefore, we must expect a growing gap between—I will be optimistic — a growth rate of 2.5 per cent. in resources and a growth rate in demand of 5 per cent. Such is the nature of exponential growth that the gap grows; so what starts at 2.5 per cent. becomes 29 per cent. over 10 years but over 20 years— that is not very long in the lifetime of a health service — it becomes 62 per cent. That is the nature of geometric progression. That is the real problem to which the House has to address itself.

The House may think that I am exaggerating when I hypothesise, as Bryan Thwaites did, a 5 per cent. growth rate. Following your instructions to be brief, Mr. Speaker, I suggest, almost in synoptic form, some factors that have led Bryan Thwaites and myself to that view. Indeed, I think we are being conservative in putting as low a figure as 5 per cent. on the growth of expectations.

The first factor is the continuing advance in medical knowledge and in medical practice which makes possible what was hitherto impossible. We have heard all the arguments about the Birmingham hospital and about hole-in-the-heart surgery. When I first came to the House —a long time ago—hole-in-the-heart surgery was not an issue, because it did not happen.

Secondly, following that advance, there are more sophisticated treatments for more conditions. That increases the demand upon available resources. More people get more treatment. That is admirable in itself, but the process is self-generating. I need only refer to hip replacement operations as an example.

My right hon. Friend touched on the third factor, that more people are living longer. The old, and especially the very old, are heavy users of the National Health Service — surprise, surprise. So an increase in the numbers of the very old leads to a disproportionate increase in the demands upon the National Health Service. Today those aged 80 and over total 1.8 million. In 20 years they will have increased from 1.8 million to 2.3 million, or from 3.2 per cent. to 4 per cent. of the population. God willing, I shall be one of them.

Mr. Nicholas Winterton (Macclesfield)

And still here?

Sir David Price

An ancestor of mine remained a Member until he was 96. He had served the House for 64 years. I have only done 33.

Going to the other end of the age scale, the fourth factor is the survival of more severely handicapped children. A great plus for society is that many are surviving today who in previous generations would have died at birth or shortly afterwards. Many of them are multiply handicapped and for their entire mortal existence will require help. I do not think that we have begun to face up to the resource consequences.

The fifth factor is the technological advances in equipment which follow the almost explosive rate of development in science. I point only to microelectronics to illustrate the point. As a result, equipment within the service rapidly becomes technically obsolescent. Of course, the consequences affect both the capital budget and the revenue budget.

Another factor, number six, is professional expectations, which again put an increasing demand on resources. It can be summed up in the simple phrase, "My patient must get the best." That is totally honourable and right, but it is very demanding on resources. To put it another way, the more cynical might say that it is keeping up with the professional Joneses.

The seventh factor is the public's expectations, which are self-perpetuating. They are encouraged by a growing public awareness of the potential of modern medicines. These expectations apply not only to the practice and the delivery of medicine, but to the general standards of patient care and patient comfort, which some people like to call the hotel aspect of hospital treatment.

Factor number eight is the general determination of the 1 million or so people who work for the National Health Service in the four countries within the United Kingdom that they should share in the growing prosperity of the nation as a whole. Nurses, as well as other groups within the NHS, wish to push their position up in the general pecking order of pay and remuneration. That is a major growth factor within demand on the service when one remembers that staff costs represent roughly 75 per cent. of total revenue costs within the NHS.

That is a factor that my right hon. Friend referred to. We underestimate staff expectations at our peril. There is also a desire to share in working less anti-social hours and to have more leisure and holidays, which has not been taken into account sufficiently in forward costing.

The ninth factor is the potential threat of new diseases that might make heavy demands upon resources. Last year, in the Social Services Select Committee, we were looking at what could happen to this country if the AIDS epidemic really took off. I do not wish to go on about AIDS, because everyone is probably bored with the subject and has heard enough about it. But diseases do not remain static, nor do viruses cease to mutate, merely because they are not recognised in the Treasury computer model of the economy.

We must take it into account and not be surprised if there is a new virus or, as we have with AIDS, a retrovirus, which I have described as an "Alice Through The Looking-Glass" virus. It behaves in the opposite way to a normal virus. We must expect this outcome, and not be thrown by it. Indeed, it could well be that some old disease comes back with a new and much stronger form as a result of mutations. We should be ready for the unexpected, if that is not too Irish a thought for the House at this hour of the evening.

I hope that I have said enough to explain to the House that there is a growing gap between expectations and resources, which will be present under any Government. The sooner we realise it the better. I hope that the Select Committee will be able to throw a little light on it. We will come back in a few months with a thoroughly constructive report. Whatever the Government do, we shall offer some solutions to the problem.

Certainly, in playing my own part in the work of the Select Committee, I am very conscious of the cautionary words of the Royal Commission on the National Health Service, which reported in 1979, as my right hon. Friend the Member for Brentford and Isleworth reminded us. The report said: it is important for any Health Service to carry its users with it, given that it can never satisfy all the demands made upon it. It is misleading to pretend that the National Health Service can meet all expectations. Hard choices have to be made. It is a prime duty of those concerned in the provision of health care to make it clear to the rest of us what we can reasonably expect. I remind the House that this Royal Commission was set up by a Labour Prime Minister, so let us abandon minor party skirmishing and try to work together, as the hon. Member for Greenwich (Mrs. Barnes) invited us to do. Let us find a solution to this very real problem. There is no pot of gold at the end of the rainbow for the NHS, but if we play silly partisan politics with the NHS, the rainbow of hope will disappear and our constituents will be left only with the bitter tears of disappointment.

6.34 pm

Mr. Barry Jones (Alyn and Deeside)

The hon. Member for Eastleigh (Sir D. Price) has quoted some chilling figures. I hope that he achieves his century. It seems from this side of the House that there is plenty of life in him yet.

I agreed with the right hon. Member for Brentford and Isleworth (Sir B. Hayhoe) when he called for urgent money in the short term for the National Health Service. I thought that he spoke with some insight into the Treasury. He should know; he was speaking from experience.

Yesterday, 17 Labour Members of Parliament from Wales met the Secretary of State for Wales, and also his junior Minister, and senior health advisers. It was a serious session and a businesslike encounter. We told the Secretary of State for Wales of the problems in the south and north of Wales, in the urban and rural areas and in the industrial valleys of the south-east.

We said that every health authority in Wales claimed that it was underfunded. Each Welsh Member of Parliament gave convincing examples of underfunding. There were reports of low morale among ancillary workers and of consultants being told to treat fewer people. There were calls for more hospitals, and for more nurses in special and intensive care units. We urged the Secretary of State for Wales to put a paper to the Cabinet, and use it to argue for more and urgent funding to deal with the very pressing and real problems in the Principality. We said that he had a crisis on his hands and that he would need much new money to cope with the problems that we reported to him from our constituencies.

The people of Wales have special needs. We still suffer from major unemployment. Nobody would deny, that, arising out of mass unemployment, there are greater demands on the Health Service. We still have in Wales an unenviable reputation for ill health, specifically for heart disease, which may come top of the league in Europe, and, arguably, in the world, and for other diseases related to smoking.

We gave the Secretary of State some woeful instances of the cycle of deprivation. There are many deprived, under-nourished, under-privileged and unemployed communities in Wales. We pointed to the problems of the economy, where basic industries are declining. We know that in mining there are special health problems, and we are having to cope now with mine-working throughout this century.

We know that our housing problem is the worst in Britain; we have more houses that were built before 1917 than any other region. We know that housing conditions are directly related to health.

Major steel closures have taken place in the 1980s. Some of the steel communities are still reeling from those closures. There are consequences for their health and demands for health care. We could argue that the Health Service might have been conceived or invented in Wales. Certainly, it was the great Aneurin Bevan who put the Health Service together for the people of Britain. His achievements have been great and lasting. He said that preventable pain is a blot on any society and that a society is spiritually healthier if it has access to the best of medical skills.

I shall briefly instance the difficulties faced by the Health Service in Wales by specific reference to my constituency. Many people in north-east Wales who suffer from cancer cannot get treatment there. My constituents have to travel to Mersey hospitals. This year, as before, we were promised a major new community hospital, which was to have been started in 1985. It will probably not be started until next year.

The neighbouring district health authority is Chester, and thousands of my constituents receive treatment there. But I have received letters from consultants in Chester who complain of the worrying situation because they are required to cut back their care. There is a major hospital in Shropshire, which was referred to by my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody), at Gobowen. Beds are being taken out of service there, and wards closed. That hospital serves north-east Wales, and the consequence of cuts there is very real to my constituents and the people of Clwyd.

I can tell the House of a young woman in my constituency who had trouble with her ear. She had to wait for two years before she could have treatment, when it was discovered that she had a hole in her ear-drum.

We have a special school in my constituency. There have been complaints about there being insufficient incontinence pads available for the daily working of that school. Cuts are planned in a much cared for hospital in Holywell, the Lluesty hospital; and many of my constituents have complained bitterly to me about the likely consequences of those cuts.

The Secretary of State in his speech—not a happy speech — said that he wanted to see the use of spare capacity. The experience of my constituents is that there is insufficient capacity. Indeed, there are cuts not only in my area, but in neighbouring health authorities. I will instance the result of a very distressing one. On the eve of Christmas, the Daily Post, a newspaper in north Wales, reported as follows: Chester district health authority is facing a demand for a government inquiry over the hospital transfer of elderly orthopaedic patients in a huge van. The front page has a picture of that four-ton red Bedford van. The article goes on: Said one hospital employee: 'The van was dirty, freezing and smelt of something like stale cheese. Nurses were crying openly. They could not believe that this was actually happening.' That was also reported extensively later in the Mail on Sunday. I bring it to the attention of the House because the very unfortunate manner in which two elderly citizens and patients were transported between hospitals on the eve of Christmas was the consequence of cuts, however temporary. That does not sit well with the posture of the Secretary of State for Social Services. I go further and say that it is vital to maintain the quality of our social services and to ensure that they are fully available to those who most need them.

Governments exist to ensure that the strong do not tyrannise over the weak. It is necessary to care for the nation, for the whole of society, and to express that care. Those are not my words. They are the reported words of the former right hon. Member for Cambridgeshire, South-East, a former Cabinet Minister, now ennobled and in another place, Lord Pym. That was perhaps one of the toughest and most bitter speeches made by a former Cabinet Minister in the autumn of 1983, but I think that he summed up the situation.

Social justice demands that Her Majesty's Government should provide more financial support for the beleaguered National Health Service. It is my fear that before very long, unless there is urgent Government action, we shall have two forms of health service: one for the rich of our land, a Rolls-Royce service that can provide miracles, the best of health services for the very privileged; and the second, which we are in danger of getting, for poor people —a system that is shabby and does not deliver the best and most needed services.

That is the drama of the situation in which Britain finds itself today, and unless the Government, in their remaining years in office, are prepared to find the funds and take the decisions, our Health Service may be lost to all the nation as a free service giving the best of care, as the great Mr. Bevan would have wanted it to do.

My demand is that we avoid the temptation of tax cuts to buttress the political standing of the Government among the upwardly mobile. Indeed, Her Majesty's Government should realise that the divisions in British society which are now manifest and growing could be narrowed and partly eliminated if our Health Service were made better. The Health Service in Britain can be a unifying factor for all our people. Major tax cuts would put massive pressure on the balance of payments problem that will face our country for the immediate future.

Huge investment or even urgent investment in the Health Service would create work and give greater happiness and security to countless families.

I urge the Government to think again about their attitude and strategy and, when the Budget comes along, or even before, to give massive new funding to help our National Health Service.

6.45 pm

Dame Jill Knight (Birmingham, Edgbaston)

Perhaps I should begin with the charges. The charges made against my right hon. Friend and the Government today deserve to be rebuffed with energy, determination and, indeed, contempt. I say contempt because of the disgraceful personal attack on the Secretary of State over his recent medical treatment. The Opposition really have it both ways on this. Had my right hon. Friend not used some of his salary to pay for his own medical attention and therefore had taken up a bed in an NHS hospital he would have been under attack for that. I have always understood that the Labour party believed in rich people paying for what they get and not getting it for nothing.

Mr. Jeremy Corbyn (Islington, North)

rose—

Dame Jill Knight

No. Mr. Speaker is anxious that all Members be very swift in their speeches, and I intend to be so. The hon. Member can make his own speech.

When people are in receipt of a fairly high salary for the job that they do, it seems to me to be absolutely right that they should pay for their own health care and leave a bed available for someone who is less well off.

As for the remarks made a moment ago by the hon. Member for Alyn and Deeside (Mr. Jones), who seems to be about to leave the Chamber, he is quite wrong about the private sector. All too frequently the National Health Service is the one that provides the highest standard of very complicated care. In many cases, if very complicated cancer or other treatment is needed there is nowhere but the NHS to get it. For that, too, I salute the NHS.

We affirm that our Government have an extremely good record. We are not saying that every last thing has been done, every last "t" crossed and every last "i" dotted. But we are saying that there is an extremely good record to talk about. Almost unimaginable extra funds have already been made available.

The hon. Member for Greenwich (Mrs. Barnes), who does not grace the Chamber with her presence for very long, said that the Secretary of State cited the extra amount of money spent and said that all was well. He did not say that all was well. None of us on the Government side of the House would say that all is well with the Health Service. We are as anxious and worried about the difficulties that come to our notice as any Member of the Opposition. But we are entitled to say that very large sums of money have been made available. Waste and inefficiency have been tackled as never before, and goodness knows action was very badly needed there. They would never have been tackled by the Labour party.

The recruitment of doctors and nurses is up, with substantial extra money being paid out in salary increases. There are far more patients going into hospital for treatment and far more being dealt with in out-patient clinics as well. Of course, it is also true that there are people waiting for treatment, but we are spending very much more money on extra treatments, extra doctors, and extra nurses, and all of these are being used to help patients in the NHS. And we are to a certain extent victims of our own success. We are short of money because so much is being done. If so much were not being done, we would not be short of money.

The press seems to concentrate exclusively on those people who have not had treatment. There is a lot of emotional mileage in postponed operations and closed wards. Some papers with more space than taste print pictures of funerals, wreaths and tears. If that happens, it is fair enough, but surely something should be said sometimes about the tremendous number of people who are getting treatment. Is there no emotional mileage in someone having a cornea transplant and suddenly being able to see, or having any of the other transplants which miraculously, although expensively, are now available, such as coronary artery bypass grafts? Surely there should be some human interest in that, but we never see any stories of that kind in the press. The only accounts are those of people who have not immediately been able to have treatment.

Statistics do not count very much to those in need of treatment. It is rather like being unemployed. If you are not unemployed, it is not nearly such a 100 per cent. issue as when you are unemployed. Many people are getting treatment and the media should highlight their success and the alleviation of their conditions.

The press and some Opposition Members tell us that everything is fine everywhere else in the world and that only the NHS is in terrible trouble, but is that true? As we have been reminded, heavy cuts in expenditure are being made in West Germany where there is huge overstaffing in many hospitals. There was an estimate at the weekend of 50,000 beds lying empty at great expense. Opposition Members will be riveted to hear that in Russia they cannot even provide lavatory paper in the hospitals, let alone vital drugs. In Italy, hospital patients have to provide their own food and strikes by nurses and doctors are common. In France, the Health Service is described as being on the verge of bankruptcy. Although I warmly recommend Greece as a delightful place for a holiday, I do not advise hon. Members to become ill there because its health service treatment is appalling. We all know what happens in the United States where many people are literally bankrupted when a member of their family is ill.

I was disappointed that my right hon. Friend did not say very much about future funding of the National Health Service. As is apparent from many of tonight's speeches, there is real concern about getting more money for the National Health Service. The figures need careful examination, given that inflation in Health Service technology is far higher than it is in the outside world. We need new pieces of equipment and we want to buy them when they come on stream, but they are extremely expensive. There are growing numbers of elderly people and the problems that we shall have to face on that score are very severe. We do not know how much we shall have to spend on AIDS. The amount we spend on abortion is amazing. We must consider all these matters when discussing funding.

The cost of drugs has increased very much. The Government deserve a bouquet for having brought in the restricted list. Let nobody deny that that has given an extra boost of money to the National Health Service. Although, at first, there was an immense row and the Opposition were in there fighting, we hear nothing about it today because the idea has been a great success and has saved a lot of money. The Government do deserve credit for that.

We need two sorts of cash. First, we need an immediate cash increase because we all know places where more cash is needed. The trouble is that it is virtually impossible to be told how much is needed to end the problems. Secondly, we must consider long-term funding. The Opposition attack us on the Health Service because there is nothing else on which to attack us, but they are on a false trail.

6.54 pm

Mr. Robert Litherland (Manchester, Central)

The Opposition make no excuse for highlighting the starvation of resources and finance in the National Health Service and its contribution to hospital problems. Not a day passes without reports of hospitals facing extreme problems of finance and manning levels in their attempts to provide a medical service to people in need in their catchment areas. Rural cottage hospitals and major inner-city hospitals are in a state of crisis unknown since the introduction of the National Health Service.

I shall take one hospital which epitomises the situation in the National Health Service. The Manchester royal infirmary in my constituency is a hospital whose management continually strives to achieve a balanced budget. It has sold land and property belonging to the hospital, introduced privatisation, reduced general nurse training, reduced midwifery nurse training, consolidated operating sessions in one fewer theatre and saved through early retirement and changes in shift work patterns, yet it still faces an overspend of £1 million. The Government are coming back for further cuts. In fact, the hospital is a victim of its own efficiency.

What have been the consequences of this budget balancing? The Manchester royal infirmary now faces the worst crisis in its 200 years of existence, because the word "bankruptcy" is being bandied about. This is confirmed by letters being sent to 2,500 hospital staff, saying that the hospital may not be able to pay their wages.

Mr. Favell

Will the hon. Gentleman give way?

Mr. Litherland

I shall not give way, because I know from experience that the hon. Gentleman's intervention will be longer than my speech, and shorter speeches have been requested.

Balancing budgets by delaying payment to major suppliers has resulted in a debt of £5.6 million. The suppliers are now demanding payment and threatening to cut off these vital medical supplies. What are the consequences of this situation? Just before Christmas. I was informed that babies are dying because the intensive care system has collapsed; five cots for premature babies were closed at Christmas. The electricians came in to cut off the oxygen supplies. These are not the words of politicians making political capital out of that sad situation. They are the words of the head of the special care baby unit at North Manchester general hospital.

Mr. Stephen Day (Cheadle)

rose—

Mr. Litherland

Young women with abnormality of the cervix are turned away because the hospital cannot cope with an increasing waiting list. Women are already facing a six-month wait for treatment and, because of lack of funds, there is no possibility of cutting that waiting list. There are cuts in nursing and closures of wards and operating theatres. Babies are turned away and young women with cancer of the cervix are refused treatment.

All this is happening in one hospital in an inner-city area that has suffered enormously because of the Government's policies. The area is more reliant than ever on a good hospital service. There is a correlation between unemployment, deprivation and bad health. Once again, these are not the words of politicians, but the findings of a report by eminent people in the medical profession. Life expectancy in my constituency is well below the national average. The child mortality rate is higher than the national average.

In an article in the Manchester Evening News, a Dr. Thatcher—I shall not hold his unfortunate name against him—reminds us: In South Manchester, all the cost-efficiency savings that can be made have been made, and we arc now down to the bone. There's basically no money for new developments so this means the so-called contingency plans are drawn up—and we've seen this happen before in the last five years—and the wards are closed about four to six months later. Or the contingency plans have a lot of adverse publicity which dies down, and then, usually around May or June, the bed closures are put into operation. We've lost over 250 acute medical and surgical beds in South Manchester in that time. He goes on to point out how two-faced the Government are. They are consistently praising the hospital service for being more efficient, which means more patients are being treated. He says: Wythenshawe Hospital has the highest clinical performance indicator of any major acute hospital, therefore by definition it is highly efficient. But because it is so efficient and attracts patients throughout the North West region and elsewhere, we are to be penalised by the administration who say they haven't got the money to treat all these patients. The patients come to Wythenshawe and Manchester royal infirmary for special treatment that they cannot get anywhere else.

In this debate we have talked about other means of finance, but what has the hospital service come to when 90 per cent. of the equipment in the intensive care unit at Manchester royal infirmary has been bought with money raised by its staff? What has the hospital service come to when ultrasound scan pictures of unborn babies are sold at £3.50 a time to raise money? Hospitals cater for weddings and other functions, sell babywear, even book trips on Concorde and develop shopping malls, all in an effort not to increase the hospital service, merely to maintain it and to ensure that it continues to provide a service. That is happening in what the Prime Minister and Chancellor inform us is a buoyant economy, when consideration can be given to a further cut in income tax. It is the Government who are sick to allow this unnecessary predicament to exist. Babies are turned away to die when tax handouts can be given to the rich.

The Government should listen to the leading doctors when they inform us that the NHS is on a downhill slide. They should listen to the dean of the medical school at Manchester university when he informs us of the dangerous impact of the cuts on undergraduate medical education. They should listen to the nurses who are forced to strike because they cannot exist on a pittance and with poor service conditions.

For their pains, the nurses receive snide insults from Conservative Members about lining their own pockets. The former chairman of the Conservative party, the right hon. Member for Chingford (Mr. Tebbit), referred to nurses moonlighting. That is rich coming from a man with so many directorships. From being held in high esteem as angels of mercy, nurses suddenly become devils of greed. There has been talk about shroud waving and whingeing.

Above all, I ask the Minister to listen to the people who are in desperate need of treatment—to listen before it is too late for them and too late for the NHS.

7.4 pm

Sir Rhodes Boyson (Brent, North)

The genesis of the Health Service came in the Labour Government after 1945 at a time when, after total war, there was a feeling on both sides — more strongly on the Socialist side than the Conservative side — that, having won the war by a concentration of resources and people, one should win the peace in the same way. The National Health Service represented that.

The National Health Service is a nationalised, not a national service. I shall define the difference between the two shortly. The Health Service was nationalised at the same time as the railways, the coal mines and all the rest. It involved the nationalisation of 1,000 voluntary hospitals, 500 municipal hospitals and many private hospitals.

At the time, nationalisation was popular. The general climate of opinion in Britain among Socialists was strongly in favour of it and the Conservative party was halfheartedly in favour of it, if I may put it that way after reading speeches of the time. The National Health Service grew out of a time when nationalisation was a popular policy in Britain.

Since 1948, 40 years have passed and three things have happened which have led to the crisis in the Health Service. This is a crisis not just of resources, but of design—whether the service now meets the needs of the present time. That must be said to Opposition Members, each of whom I respect.

It is interesting that no other country has followed our example. If ours was the best service in the world, people would be coming here to see it. The NHS grew out of a general belief at that time and out of the Beveridge report, as all of us know.

Nationalisation, in the view of the general public, is entirely different now from what it was between 1945 and 1951. That is why the Conservative party has fought three elections on denationalisation and has won with votes from all classes in our society. Nationalisation is no longer seen as a great frontier advance. It is now seen as something to be rid of, so that we can return to some form of competitive enterprise for the benefit of all classes and groups in our society.

The second difference is the rising standard of living. Rationing was all around us between 1945 and 1951. That has gone. People then were used to waiting. I am not making a virtue of that, but people were used to waiting. The war meant that rationing continued for a considerable time.

That time has gone. Now, 16 million people holiday abroad. People buy videos and cars. They do not expect to wait. They do not go to the travel agency to be told that there is a queue and that they should come back in two years' time when they may get a holiday in the back streets of Turkey. People read their brochures, save their money and go away when they want for as long as they want.

The outcry about queues in the NHS is because queues do not exist in any other area. People realise how important health is. All hon. Members do. That is why so many have been present for the debate today. The Government must be given credit for the change in people's expectations. The Government are responsible for the economic advance and, in particular, for how much better off those in work are now than ever before. People are no longer willing to join queues for a long period.

Thirdly, great technical advances have been made and the cost of medicine has increased. Many of those advances were unheard of 40 years ago. It is always well to go back to first principles, and one reads in the Beveridge report an estimate of what the NHS was expected to cost. In 1945 it was estimated as £170 million. Index that for inflation and we now are spending 10 times more in real terms than Aneurin Bevan—all credit to those who brought it in—thought it would cost at that time.

First, nationalisation is no longer popular. We live in a denationalising age. Secondly, people are not prepared to queue because the consumer goods society has given people a taste of getting things when they want them. Thirdly, technical medicine has become very expensive.

Let me define the difference between a nationalised and a national Health Service. A National Health Service is one in which the Government somehow ensure that all parts of society, including the poorest, get health care. No one in this House would disagree with that. However, the Government do not need to provide that health care; they need to ensure that it is available to everyone. Local authorities now use competitive tendering for their services, and they do not provide them. They ensure and expect that the best service available is obtained. No longer do we need a nationalised Health Service.

My right hon. and hon. Friends and I differ in this continuing debate. Often, these days, we Conservatives have to provide our own debate within the party, which is sad, but I am glad to contribute to that debate. There is something wrong with the design of the system. I shall not throw figures around; I shall be brief. We now know that we have more than twice as many nurses as we had in 1960 — 480,000 as against 236,000. We have fewer hospital beds, and a shortage of nurses that we did not have then. The ordinary man or woman in the street might say that that looked odd, and he or she might have a point. I have some odd figures to illustrate this, which are interesting but do not require deep analysis. On one set of figures—many are going around—510,000 more people are employed in the Health Service now than were employed in 1970. Since 1970, the population of this country has risen by 500,000. So we are employing 510,000 more staff for a population that has grown by 500,000. Thus, on a straight-line graph projection, there will come a time when more people are employed in the Health Service than live in this country. It will not happen in our lifetimes, but the man or woman in the street or in the public bar—on second thoughts, we are all in the saloon bar now, thank goodness — may say that that is odd. And I say that he or she may have a point.

Because of the lack of time, I cannot advance a detailed scheme now; nor do I have one ready. Bright lights in dark corners, I always say, and one must start looking at what must be done to improve things now. Money must follow the patient. Wherever there is a service in which the money drips down from the top there will be massive numbers of administrators, and a lot of the money will go to the wrong places. Money following the consumer is the basis of denationalisation, and consumer control has transformed so much of the economy of this country which before was an economic dinosaur.

Some form of insurance will have to come. The Government's job will be to ensure that all the people can properly insure themselves. It will cost somewhere between £300 and £500 per person. Three booklets that have come out recently — the author of one is sitting on the Conservative Benches now— on the subject all give different figures, so if I average the lot, we shall say that it will cost £400. Every person in the country could be given a voucher for £400 for health insurance. It is the same system as we have for car insurance, which is not done by the Government. One insures the car, and the insurance company has to provide the service so that one is not bankrupted. That is one way of doing things.

The trade unions began as benevolent—

Mr. David Hinchliffe (Wakefield)

rose—

Sir Rhodes Boyson

I have no intention of giving way. I have made up my mind on that, which is a good thing to do in society. The hon. Gentleman is a good man and I have the greatest respect for him. Long may he remain up there on the Back Benches. No: why not welcome him to the Front Bench in a generous-hearted way?

The trade unions, which are losing their meaning these days, could go back to being the benevolent societies that they began as. In France, one can insure with a trade union. After getting the bill, one goes along and expects to pay something oneself, and the trade union pays the rest. If people cannot pay, they go to social security. It is a relatively effective system, and I inspected it when I went to France in the course of my ministerial duties.

The Government lack the wisdom—even more now that I am no longer a member— to run 1,800 hospitals effectively by means of Ministers, civil servants, regional and area boards, trades unions and professionals, who are all battling for control. It is no wonder that efficiency is lost somewhere along the way. So why not denationalise many of these hospitals and, as happened with the Wembley hospital, which began under local control, put them back under local control? They would raise vast sums of money. Why cannot the trade unions take some of the hospitals? Why cannot the churches? That would give them something to do at last. They spend enough time talking about social events. Why cannot they take some of the hospitals over? It would give them something to do. Why do not the workers take some of them over? The Opposition believe in that until it happens. Why do not these people take over the hospitals and answer to the market?

The hon. Member for Livingston (Mr. Cook) mentioned me in his speech, and I am always grateful for that. He talked about whether the churches could do something, mentioning the Church of England. As a Methodist lay preacher, I never mentioned the Church of England; I think that the non-conformists can take their share. On behalf of them, I make that point.

I have said it outside the House, and I now say it here: this problem is the Government's Achilles heel. As one who has suffered from that trouble, I know how painful it can be until it is cured. The House, in its charity, will allow me to mix metaphors. This problem could become the Government's albatross, with the ancient mariner, in different garb, sitting outside each hospital. The problem will have to be dealt with. It is no good doing it piecemeal, either. While sorting out the immediate problems, the time has come to change the whole basis of the Health Service's design. It is antiquated and will have to change. I only hope that the Conservative party, of which I am proud to be a member, will be as radical in social matters as it has been in economic matters. The Government have put the market in control in economic matters to the advantage of everyone in society, and I trust that we shall do the same for health, so that everyone, from the poorest to the richest, can be dealt with, not by a nationalised Health Service but by a national Health Service.

7.18 pm

Mr. Sam Galbraith (Strathkelvin and Bearsden)

In contrast to that of the right hon. Member for Brent, North (Sir R. Boyson), I enjoyed the contribution made by the hon. Member for Eastleigh (Sir D. Price) and his excellent analysis of the stresses and demands on the Health Service, and I agreed with part of the reason he gave for the problem. He outlined the numerous things that put pressure on the Health Service, but I want to take issue with one part of his analysis. He spoke about demands. There is an important distinction to be made between demands and needs. We should try to meet needs, not demands. Demands do not necessarily correspond to needs.

The advantage of the Health Service is that it is more related to need, which it can control and examine. A private system, such as that suggested by the right hon. Member for Brent, North, leads to a system that is demand-led. Then there are difficulties in fulfilling people's expectations from available resources. I hope that the hon. Member for Eastleigh will take that into account. Only the NHS deals with need; private systems deal with demand, which has only a tenuous relationship with need.

I want to address some other points about the market and the National Health Service that have been made by hon. Members. I shall deal, first, with another factor that is used as an excuse for the problem. We have heard that the consultants, the nurses and, finally, the Minister himself were to blame. Another factor is known as the bottomless pit. We always hear about it, but I do not think that health care is a bottomless pit. It is certainly true that health care expenditure can and does increase rapidly, but that is true of every country and health care system in the world.

If Health Service expenditure is to be controlled and used correctly, the most fair — and the only — way of doing that is to have a National Health Service. In the National Health Service, which is a system based on need rather than demand, staff examine new techniques and treatments. Doctors and nurses in the NHS agonise whether treatment is needed. They must go through the whole system before eventually deciding that treatment would be appropriate under the National Health Service. During the past few years, having looked at new techniques and systems of care and decided that they will meet a need, doctors and nurses find that there is no money with which to meet it. That is the crisis in the National Health Service.

We have heard a lot from Conservative Members about the market philosophy and the National Health Service. It is not appropriate to look at the National Health Service and the health care system in those terms. Silly statistics were quoted by the right hon. Member for Brent, North. He said that we have many more nurses but fewer beds. I will tell him the reason for that. Intensive care units, which we did not have in the 1960s, require about 50 nurses. Before the 1960s those nurses could have looked after seven or eight wards with 40 or 50 patients.

The market economy does not apply to the NHS, for a number of reasons. The first relates to consumer knowledge. I cannot make an absolute statement that within the health care services consumer knowledge is limited, but it is not easily defined. The lack of consumer knowledge is part of the reason for not applying a simple market philosophy to the NHS. Secondly, there is no competitive advertising, because advertising is against the General Medical Council's code of practice. There can be no advertising within the NHS. I suspect there would have to be some arm-twisting to get the GMC to change that.

The right hon. Member for Brent, North likened health care to choosing a holiday from a range. However, when we choose a holiday, we must look at our finances to see whether we can afford a holiday in a far-flung part of the world or whether we will have to take a holiday nearer home. That choice is based on resources. However, if someone needs an important operation, such as a gastrectomy or a neurosurgical operation, there is no such range of choice. A person cannot say, "I have limited resources, so can I have only half of my brain tumour removed?" That is an important reason why the market philosophy is not relevant to the National Health Service.

We constantly hear the Secretary of State talk about better value for money, and in particular about clinical efficiency. First and foremost, that is not a new concept for me or for other Opposition Members who have been campaigning for years that resources should be used much more efficiently. The Government have not listened. We recognise the great discrepancies in the use of operating theatres, beds and investigations. The Minister must realise that improved clinical efficiency will cost more money. It is not a substitute for putting money into the NHS. It will cost more money if a bed is used by five patients in a week instead of by one patient. If an operating theatre is used by more patients, it will cost more money. We need more money to treat more patients. We do not want clinical efficiency because it will save money. We want the correct and proper use of resources that have been under-used to benefit the patients and eliminate waiting lists.

The right hon. Member for Brent, North and other hon. Members spoke about alternative systems. I want to clear up a few fallacies about the United States and various European systems. First, the administrative charges in those systems are much higher than ours. We hear all the nonsense about the National Health Service being a lumbering bureaucracy. It is not. In the National Health Service 5 per cent. of the costs are used for administration. In some parts of the United States that can be up to 31 per cent. of the costs. Is that what Conservative Members want?

When we examine the care provided in those systems which are demand-led, not need-led, we find that many more operations are done. I shall give some examples of that from Mr. K. McPherson in Social Sciences and Medicine: Regional Variations in the Use of Common Surgical Procedures. It says: Hysterectomy rates in the US and Canada were around three times greater than for England and Wales. Similarly Prostatectomy was around two and a half times more common in the United States and Canada than in England and Wales, while tonsillectomy was around twice as common. That is what happens in a private, demand-led system. I understand the reasons for that. I have worked in such a system. If a difficult clinical decision is involved as to whether an operation is needed, in a demand-led private system an important aspect is that it will receive £1,000 for the operation. That is a reason for the discrepancies. That is why those systems are subject to such pressure.

In Britain, doctors agonise too much about whether to carry out an investigation or an operation. In demand-led private systems they do not think about that. They go ahead with the investigation or the treatment. I have worked in both systems, and that is what happens. It is part of the reason for the escalating costs in private systems, and that cannot be controlled in a demand-led system as opposed to a need-led system such as the National Health Service.

Mr. Ray Whitney (Wycombe)

I wonder whether the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) saw the report in The Sunday Times which compared the experiences of a man in Bristol with that of a man in Germany. They had both had heart attacks, but the man in Bristol had to wait 15 months for his operation and was out of hospital within a week. The German was immediately given his heart operation and was given three weeks for recuperation in hospital and another six weeks of convalescence. That is another example of the service enjoyed by Germans compared with the British system.

Mr. Galbraith

The hon. Member for Wycombe (Mr. Whitney) has highlighted our case for the need for more money within the NHS to provide a better service.

Finally, the Minister made great play about primary care and how it is a way forward. The primary care sector is the back bone of our system. If we change to a demand-led system, we will eliminate primary care and people will be pushed off to specialists. For all those reasons, I should like us to consider no further the question of demand-led, private health care.

We cannot apply market forces to health care. The correct and proper system is the National Health Service. Resources are limited and we have to ration and use them properly. We want that rationing to be based on medical need, not on some nebulous demand stimulated by private finance. The most cost-effective and cost-efficient way of doing that is through the National Health Service. That is why Opposition Members wish to sustain the National Health Service, and ask that it be given more money.

7.28 pm

Dame Elaine Kellett-Bowman (Lancaster)

In Lancaster we do not fear but welcome the Secretary of State's determination, put forward so forcefully, to compare costs and achievements in the regions, because we would do well on any tests so far devised and any he may put forward. We welcome the extra £100 million that the Government gave on 16 December. Contrary to the local gloomy forecast that Lancaster's share of the additional £5.8 million allocated to the north-west would be "negligible if anything", we got the largest district allocation of £600,000. That was good news for Lancaster and it goes some way towards meeting my plea that we need more money because 23 per cent. of our population are aged and need a great deal more care.

Twenty years ago in Lancaster the decision was taken to centralise hospital services on the Royal Lancaster infirmary site for midwifery, elderly services and acute services. Since then our programme has gone ahead steadily, except for the unfortunate check in 1978 referred to by many hon. Members when all hospital building was halted abruptly by the Labour Government because of the financial crisis. That delayed our progress, but phases 1 and 2 for maternity and elderly persons have been successfully completed. Phase 3 for acute services is at the planning stage, as announced by my right hon. Friend the Minister for Health when he came to Morecambe in the autumn.

As new facilities are provided, old ones must close, and regrettably that leads to much heartache. The Beaumont hospital, which is to be closed, was built as a fever hospital with widely spread buildings to insure against cross infection. It is unsuited to modern needs and is wasteful of the time of doctors and nurses. It is definitely not in the best interests of the health services in Lancaster to campaign for it to remain open when the specialist facilities can be provided elsewhere. Discussions are now under way in the health authority to decide where to reprovide the specialist facilities currently provided at Beaumont. It is still in the melting pot, but if it is decided to provide them at the RLI — which, I believe, is the best place for them, because all the advanced support facilities are available on the spot—the building of a new ward block for ear, nose and throat, dental and neurology services could begin in April, and the £600,000 additional funding will cover most of the cost.

At the same time, the accident, emergency and intensive care facilities at the RLI will be upgraded. When I saw those facilities yet again at Christmas I was horrified by them. Given that we are near the motorway, where, sadly, many multiple accidents have occurred, it is absolutely essential to upgrade our emergency and intensive care services.

On Friday I received news that services will have to be reduced in the orthopaedic and accident and emergency departments, not because of a shortage of funds, but because we are short of six junior hospital doctors, For whom we have been adverising since October. We recruited one on Friday and we hope to fill the other posts in February. When we do, the facilities will again be opened. Another hospital in the north-west has had to close its maternity ward, for the excellent reason that 11 midwives are on maternity leave.

In Lancaster we are proud of our leading role in many aspects of health care. We lead in the proportion of our children who are immunised. Having a large elderly population, a year ago we purchased laser equipment for eye surgery. Because our citizens are intensely proud of our reputation for health care, since for many generations we have been the primary hospital area for the whole of the north of Lancashire, up to Cumbria, we have raised £10,000 to buy another keratometer to use in the eye unit, and the local service for cataract sufferers has been revolutionised. No longer must we send patients to Liverpool or Manchester for the measurement and supply of customised lenses. Some eye patients, who had to spend lengthy stays in hospital, can now return home the same day, or after only two days, and up to 160 patients per week can be dealt with at clinics.

The new techniques have reduced the numbers of beds required from 24 to 14. That is a reasonable way to reduce beds. Nobody can say that we have lost the beds; we have made them unnecessary because of the rapid treatment in that specialty. But I do not intend to let the Government off the hook. In our large district, which covers 170,000 people, we have only one orthoptist, and we would like another to detect the early stages of glaucoma and to treat squints in children We are an efficient health district and our treatment costs compare favourably with those of other areas. Our good housekeeping keeps waste to a minimum. We had a limited list for drugs long before the Government brought it in. We are always looking for ways to improve efficiency and reduce unit costs. We never rest on our laurels. We believe in cash generation and, before it became the fashion, we were winning orders for outside laundry contracts to keep our modern machinery fully occupied and reduce the cost of our own laundry. Money allocated to Lancaster is never wasted. We would dearly like to build on the immense progress we have already made and to cut our waiting lists for miraculous treatments that we could not even have attempted a few years ago. We are determined to provide for our citizens in the future, as we have in the past, the highest standard of health care that modern techniques can achieve. We are looking to the Minister and his colleagues to ensure that we get a fair share of the health cake.

7.35 pm

Rev. Martin Smyth (Belfast, South)

Despite the crystal ball gazing of my friend from past years, the right hon. Member for Brent, North (Sir R. Boyson), I agree with the Association of the British Pharmaceutical Industry which said that for the foreseeable future health care will spring predominantly from the Health Service. It is important to put on record the words of the association's director of public and economic affairs, who said: But ideologically based criticisms of the NHS and/or its funding and performance from both the extreme left and the extreme right which exaggerated … its failings should not be allowed to obscure the successes of the British health care system. I believe that would be the view of most people and most hon. Members.

In the light of the pressures on the Health Service, the only real grain of comfort I got from the Secretary of State was when he said that this is the 40th anniversary of the Health Service. I was reminded of the old saying that life begins at forty, so there is hope that we can build on the success of the past.

The question from the right hon. Member for Plymouth, Devonport (Dr. Owen), which was not answered, was not whether the recommendation should be funded but, if the Government decide on a salary increase, whether that would be funded fully by the Health Service rather than the health authorities. That has been the source of tremendous discontent and problems in the past.

It is difficult to find factors to assess efficiency. Some authorities and hospitals are seeking to change the system of health care by providing more day care in hospitals, but the National Audit Office did a survey at midnight, so those hospitals that were efficiently using beds during the day were penalised. It would be better to take audits at midnight and noon to establish the real use of beds. The National Audit Office has taken figures on the use of operating theatres which showed that some hospitals had a high usage of theatres. On closer scrutiny it may have been discovered that the nursing staff and theatres were ready for the operations, but on many occasions the surgeon was not in post, so the theatres, as well as the equipment and staff, were not being used efficiently. I make that point to remind us all that it is not just a simple matter of assessing efficiency; other factors must be borne in mind.

I hope that when the Minister replies to the debate there will be an understanding that the funding of the National Health Service should not only keep pace with the growth of GDP — if I understood the Secretary of State's statement correctly—but should raise the proportion of GDP to meet need throughout the nation.

I am speaking particularly as a representative of Northern Ireland. The hon. Member for Alyn and Deeside (Mr. Jones) said that Wales was the most deprived area of Britain. I do not wish to bandy figures, but the region that I represent suffers from the highest number of deaths from cancer of the colon, which is 30 per cent. higher than other regions, diabetes is 25 per cent. higher and ischaemic heart disease is 60 per cent. higher. Unemployment is also higher than in any other region, which accordingly has a health impact.

I know that expenditure on health in the region is 25 per cent. greater than that for England and Wales, but professionals in the service say that it does not meet the present need.

I regret that recently there was a public dispute between the Under-Secretary of State with responsibility for health care in Northern Ireland and the chairman of the Eastern Health and Social Services Board, who is a careful economist. He judiciously chooses his words, and during his chairmanship there has been a tremendous increase in efficiency. The area caters for more people than in any other region in the United Kingdom not only in the health sector, but in social services as well.

It is necessary to take a hard look at the facts. In Northern Ireland, between June 1981 and June 1987, not in exotic surgery or treatments but in everyday medical care, there was a 16 per cent. increase in ear, nose and throat cases, a 56.5 per cent. increase in plastic surgery and a 51.7 per cent. increase in general surgery waiting lists, despite the acknowledged efficiency of the Province. We are faced, as is every other part of the nation, with the challenge of our own success. It is to that that we must direct our attention.

I used normal surgery as an illustration rather than what I called exotic surgery because those who can paint a dramatic picture of need in particular specialist cases —heart surgery, renal treatment and such like—often use emotional blackmail, which catches the imagination of some of the media, and indulges in a bit of queue-jumping. I find some measure of concern in that practice.

I have no axe to grind about the use of private medical care. It is obnoxious, however, that a person can be admitted to a National Health Service hospital because of clinical need and great pain but be told by the specialist at the hospital who is attending him, having obtained him that bed, "I cannot operate on you for 15 months, but if you go private I can do it very shortly."

There is something equally obnoxious in the case of a young man who had private insurance that covered his mother as an elderly person who managed to obtain treatment for her, without difficulty, in a National Health Service hospital. We may quibble about the use of a private bed in that instance, but when that insurance ran out, the specialist said, "I can no longer treat you." That is a reflection on the tension between the National Health Service and private health care.

I agree with the right hon. Member for Brent, North that where the treatment is given does not matter as long as we ensure that it is given. However, in many cases, it has not been given as it should have been.

The Eastern Health and Social Services Board has been told that the Government have said that the increase in services for Northern Ireland will be 5.3 per cent. That is 1 per cent. less than England and Wales are receiving, even though the board has made efficiency savings of 1 per cent. With a higher level of provision than England and Wales, it is discovering that it will run into greater difficulties in the coming year.

At a time when the Treasury is reporting tremendous surpluses, the House should reflect the views of the nation. The average citizen would prefer not to have his tax reduced if cutting taxes meant that the level of health care would not be maintained.

7.46 pm

Mr. Nicholas Winterton (Macclesfield)

I am delighted to follow the hon. Member for Belfast, South (Rev. M. Smyth). He and I have campaigned politically together and as members of the Social Services Select Committee.

As has been mentioned once already during the debate, the Committee will tomorrow be taking evidence from the presidents of the three royal colleges — Messrs. Todd, Hoffenberg, and Pinker. Perhaps one of the questions that we shall put to those three distinguished members of the medical profession is whether they believe that the doctors and consultants in the Health Service honour to the letter their contract with the Health Service. I hope that we shall receive a truthful answer, because while some members of the medical profession have been highly critical of Government — the Government have a major role to play in solving the current resourcing crisis in the Health Service — the medical profession, the doctors and consultants, have a major role to play in contributing to the solution of the problem with which the Health Service is faced.

My speech will be short. It will contain few sterile statistics, which unfortunately have been the hallmark of debates such as this and exchanges across the Dispatch Box. Having spoken to my right hon. Friend the Secretary of State, I know that he hopes that solutions to the problems, and perhaps an element of all-party agreement on some of those solutions, might be the order of the day in the future rather than trading statistics about who did what and when. While statistics were relevant in the debate last November if one is comparing what Socialist and Conservative Governments have done, this debate is not the time for trading statistics. This is the time for solutions that will help to cure the severe resourcing problems of the Health Service.

I take my responsibilities as a member of the Select Committee on Social Services extremely seriously. My uninterrupted service of some 13 years to that Committee has given me contacts with those who work within the Health Service at all levels. Those contacts have been extremely useful to me and, I hope, have given me an understanding of the problems faced by the Health Service.

Perhaps it would be appropriate at this stage and an illustration of the all-party approach if I said that the new Chairman of the Social Services Select Committee, the hon. Member for Birkenhead (Mr. Field), would normally be here wishing to participate, but he has had to attend a funeral in the West Midlands. The hon. Gentleman will be back in the House tonight but, sadly, he and I may be in different Lobbies.

I believe that the Select Committee, by undertaking its new inquiry into the resourcing of the NHS, will play a vital role in seeking to find some of the solutions to the problems facing the Health Service. Those problems are serious. I only wish that, when my right hon. Friend the Prime Minister exchanges remarks, questions and statistics with the Leader of the Opposition, she said, "We are proud of what we have done in the Health Service. We have provided more money than any other Government in the Health Service, but there are serious problems. I recognise that, but how can we solve them?"

Mr. Christopher Gill (Ludlow)

Does my hon. Friend agree that so far in this debate there has been a presumption—evident on both sides of the Chamber—that additional funding is the only answer to the problems? Will the Committee give serious consideration to the structure and management of the Health Service?

Mr. Winterton

Certainly there is an assumption that more money is required and I must tell my hon. Friend that I intend to urge the Secretary of State—I am sorry to see that he has left his place, no doubt for just a moment — that, in the short term, the only way to solve the severe crisis in resourcing that exists in many district health authorities is a further amount of money from central Government.

I note that my hon. Friend the Under-Secretary of State is taking prolific notes at this moment. I am seeking an assurance from the Front Bench that the necessary money will be available. I also believe that the Government should set up, as a matter of urgency, an inquiry into the long-term resourcing of the Health Service and that that inquiry should report before the end of the year. I do not believe that there should be a Royal Commission, because that would take far too long—a minimum of two years. I do not believe that the inquiries taking place within the Department will be enough to deal with the fundamental problems facing the Health Service.

As a member of the Select Committee, may I give my hon. Friend the Member for Ludlow (Mr. Gill) the catetorical assurance that the matters to which he referred — the management of the Health Service and its structure—will be part of the inquiry undertaken by the Committee. My hon. Friend's question has brought me to other matters of consideration because I believe that we must look at alternative forms of resourcing the NHS.

We should consider whether that funding would include the extension of private medical assurance and the additional involvement of the private sector in the operation of the NHS. Such involvement is already taking place to some extent in some district health authorities. We must also consider whether we should extend the contracting-out of services that are currently undertaken in-house within the NHS. We should consider further privatisation and hotel charges. I also believe that we should consider—the hon. Member for Greenwich (Mrs. Barnes) made a similar suggestion—the use of national and local lotteries to raise additional funds.

My right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe) spoke at some considerable length on the basis of his experience in various Government Departments. I believe that the Government must control the Treasury rather than the Treasury control the Government. If we raise extra money for the Health Service I believe that it is wrong that the Treasury should automatically deduct that sum from the money that it would otherwise give towards the running of the NHS. I hope that the Chancellor and other Ministers are of the right calibre and competence to counter any such activity at the Treasury.

Mr. Ian Taylor (Esher)

When the Select Committee is considering this problem, will it also take into account the attitude of the Treasury to splitting out a tax charge as part of the tax system? I hope that my hon. Friend would agree that, if we continue with a tax-based financing of the NHS, it remains almost impossible for the public to understand what it is that they are contributing to health care.

Mr. Winterton

I am delighted to have the opportunity to answer that question. Perhaps I could refer my hon. Friend to an excellent article that appered in the Sunday Telegraph on 17 January. A five-nation survey was undertaken and reports were produced on Germany, France, Russia, America, Italy and the United Kingdom. Mention was also made of New Zealand. In the introduction to the survey, Martin Ivens said: Like Britain, New Zealand is one of the few countries to pay public hospitals for their costs, not what they actually do. An official report to be published soon"— in New Zealand, I understand— is expected to recommend privatising the hospitals and making patients pay for treatment. I am not suggesting such a policy for the United Kingdom because I remain convinced that, in the main, the NHS should be free at the point of delivery—it is not free as such, because we pay for it in taxation and other ways.

May I pick up a point made by my right hon. Friend the Member for Brent, North (Sir R. Boyson)? I do not go along with many of the things that my right hon. Friend said about marketing the NHS and denationalising the Health Service. However, my right hon. Friend did warn the Front Bench—we should take note of such warning — that the Health Service is the Achilles heel of the Government. Indeed, to pick up an expression that my right hon. Friend used, the Health Service could become the albatross for the Government unless we are seen not only to understand the problems, but also to tackle them in a meaningful way.

I hope that my suggestions will come out in the recommendations from the Select Committee. Indeed, we will be producing interim reports because we are undertaking a major inquiry into the NHS. We must provide additional resources for the NHS.

The hon. Member for Manchester, Central (Mr. Litherland) spoke with great passion about the Manchester royal infirmary. I have a number of constituents who are consultants at that hospital. I have visited the MRI in a private capacity; otherwise I would have notified the hon. Gentleman, and have spoken not only to the management, but to some of the leading consultants. That hospital faces a serious crisis in resources and it must be tackled by Government. The Under-Secretary may turn away in disgust at what I have said, but I assure her that there is a crisis.

The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

I am noting down what my hon. Friend says.

Mr. Winterton

I am glad that some of what I have said is being noted.

The MRI is a centre of excellence and a leading teaching hospital in the centre of Manchester and part of the central Manchester health district, which is part of the North Western regional health authority. Its catchment area is relatively small. However, that hospital draws in from a wide area because it is a teaching hospital and a centre of excellence. I believe that the Government must pay special attention to hospitals such as that.

I believe that the Government mean what they say when they speak of value for money. Can it be right that in the Macclesfield district health authority an expensive and excellently equipped first phase of a district general hospital, costing some £18 million, should have two of its important acute wards closed at this time? Is that value for money? Is that bringing a return on the substantial capital investment? No, it is not.

However, there is more that is wrong. The consultants have been co-operating with the management of that district to bring about the savings that the Government have urged all district health authorities to make, but is it right that the management should say to those consultants that they must reduce their theatre sessions? Are they going to go out on the golf course or undertake more private practice? I urge them to fulfil their National Health Service contracts to the letter. However, what happens if they cannot fulfil their NHS contracts to the letter because, for example, they cannot use the operating theatre to carry out the operations for which there are waiting lists? The Government did well on waiting lists until last October when the crisis developed. Waiting lists, which were falling, are now beginning to increase again. That is a very serious matter.

I pay tribute to my right hon. Friend the Minister for Health, who met a delegation led by me just before Christmas. He heard at first hand of some of the problems with Macclesfield health district. In spite of what the media and some hon. Members say, the problems facing the Health Service have arisen not because of cuts but because of the Health Service's outstanding success. It is because of the success of the managers — following Griffiths — consultants, doctors, nurses and all NHS staff. Medical techniques have advanced so fast in recent years that we can now carry out operations that were mere pipe dreams a year or two ago. We are now treating more patients in our hospitals. The replacement of joints—not just hips but ankles, knees, elbows and wrists—is now possible but the operations cost a great deal.

The Health Service is precious to all the people of this country and to most Conservative Members. I urge the Government not only to provide a further sum to help the Health Service through the present crisis but to set up an urgent inquiry into the long-term resourcing of the Health Service so that we can continue to be proud of the finest health service in the world.

8.1 pm

Mr. Eddie Loyden (Liverpool, Garston)

I listened carefully to the remarks of the hon. Member for Macclesfield (Mr. Winterton). It is encouraging to note that there are Conservative Members who recognise the value of the Health Service.

It is important that we should remind ourselves that the legislation that brought the Health Service into being in 1948, introduced by the then Labour Government, was probably the most progressive for many years. In that respect, it may not have been superseded since. Like other hon. Members, I can remember when there was no National Health Service and compare the health care of the pre-war period with that following 1948, when the Health Service was established. It is because they are able to make such comparisons that people outside the House recognise the importance of the Health Service and are prepared to defend it at all costs. That is why there has been such an outcry from the public at large. As they see it, and indeed as we perceive it, the recent deterioration in the National Health Service has reached crisis proportions.

The establishment of the Health Service largely ended the appalling and unacceptable pre-war divisions in the administering of health care. We must remember how the working classes were treated during that period. The poverty of the working classes and the environment in which they lived resulted in almost daily visits by hearses, arriving to carry away young children or their mothers or fathers. The life expectancy of such people was drastically shortened because the conditions that prevailed caused widespread and serious disease and illnesses. We saw the great value of the Health Service and the benefits that accrued from it when we watched the first generation of post-war babies growing up.

Especially after having listened to the Secretary of State this afternoon, Opposition Members are concerned at the way in which statistics have been to the fore in our debates on the National Health Service. Those outside the House who are worried about the Health Service are not concerned about the accusations or statistics that have been bandied about every time that the NHS has been debated in this House — particularly by the Prime Minister, who has ignored Opposition, and sometimes Conservative, warnings that the statistics disguised the reality at the coal face of the National Health Service.

Many hon. Members are more sensitive about this subject than they were, because there have been clear signs of the decline in standards in the areas that they represent. That decline cannot be measured by statistics. It is seen in the number of people waiting for hospital treatment, in the number of beds that have been withdrawn, in the closures and in a whole range of factors which are recognisable and which have been identified by patients and their families —those who are directly involved. They know about the decline in the National Health Service.

I do not want to bandy statistics around to verify the argument that the crisis exists. I am glad that the hon. Member for Macclesfield recognised that the Health Service is a regime. That regime includes people who may not be directly associated with medical care but who are as necessary as nurses, doctors and other hospital staff. It includes those who provide patient care in other ways—who keep our hospitals clean or provide direct services to hospitals. Frankly, those people have been treated most callously by this Government, with the result that this concept of patient care has changed. Patient care must include the role of the person who pushes the trolley that takes patients to the treatment room.

Let me give an example from my constituency. An 83-year-old woman waited for three and a half hours to be moved to the place where the ambulance would pick her up. That is one of many examples of the stresses unnecessarily caused to patients and arising from the changes that have taken place among ancillary staffs in hospitals. whose role is as important as the role of anyone else in the hospital. It is paramount that we should view the Health Service as a total regime. The decline started with the privatisation of cleaning and other services, which has left a bad taste in most people's mouths and has led to a deterioration of standards.

Those of us who sought the establishment of the Health Service saw the great benefits that derived from it. Opposition Members recognise the importance of the steps taken to end the scandalously poor health care available to hundreds of thousands, if not millions, of people in this country. The first post-war generation exerted pressure on the Government and made it clear that they were not prepared to return to local authority hospitals. It is ironic that Conservative Members should argue for a return of the control of hospitals to the local authorities, while at the same time slashing local authority funding. When hospitals were under local authority and charitable control, the care given most people was of a very low standard indeed. We all have a responsibility to ensure that that legislation that transformed the health care of people in this country, which, quite frankly, has been in decline for several years, must be arrested.

Statistics cannot alter the fact that there is a wide-ranging crisis in the National Health Service which needs to be tackled now, not in a year or two or later, following inquiries. The Government must respond to what is happening. They must recognise that people are waiting for treatment but not getting it; that people have been moved out of hospital too quickly, only to return, and that many people, especially old people, are waiting for cataract operations that they cannot have for the next 18 months or two years. My wife attended Clatterbridge hospital as a cancer sufferer. She was turned back five times because the machines were not functioning. That is the state that the National Health Service has got into over the years.

I hope that this debate will not be meaningless but that the Secretary of State will take it on board. I hope that it will end the jargon of statistics and that the Government will recognise the reality of the situation in the Health Service and the fact that it needs immediate and urgent attention—which means funding to ensure that people who are waiting for treatment get that treatment. The Government should ensure that hospital services are brought back to the standards that those who established it envisaged, not only for that time but for the future. It was envisaged that there would be constant improvements, rather than constant decline, in the National Health Service.

We believe that the National Health Service is not only worth defending, but that standards should rise. We should ensure the standard of health care to which our people are entitled. I advise Conservative Members that the most important investment that any country can make in its people is the investment in their health care. Without that, all else is meaningless. One cannot achieve production or the type of society that one wants if one does not provide the Health Service and health care that the people of this country need.

8.11 pm

Mr. Roger King (Birmingham, Northfield)

The city of Birmingham and, I suppose, the West Midlands regional health authority have been much in the news recently for various reasons, which centre, possibly almost exclusively, on the role of the Birmingham children's hospital.

It was apposite of my right hon. Friend the Secretary of State to say in his opening speech that much has been achieved by the Health Service during the past nine years under the Conservative Government. Indeed, a great deal of evidence is available in Birmingham and the west midlands to support that achievement. We can boast of many successes in terms of extra doctors and nurses and the number of family doctors has increased during the past few years. There has also been a reduction in the child death rate and in the number of stillborn births.

In Birmingham the improvement that has been brought about by the £4 million reduction in costs has meant that that sum is available for improving patient care. The number of staff has increased. In Birmingham, for example, the hospitals now employ over 800 more nurses than in 1979. The statistics are fairly substantial and most people, whatever their view, would accept that an enormous amount has been achieved since 1979. The trouble is that politicians jump on certain bandwagons to try to point out and identify areas in which there are problems.

The Birmingham children's hospital does have problems. It does not have its full complement of nurses for intensive care. Such nurses are not available, despite national advertising. Training such nurses takes time and there is nowhere else, outside London, where such training takes place. The West Midlands regional health authority has taken the initiative and is to start to train its own nurses in the hope that out of the 12 who start to train shortly, provided agreement can be reached with the nursing unions, most will stay in the west midlands area and at the Birmingham children's hospital.

Operating on young children is not a straightforward task. One cannot simply say that on 25 February one will give a certain child a major operation on his or her heart. Whether the operation takes place is dependent on the state of the child when the operation day arrives. The child may not be well enough to take the difficult and intricate operations that are carried out at that hospital.

Some of the publicity during the past few weeks has perhaps put hospital staff under tremendous pressure when making decisions which may not always be in the interests of the child, but are certainly in the interests of responding to widespread public feeling. The decision to operate is difficult for consultants and it is not pleasant for them to see television cameras and news reporters outside the children's hospital waiting for the latest crisis to emerge.

It is not helpful for Members of Parliament to place great emphasis on the problems in their community. I draw attention to the outrage that occurred in this House during prayers on the first day that we were back when the hon. Member for Coventry, North-East (Mr. Hughes) made a great crusade. Obviously he felt strongly about a child, presumably in his constituency, who was being denied an operation. It was a life and death situation. One would have hoped that the hon. Gentleman might have been present today to give us further background on his problems and that he would not have had recourse to such cheap publicity. As my right hon. Friend the Prime Minister said during Question Time this afternoon, the consultant of the child in question does not want to operate for another 12 months or so. That decision has been made to ensure that the child stands a good chance of recovering from a difficult operation when he or she has the strength to undergo it, not when a politician demands it. We are owed an explanation by that Member of Parliament.

Mr. David Winnick (Walsall, North)

rose—

Mr. King

No, I shall not give way. Time is pressing and other colleagues want to have a say, so I must get on.

When one considers the funding of the National Health Service, there are obvious opportunities to improve the resources available to the Health Service. We want to know where our money is going. We want to be absolutely certain that a pound that is given to the Health Service is a pound that is spent on hospital and patient care. Arguments are made about tax cuts versus extra resources for the Health Service. We need to be reminded that 1 million people work for the Health Service. Unfortunately, those people usually receive a low income. I am certain that they benefit enormously from the tax cuts that we have given during the past few years and that they will benefit again when my right hon. Friend the Chancellor has his say at Budget time. It is right to point that out because Opposition Members are always saying that Health Service workers receive low pay. However, when the Government try to bring their pay up to an acceptable level, using the mechanism of tax cuts, that is not acceptable either.

I recently appeared on the Kilroy-Silk programme from an excellent private hospital in Birmingham to talk about the problems of the NHS. Following that programme, a mother who was having difficulty obtaining an operation for her child asked me, "Where has all the money gone for the Health Service?" I explained to her that we were putting record sums of money into the Health Service. I told her that she was in a building that had been created because of resources that had been taken out of the Health Service because private patient treatment used to be part of the National Health Service responsibility many years ago. Those private patients were thrown out of the National Health Service as a result of doctrinaire decisions by the then Labour Government. Their money has gone into the creation of new private hospitals. Therefore, to a large extent, many of the resources that the Health Service used to have have gone elsewhere, to the detriment of the Health Service.

Miss Mowlam

rose—

Mr. King

I repeat that time is pressing and many hon. Members wish to speak, so I must get on.

The concept of free health, as we have understood it since 1948, when disposable incomes were non-existent because people had a job to house, feed and clothe themselves, is inapplicable now. They could not decide to have a new car or a continental holiday or anything else like that. Therefore, a free Health Service at the point of receipt was well received at the time. However, things have changed. Although we need extra resources in the Health Service, I want those resources to be bought by the prospective patients themselves. National insurance contributions could be reduced by a significant amount, provided that we established the principle that those who could afford it—not those of pensionable age, those on low incomes and the unemployed — would pay 50 per cent. towards the cost of their operations.

What would those people do in turn? To guarantee that they did not pay the 50 per cent., they would take out an insurance policy. And who would offer the best insurance policies? I hope that the hospitals themselves would offer competitive opportunities and treatments to patients in their areas and regions. I see no reason why such a system could not be introduced.

We should also look at reorganisation of the Health Service. To a degree, the service is too closely attached to this Parliament. Perhaps we should look at a British health corporation, which could operate at arm's length, and whose board and chairman could be given the money and told to get on with the job of running the Health Service.

I also believe that some of our specialist hospitals, which are wrapped up in the general morass of the Health Service — examples are the Birmingham children's hospital, the Queen Elizabeth hospital, the orthopaedic hospital at Oswestry and the Great Ormond street hospital — could be taken out of the existing organisation of areas, regions or districts in which they now operate, and put under a single national hospital organisation. An organisation of hospitals of excellence could well extract a substantial income from voluntary contributions through a national lottery. The trouble with a national lottery is that the £100 million or so that it would raise for the National Health Service would go a very short way to providing extra services all over the country. However, if the resources went only to hospitals of excellence, they would go a substantial way.

The challenge that now faces us is neither an Achilles heel nor an albatross around our necks. It is an exciting opportunity for us to get the Health Service right. We need to start a series of debates such as this, in which we can debate new ideas and exchange our visions of the future.

We are not talking about updating the service, or reverting to 1948. We are planning for a Health Service for the year 2000 and for the next century. This debate should form the groundwork for a national debate on what future structure the Health Service should take. It is a great challenge for the Government.

8.21 pm

Mr. Dennis Turner (Wolverhampton, South-East)

It is said that we live in hope and die in despair. I further despair after listening to the hon. Member for Birmingham, Northfield (Mr. King). What he said shows clearly the dilemma faced by the Government and their supporters in their attitude to, and philosophy on, the National Health Service.

The hon. Member for Northfield demonstrated, to me at least, that he is echoing one of the views of the Conservative party that is the most worrying to people in this country who cherish the National Health Service and wish us to address ourselves to the problems that it faces, not to misrepresent the difficulties of sick people who should be receiving our attention tonight.

Since I was elected in June, rather than thinking in party-political terms, I have sought to represent the interests of the people of Wolverhampton and the west midlands in facing up to our health problems. In my maiden speech, I mentioned that, in the last few weeks before the general election, 85 people in Wolverhampton had been turned away from hospitals in the town. I also said—and it was not challenged, then or subsequently, by the Minister—that we had lost £3.9 million from our budget since 1983. A more local issue, but a very deeply felt and sensitive one, was the reduction by 50 per cent. of the provision of incontinence pads for the elderly and the disabled.

On 7 December, I was kindly allowed to contribute to the debate on the Health and Medicines Bill. I was able then to illustrate the problems that faced Wolverhampton by pointing out that three people had died in recent weeks as a result of not being admitted to hospital, because no beds were available. Four hundred people had been refused admission, although, again, they were seriously ill. I also pointed out that we were experiencing considerable difficulties with the temporary renal unit, which could not meet the needs of kidney patients.

The Under-Secretary of State, the hon. Member for Derbyshire, South (Mrs. Currie), was present at that debate on 7 December; indeed, she wound up for the Government. She did not challenge the point that I made, although she had the opportunity to do so.

Miss Mowlam

The hon. Lady is not even listening now.

Mr. Turner

I do not believe that she was listening when I spoke last time. Perhaps there is something wrong with me. I do not know. However, my voice is coming across more clearly tonight. In any case, I shall continue, even if the Minister is not listening.

One can imagine how people in Wolverhampton, felt. In contrast to the argument that, while we know that things are bad, they are getting better, I am trying to illustrate that, in Wolverhampton, things are getting worse. I know that we have certain views about the accuracy of the press; however, on one occasion the press reporting was accurate. Let me give the House a picture of developments in our hospital service during the Christmas period. First we saw: 114 more beds to close". They were at the Royal and New Cross hospitals. Next, we read: All admissions to town's hospitals temporarily suspended". Patients threaten to chain themselves to beds to prevent closure. Surgeons in scathing attack on Heath Service funding". The hon. Member for Northfield talked about Birmingham, and said that the focus was on the children's hospital. No doubt he saw the headline announcing that 18 cancer sufferers at the Queen Elizabeth hospital had died as a result of not being able to receive the treatment that they needed. We met many parents and little children yesterday whom the Prime Minister did not see. We have seen the cases of David Barber and Matthew Collier, and we are all very pleased—

Mr. Winnick

In view of what was said by the hon. Member for Birmingham, Northfield (Mr. King), does my hon. Friend agree that the reason that my constituents Mr. and Mrs. Collier went public was that the child was given an appointment—not admission—only at the end of February? The only reason that he was not admitted was that there were no beds available. It was agreed that Matthew should have an operation as quickly as possible and, in those circumstances, the parents decided that there was no alternative but to go public. They were right to do so. If I was of any assistance, I am very pleased I hope, as we all do, that Matthew will recover fully and will live a long life. As to the Queen Elizabeth hospital, is he aware that when I visited the hospital on the same day two weeks ago that I visited the children's hospital, I was told that 27 beds in the section dealing with cancer patients had been closed last year?

Mr. Turner

My hon. Friend has made a valid point, that the problem in both hospitals is a shortage of beds. Wolverhampton hospitals in all the acute specialties, with the exception of ophthalmics, are short of beds. As I said on 7 December, in some cases the shortage is as great as 50 per cent. The case has been made for Birmingham as it has been for Wolverhampton.

The Department belatedly and reluctantly responded to the crisis by giving the non-recurring £700 million, which we were told was equivalent to £6.7 million for the west midlands and £200,000 for Wolverhampton, which will have to meet a deficit of £650,000 by 31 March. How can that contribution of £200,000 be reconciled to the crisis that we will face at 31 March and, indeed, the impossible task of meeting the 1 per cent. efficiency demands that apparently will be made for 1988–89?

There is non-reality about where we are moving in 1988. We can see no hope, only despair, for the people we represent in Wolverhampton. It is not a party-political issue. We are stating the case on behalf of the people that we care about. The greatest contribution that the Minister could make for the Government would be to give us a full and total commitment to the principles and values of a national, centrally-funded Health Service available to all at the point of need. We should start to restore the faith and confidence of all who work in the Health Service. We should acknowledge properly their skills and ability. Further, we need at least £1 billion to begin the process of putting the heart back into our National Health Service.

8.33 pm

Mr. Robert McCrindle (Brentwood and Ongar)

My basic approach to the debate is that there are no simple solutions to the dilemma in which we find ourselves in the National Health Service. Anyone who speaks to the contrary is misleading the people whom we represent. There is certainly no point in pouring funds in without a real understanding of the nature of the problems that confront us. I was struck by the fact that the hon. Member for Livingston (Mr. Cook) talked about nothing else but the need to provide additional funds. Many of us would concede that that has a part to play in solving the problems, but to say that that alone is the matter to which we should turn our attention is wholly misleading.

I find it equally unacceptable to contemplate what I think my right hon. Friend the Member for Brent, North (Sir R. Boyson) calls the privatisation of the National Health Service if by that he means the selling of hospitals and the provision of health vouchers to the population. That is unacceptable, although it is different altogether from saying that I am other than a firm supporter of the private sector in health care. I want to see that expanding and playing a more vital role in total health provision. Apart from believing that the proposals of my right hon. Friend the Member for Brent, North are politically unsaleable, I believe that in 1988—things may change in the years ahead—the majority of the people continue to support a National Health Service which is funded predominantly by taxation. I repeat that that is different from saying that there is no argument for additional sources, but I do not believe that we should lose sight of the fact that the National Health Service as we have known it for 40 years remains basically acceptable to the vast majority of people.

As in most things, the likeliest solution to the problems of the NHS may lie in what I shall probably be ridiculed for calling the middle way. That means that sufficient funds must be made available in the short term but that Her Majesty's Government must simultaneously take a grip on the many administrative difficulties which in turn may require the establishment of a swift, meaningful examination by an impartial body. I listened with interest to the suggestion of my hon. Friend the Member for Macclesfield (Mr. Winterton). He is correct in saying that we do not need a Royal Commission, but I am less persuaded about whether we can be so certain that we understand all the basic administrative problems.

I suspect that sufficient funds are available — they have already been allocated — but there are two immediate areas of concern to which the Government should pay attention and for which funds must be provided, if they are not available, within the additional sums that will come forth in the next financial year—a point, incidentally, to which very few hon. Members have paid attention. We keep pressing for more expenditure in the next financial year without recognising that we already know that a substantial amount of additional health expenditure will be forthcoming as a result of the Autumn Statement.

The Government must accept that if there is a nurses' pay award in the next few months at the same level, say, as that for last year of 8 per cent., they must pay that 8 per cent. They must not accept the award and pass on half of the responsibility for meeting it to regional health authorities. If they do that this year, as happened last year, the additional 4 per cent. which will have to come from existing budgets can be found only by a reduction in patient care. We should not countenance that.

There is a strong case for the restructuring of nurses' pay so as to provide incentives to attract people into those specialties where, as the popular press has been telling us over the past few weeks, there is an acute shortage.

In the short term, there is also a strong argument for again targeting a limited amount of funds at the reduction of waiting lists. The success of last year's efforts, with minimal resources, was such that I recommend to my hon. Friend the Under-Secretary of State that further consideration be given this time, not to targeting waiting lists in general, but to taking note that in some parts of the country the waiting lists for kidney and cataract operations are in all conscience far too long. Whether on this occasion we should target the additional resources not to waiting lists as such but to the ailments in respect of which we know there are long waiting lists is worthy of exploration.

Beyond that, additional funds may still be required. That will be so only after we have cleared our own minds as to exactly where money is required. I repeat that there is no advantage in saying indiscriminately that we should invest more in the Health Service without being clear as to the reasons why the Health Service is in difficulty.

Let me give the House some examples of the questions I believe must be answered before we have a clear idea of the direction of additional funds. Why, for example, is there such a disparity in the efficiency of district health authorities? Why are waiting lists in one area so different from waiting lists in another? It cannot be purely accidental. Is bed management better in some areas? Are there bed managers in some areas but not in others, and should they be a requirement? Do we need—dare I say it in quite basic terms that I know will provoke some people outside the House—regional health authorities at all? We seem to have survived perfectly well without area health authorities, which were considered to be essential before 1974.

What future role is there for the private sector? Should there not be more cross-fertilisation with the NHS, and should we not have more choice within the NHS with the development of an internal market? We need answers to all these questions, but they need not necessarily require additional resources. If the answers to these points require more money, then I would willingly go along with that. This is again a personal viewpoint, but I would willingly forgo some of the tax cuts to which we can look forward, if that is the way to achieve it. I believe that we can achieve desirable tax cuts and the desirable increase in expenditure necessary for the Health Service.

What we must not do is convince ourselves that all that is needed is to throw money at the problem. We must first establish priorities. Again I say to my hon. Friend the Under-Secretary of State that there seem to be a myriad of inquiries within the Department of Health and Social Security, and within health regions and health districts. It is high time that there was some co-ordination of all these inquiries. Indeed, if I were to send just one message to the Secretary of State, it would be that it is time for him to take a grip of the National Health Service, and no longer to be pushed around and fobbed off by some of the representations made in recent months by the health regions and districts and by trades unions. If in the process he can come close to taming the bureaucratic monster, as my hon. Friend the Member for Wokingham (Mr. Redwood) has rightly described it, so much the better.

I should like to add some random final thoughts. The blood transfusion service, a main centre of which is in my constituency at Brentwood, provides and has provided in the past a great service to the people of this country. I was alarmed to notice, however, during the recent King's Cross disaster that we only just managed to cope with what was by some measurements a fairly small disaster. I wonder whether there is a case, as I see suggested in the press today, for greater centralisation of the supply of blood so that we can co-ordinate it to a greater extent and make sure in the event of such disasters that there is never a suggestion of a shortage of these necessary supplies.

Mrs. Currie

I hesitate to interrupt the excellent flow of my hon. Friend the Member for Brentwood and Ongar (Mr. McCrindle). I have been listening to him with great interest. As he knows, I attended the hospitals on the night of the King's Cross disaster, and I was repeatedly assured that there was no problem with the supply of blood. The patients there did not require blood; their problem was that, because they were burnt, they needed albumin. That is a highly specialised material which tends to be produced only on demand in small quantities. That is why the hospitals had to call for the material from Scotland. I was never at any time told that there was a problem with the supply of blood.

Mr. McCrindle

My hon. Friend had the advantage of being there, and I have had to rely on press reports, which I hope she has seen in the past few days. They show that my point was valid, but if it was not I am happy to withdraw it.

I do not think my hon. Friend's remarks invalidate what I have said — that, while the blood transfusion service has done a lot for the country in the past few years, there is perhaps a case for seeing whether greater centralisation is called for.

Another hobby horse to which I must turn my attention is the funding for the Thames regional health authority. It is high time that RAWP was overhauled. When it was introduced, many of us were prepared to accept that our level of provision was good, whereas that was not the case in Liverpool, Huddersfield or Manchester. With the greatest respect, and bearing in mind that my hon. Friend the Minister represents a Derbyshire constituency, I say that we are now suffering after several years of the operation of RAWP. I also remind the Minister that the former Secretary of State for Social Services promised me in October 1986 that a report would shortly be received concerning the revision of RAWP. So far, that report does not seem to be forthcoming. It is an inordinately long time to wait, and the level of patient care has become endangered as a result of the progressive funding of other parts of the country in preference to the Thames region.

I do not suggest for one moment that we should cut the provision that we make for other parts of the country, but if it means that we need additional resources so that the four Thames regions can obtain some advantage, then. I would have to say to my hon. Friend that it is high time consideration was given to that.

I repeat my fundamental conviction that more funds are required in the short term, but much more besides is required if we are to reshape our National Health Service to meet the requirements of 1988. It is crucial to recognise that. If more funds are needed, then so he it, because having willed the end we must will the means.

8.46 pm

Mr. David Hinchliffe (Wakefield)

One of my hon. Friends, who unfortunately is not in the Chamber now. refers to the "clockwork parrot" from Downing street who appears twice weekly to churn out endless cold statistics. I prefer to regard her as a heartless, aged ostrich who comes here, with her head in the sand, denying the facts that are presented to her daily about what is happening in the National Health Service under the present Government.

The vital issue in the debate is how to get the Government to accept what is happening throughout this land at local level to the National Health Service. I shall refer briefly, Mr. Deputy Speaker—I appreciate the need to be brief— to the situation that prevails in my constituency, and the difficulty that I have experienced in getting a response from the Government.

I am passed from the district health authority to the regional health authority, and from that authority to the Government. The Government blame the DHA and the RHA. It is a buck-passing exercise second to none, certainly in my area, and, I have no doubt, elsewhere in the country.

On 11 September, I wrote a six-page letter to the Under-Secretary, who never listens when I am speaking—I am sick and tired of addressing the hon. Lady who constantly and deliberately ignores the points I am making. I wrote in September a six-page letter about the cuts package that affected people in my constituency. I saw the hon. Lady subsequently and she promised to reply to me. I had a letter back on 5 October referring to what she called "the proposed changes" in health services in Wakefield. not the fact that the Health Service was being systematically run down before my very eyes.

On 26 November we had a debate in the House, and I was told off for speaking too long. I spoke for about 20 minutes detailing the situation facing my constituents. I should like to remind the House of those points, because the situation has not changed. If anything, it is worse. We are talking about the closure and sell-off of Snapethorpe hospital, the most modern hospital in my constituency, and the failure to open a ward at Clayton hospital. Earlier this week, I did receive an answer from the Minister, saying that it was nothing to do with her. The authority cannot open the ward, which has had thousands of pounds spent on it in an improvement programme, because it cannot afford the staff.

We have also seen the introduction of an allegedly unsafe cook-chill system of catering, again to bring about a saving with the local health service. Within the past year, 38 acute beds have been closed when there is a 25 per cent. increase in the waiting list for these beds.

When the cuts package was agreed, the consultant representative on the health authority said that, quite clearly, that action would increase morbidity and mortality rates. That will affect my constituents.

I had no response from the Minister to the points that I made in a 20-minute speech. There was not one comment from the Minister in her wind-up at half-past nine. I went up to her afterwards in front of the Prime Minister, and she will recall that I asked her why she had not responded to my problems in Wakefield. She said that she had not got enough time to respond.

So I wrote to her on 3 December asking for detailed responses to the points I had made about the problems in my health service in Wakefield. I have had no response six weeks later—not one letter back from her about the situation we are facing in the health authority in my area. Since the last debate, we have had an additional allocation of some £4.7 million to the Yorkshire regional health authority, but I have made the point to the hon. Lady in the Health and Medicines Bill Committee that that will not even restore the cuts that have been agreed in my health authority during the last few years directly as a result of Government underfunding.

My hon. Friend the Member for Livingston (Mr. Cook) made the point that there has been a directive for a further 1 per cent. reduction in health services within the Yorkshire region. I understand that it was prised out of the general manager of the Wakefield health authority at the last meeting—the chairman was not aware of it—and that it is a directive to make a further 2 per cent. reduction in the present year's allocation within the local health service.

I want answers tonight. I want to know from the Minister why she has since September refused to respond to the problems that my constituents face about the rundown of the National Health Service in Wakefield. I should also like to know why she refuses to meet the leader of the Wakefield metropolitan council to discuss the clear implications for the council of the cuts and closures that have been agreed by the Wakefield health authority. The Wakefield council estimates that these cuts and closures in the acute sector and in other parts of the health service in Wakefield will mean that it will have to spend an additional £529,000 on the provision of community care, on top of home helps and that sort of thing, to cover the problems arising from the cuts in the National Health Service.

Having referred to the local issues that directly concern me — I hope that I shall get some response from the Minister today—I think that it is even more important that we look at what the Government's real agenda is for the National Health Service. I am delighted to have sat through about five hours of different speeches, because it has given me the opportunity to hear at first hand the real agenda of the Tory party.

I listened to the right hon. Members for Chingford (Mr. Tebbit) and for Brent, North (Sir R. Boyson), and it is quite clear that the real intention of the Tory party is to transform the solid and, I am proud to say, Socialist values of the National Health Service into a free market, with the buying and selling of health care as a commodity. Quite clearly, that is the intention of the Government, and the cuts are a deliberate attempt to force people into the private sector. Increasingly, people are meekly accepting the need to bribe—I use that word because I think that it is the only explanation of the action—a consultant to treat them, to enable them to jump the Health Service queue. That is the kind of situation that Government Members want, because they want deliberately to create an expectation of paying for treatment, prior to the wholesale changes in the Health Service that they intend to generate before very long.

I want to digress to raise one small personal issue which I was reminded of when the Secretary of State, in attempting to defend his period of time in a private hospital prior to Christmas, referred to the fact that his mother, when she was dying of cancer, was treated in a National Health Service hospital. I had the experience of my father waiting for a year for admission for a serious heart operation to Killingbeck hospital in Leeds. When he got into hospital, he was dying, and the bloke in the bed next to him told me that he had exactly the same problem as my father but had got into hospital within six weeks because he had paid. Where is the morality in that kind of situation?

When I hear the right hon. Member for Brent, North talking about competitive enterprise, that is the kind of situation that I look at. What happens to mentally handicapped people, physically handicapped people and chronically ill people, those whom insurance companies will not touch with a bargepole, under this great new system? He has forgotten about them, and he could not care less about them.

Sir Rhodes Boyson

rose—

Mr. Hinchliffe

No. I will return the compliment; I will not give way either.

The Secretary of State said that all the Opposition call for is more money, and I do not think that that is fair or true. We ask for an honest response on what is actually happening within the National Health Service. We ask for a Secretary of State and a Government who use the National Health Service, not the bunch of selfish queue-jumpers that we face in the mob across the Floor. We ask for a return to a commitment to the underlying principle of the National Health Service, the right to treatment regardless of individual ability to pay.

When are we going to get some answers to those points about Wakefield and the wider points that I have raised in the debate tonight?

8.56 pm

Mr. Sydney Chapman (Chipping Barnet)

Inevitably, but rightly, as the hon. Member for Wakefield (Mr. Hinchliffe) has reminded us, Back Benchers use these occasions to raise constituency anxieties relating to the issues being debated. I intend to be no exception to that great parliamentary tradition tonight, not least because last Friday it was announced that the local maternity hospital just round the corner from where I live in my constituency was to close temporarily at the end of this month— not because of lack of funds but simply because there are insufficient properly qualified staff to give that hospital the attention it needs.

I think that it would be quite wrong to talk about these problems without mentioning that we are discussing these matters in the context of the Government's having provided significant extra resources to our National Health Service. They have done that, at least over the last eight years, not in finance alone. There are many thousands more nurses working in the Health Service, and we needed thousands more, because we cut their working week from 40 to 37½ hours. There are 13,000 more doctors and dentists working in the NHS. We are treating many millions more patients a year than in 1978. About 240 major capital building programmes have been completed, having been planned by this Government, and another 100-plus are in the pipeline, and the news is good.

The twin problems and the twin challenges facing the National Health Service are these: that demand is escalating, and demand always will escalate; and that one of the causes of that is that new treatments are being devised and expensive new prescriptions and drugs are being introduced. These are the problems we face, but they arise from the success of the National Health Service, not in any way from its failure.

One other thing must be said: we have increased NHS expenditure, which is now running at £21,000 million a year. That is an increase, as many hon. Members have said, in real resources of almost one third in the last eight years. It is incumbent on the Government to continue to increase those resources, as they have patently done in the last eight years, and to ensure that they are used in the most effective way. We are discussing a level of expenditure on the Health Service which represents £375 per year for every man, woman and child in our country.

One of the problems that we face in the Barnet health authority area is a shortage of nurses. I want to spell out precisely why this situation has arisen. If the Government increase the resources to our Health Service by, say, 2 per cent. a year in real terms, under the RAWP formula, to which my hon. Friend the Member for Brentwood and Ongar (Mr. McCrindle) referred, the London regions receive only 0 per cent. to 1 per cent. Health authorities such as Barnet, which was perceived to be the third most over-endowed district health authority in the most over-endowed regional health authority, usually receives minus 1 per cent. to 2 per cent. That is the situation this year. The latest figure for cash revenue limits for Barnet health authority in this financial year, which I got from the general manager this morning, is about £70 million. In 1986–87, it was about £68.5 million. That is an increase of 2.6 per cent., but there has been an inflation rate of about 4 per cent. to 4–5 per cent.

Mr. Corbyn

Will the hon. Gentleman give way?

Mr. Chapman

No, I shall not give way because we are up against time and I have been here for every minute of the debate.

In real terms, therefore, we are suffering a loss of almost 2 per cent. Seventy-five per cent. of the budget goes in wages and salaries, but wages and salaries have increased by much more then 2.6 per cent. Many NHS employees will say that they have not increased sufficiently, but they have gone up considerably more than 2.6 per cent. Barnet has had to cut not the number of nurses—they have left for other reasons — but some patient services. That situation cannot continue year after year.

We must have a more intelligent system for dealing with this problem. Barnet health authority is short of the equivalent of 200 full-time nurses. It is Catch 22, because the nurses cannot be recruited, even if the local health authority could afford to have them, because of the high housing and other costs of living in the area. I am aware that there is a London weighting allowance for nurses of £930 per annum, but I remind my hon. Friend the Minister that the major clearing banks in London pay a weighting allowance to their staff of about £3,000 a year. Nurses leave for other jobs which pay comparatively better and they leave the area because they cannot afford the housing costs.

I apologise for having gone on so long about that point, but it is crucial to the future successful working of Barnet health authority. There are 191 district health authority areas in England. We must have, if not differential pay according to area, a much more sensitive and sensible London weighting allowance. The present system is anachronistic and inadequate. The litmus test is quite simply that the matter is urgent. I hope very much that the Victoria maternity hospital will reopen in April after it has to close at the end of this month. It can do, if Ministers grapple with this problem now.

I look forward with confidence to my right hon. and hon. Friends on the Treasury Bench dealing with this matter and helping to continue the great and undoubted progress that we have made in the National Health Service in Barnet and other parts of the country.

9.3 pm

Ms. Joan Walley (Stoke-on-Trent, North)

The only reason for today's debate is the severe crisis in the National Health Service. It affects just about every constituency of every hon. Member who has spoken in the debate.

People are dying who need not die. People who know them and their families and live with them in their communities feel strongly that people are dying who need not be dying. They feel helpless. I blame the Government for not making available to the NHS some of the extra money that we know to be available.

We are also here today because, against their better judgment, people have had to resort to publicity as the only way to get something done.

They do not like doing that. They find it distasteful. But those of us who represent constituents who have not been able to obtain health care have chosen the crisis in the NHS as the subject for debate because we want reestablished the principle that health and treatment should be available to everybody through the promotion of good health and through a National Health Service which provides treatment for people when they need it rather than because they can afford to pay for it.

We are here today also because of the many dedicated staff throughout Britain who work at all levels in NHS hospitals, whether as nurses, ancillary workers or highly-paid consultants. They feel that it is about time that what is happening in their daily work experience is exposed to the general public. They cannot tolerate the working conditions and the lack of care for their patients that the Government are forcing them to adopt. I almost wonder whether the NHS is being deliberately run down in order to force people to turn to the private sector.

The final reason for our being here is because week after week, before and after the recess, at Prime Minister's Question Time, the Prime Minister—who, perhaps more than anybody else, is responsible for our Health Service —has come to the Chamber and repeated statistic after statistic. That has not helped the people who are waiting for treatment.

To add insult to injury, when families from my area went to Downing street yesterday to plead with the Prime Minister to do something about their problems, she refused to see them. I can only hope that she did so because she was having urgent discussions with the Secretary of State so that a major decision could be announced today to assure the nation that the extra money that is so urgently needed, over and above existing resources, will be made available. I hope that we shall have that announcement.

Like every hon. Member who has spoken, I want to refer to my constituency. The last time that we debated the NHS, the Under-Secretary of State, the hon. Member for Derbyshire, South (Mrs. Currie), said: Many hon. Members from the west midlands have spoken tonight. It is probably worth remembering that Birmingham is not the whole of the west midlands". I agree with that. However, I did not agree with her when she went on to say that the House had not heard much from hon. Members representing other areas, including Stoke, because they do not have much to whinge about." —[Official Report, 26 November 1987; Vol. 123, c. 472.] Those of my hon. Friends who represent north Staffordshire have a great deal to whinge about. We have had meetings with the Under-Secretary of State, and she is fully aware of our problems. The hon. Lady is aware that a brand-new surgical block is due to be opened in Stoke-on-Trent at the end of the year, for which an extra £4 million is needed. If she cannot assure us that that money will be available, the Government will have a lot of explaining to do all over the country.

Secondly, we have a lot to whinge about because of RAWP, about which we have heard a lot this evening. Many hon. Members have complained that hospitals in their areas are closing because of RAWP, which means that money is being spent in other areas of Britain. I want to put on record the fact that the money that we in north Staffordshire should be getting as a result of the RAWP formula is not being spent in north Staffordshire —[Interruption.] It is not being spent in Birmingham because our special deprivation programme, which should have been £500,000 last year, and an additional £500,000 this year, was suspended last Wednesday simply because the money is no longer there. The reason for that is that the Government have refused point-blank to fund the nurses' pay award in full.

How can anybody plan the National Health Service with such uncertainty? The staff who are working in the Health Service are being given undertakings by the Government that certain money will be made available, but that pay increase is not being met in full and money is being taken away from other aspects of the NHS.

Another reason why we have much to whinge about in north Staffordshire is our orthopaedic waiting lists. I have been told—I have no doubt the figures are correct—that our waiting lists for orthopaedic hospitals are the longest in the west midlands, in the country and even in the universe — and this nation supposedly cares about health. A constituent of mine, a young man with a family, is now likely to have to wait for more than two years for an essential hip replacement operation. He will probably lose his job while he is waiting. In north Staffordshire, we had a capital programme that was to give us about £10 million, to be spent on rebuilding orthopaedic units and replacing beds. Unfortunately, like the replacement psychiatric hospital service, that was another casualty of the cuts in the Health Service, and I am afraid that that capital programme has been suspended. We do not know when it will be reinstated.

Mr. William Cash (Stafford)

rose—

Ms. Walley

I have been waiting all night to speak and I do not intend to give way now.

The levels of deprivation concern me greatly. I entirely agree with the Secretary of State and the Under-Secretary of State when they say that nothing is more important than prevention. I know as well as anyone that waiting lists and deaths from lung and stomach cancer in north Staffordshire are possibly the highest in the country. I support any measure to prevent that amount of illness occurring in the first place. I want some recognition that we can solve the problems facing the National Health Service in both the short and long term.

All these issues, and many more, are crucial to people in north Staffordshire, but my final point is that the Government must accept the views of the people who work in the National Health Service. I refer to the nurses in Manchester who have already brought home how strongly they feel about proposals to introduce a flat-rate payment for overtime; to the blood transfusion workers who rightly said that enough was enough on hearing that the special duty payments that they were paid were likely to be taken away; and to all the workers who feel so strongly that the work they do is crucial to the National Health Service and who will not be satisfied until the Government, having examined the nurses' pay review, not only recommend that its proposals should be met in full, but make more money available. Such is my plea to the Government tonight.

The father of Claire Wise, my constituent who is waiting for an operation at the Birmingham children's hospital, told me when we were waiting in vain to see the Prime Minister yesterday that people who have good jobs and new homes may think that everything is all right, but if they do not have their health, their position is hopeless. I should like to think that the country was aware of his words and that some progress could be made here tonight. The Government climbed down before Christmas by giving us extra money, because they recognised that there was an overspend this year, and they climbed down over the flat-rate pay increases and the extra payments for blood transfusion workers. I hope that they will recognise their need to climb down from their failure to provide extra funding for the National Health Service. We have heard that the Treasury will have extra money. My constituents want that money to be spent on the National Health Service so that Claire Wise, like the Prime Minister, can have the treatment that she needs at the time she needs it—when she is well—before it is too late. It is a matter of life and death. The Government have the opportunity to act now. If they fail, it will be to everyone's cost.

9.14 pm

Dr. David Mudd (Falmouth and Camborne)

The hon. Member for Stoke-on-Trent, North (Ms. Walley) was absolutely right when she said that these issues are crucial to people. There has been too much of a tendency for politicians to consider their perceptions of the National Health Service, forgetting that the NHS involves members of the public and professional people working in the National Health Service. We should constantly be listening to those people, and doing our best to answer their demands.

Much has been said tonight about the RAWP formula. For the Cornwall and the Isles of Scilly health authority, that has led to a shortfall of about £30 million during the past 10 years. Now Nemesis is upon us. I shall speak briefly and bitterly of the effects in my constituency which has made the National Health Service virtually an endangered species.

Falmouth casualty unit, which treats more than 5,000 cases a year, is to be closed. Of course, the closure of that casualty unit will not stop 5,000 people needing attention for minor injuries and ailments. It will not make life more convenient for them in the height of summer when there are delays on the crowded roads between Falmouth and Truro, or in the winter when the roads are blocked by fallen trees. It will not help the manpower situation as the same number of staff will be required to deal with the same number of casualties. It will not help to increase the effective availability or use of ambulance services in critical cases.

Tehidy hospital is to be closed, causing, in the words of one consultant, "catastrophic consequences", in that the ensuing reallocation of beds will ultimately mean the loss of 23 surgical beds in the Royal Cornwall hospital in Truro. The highly successful stroke rehabilitation unit will be moved to what the consultant described as "unacceptable" accommodation in Truro and which even the local health authority admits to being "less than satisfactory". It means the loss of the highly successful mobility scheme which has assisted stroke-afflicted patients to become competent drivers.

Tragically, the Tehidy savings come when the Redruth Methodist community programme agency and the local league of friends of Tehidy hospital are pouring more practical support into the increased value of that distinguished and important hospital.

Paradoxically, Tehidy's finances could be improved by adding to its use rather than axing it. Thought should be given to it being partly used as a general practitioner hospital, catering for patients who do not need the high technology of the Royal Cornwall hospital at Truro. That would utilise the high commitment of local doctors, with the continuing dedication of the staff, and stimulate even more voluntary support from local agencies to create a lower cost per patient bed.

During the past six weeks, I have listened carefully to the views and suggestions of consultants, doctors, nurses and staff of the National Health Service in Cornwall, because, with the greatest respect, they know better than any of us that health cannot be quantified in profit and loss terms as easily as other economic issues. Some of the things that they have told me are food for thought—practical and compassionate thought, not political and insensitive thought. They told me that there is something wrong with the National Health Service when a highly trained anaesthetist is restricted in his professional choice of drugs. There is something wrong with the National Health Service when, in Cornwall, with an estimated 10 per cent. increase in confinements over the predictable future, maternity beds are being closed. There is something wrong with the National Health Service when those urgently in need of check-ups, follow-ups or screening are denied the hospital car service to keep their appointments. There is something wrong with the National Health Service when facilities are closed before alternatives or replacements are available.

There is something wrong in the National Health Service when an incontinence adviser is added to the management structure to decide how many incontinence pads a patient should have. Above all, there is something wrong with a Government who cannot in any way change the public belief that the cuts are designed deliberately to ease the burden of those wealthy enough to pay tax. when in Cornwall many people either do not earn enough to pay tax or, sadly, are unemployed and so do not even have the dignity of work.

9.19 pm

Ms. Harriet Harman (Peckham)

This year is the 40th anniversary of the Health Service. I understand that a staff member in the Department of Health and Social Security has been appointed to arrange celebrations, but in the 40th year of the Health Service there is great fear for its future and growing recognition that there is a crisis caused by lack of resources. People know from their own experience and the experience of their friends and relatives that there is a crisis in the Health Service. Nothing that the Prime Minister or Health Ministers say and no amount of figures they reel out can change that, because people know that it takes longer to get the treatment they need, and they wait in pain with their condition deteriorating. They know that when they finally get into hospital they are treated by nurses and doctors who are hard pressed and do not have enough time, and they are discharged from hospital very quickly—often before they are well enough to return home.

Not only patients recognise the crisis in the Health Service. The recognition has spread to doctors, among whom there has been an unprecedented outcry. Doctors have taken out advertisements in local newspapers in Oxford and west Berkshire. The British Medical Association has said that the National Health Service is in terminal decline and the presidents of the three royal colleges have talked about patient care deteriorating and services reaching breaking point. There have been petitions from doctors to Downing street and resolutions of regional and district health authorities.

Nurses have been warning the Government, particularly the 30,000 nurses who vote with their feet against the Health Service every year by leaving. Recruitment of nurses is dangerously low. For the first time, nurses have gone on strike in Manchester and Edinburgh. They are relatively demoralised because they cannot provide the care that they joined the Health Service to provide. To make matters worse, district health authorities are imposing recruitment freezes because they cannot pay the nurses they have.

Health Service organisations are unanimous about the developing crisis. The National Association of Health Authorities has said that the work of the Health Service is being jeopardised and community health councils have said that they are on the brink of collapse. National and local newspapers are overflowing with tragic cases of people dying before they get their operations and of mothers condemned to watch young children gasping for breath as they wait and wait for heart operations.

The Government are now slowly and reluctantly beginning to acknowledge that there is a crisis only in order to join the Right wing of the Conservative party in urging us to ditch the Health Service and start looking for alternatives. They say that we should look for an alternative system because the National Health Service is too expensive, but alternative systems are more expensive than ours. We spend £364 per head on health care, whereas in America £1,300 per head is spent on health care. The Institute of Actuaries has said that if our health system were run like that in America, we would overnight spend 10 per cent. more on health without getting any improvement in the service.

The Government try to make out that, whereas in the rest of Europe the percentage of GDP spent on health care is higher, the contribution from the public purse is lower in those countries than here. That is not the case. Our public sector contributes 5 per cent. of GDP on health, which is less than the public sector contribution in France, Belgium and Ireland. It is therefore a travesty to label the Health Service as greedy and out of control, when it is already substantially underfunded compared with health care systems abroad.

The Health Service treats patients more cost-effectively than the private sector. In the west midlands it costs the private sector £450 more to do a hysterectomy than a National Health Service hospital, and it costs the private sector £700 more to do a hip replacement operation than the National Health Service.

I expect that the right hon. Member for Chingford (Mr. Tebbit) would say that no account is taken of capital, but no account is taken in the private sector of the training of staff by the National Health Service, who then leave for the private sector.

We are told that we must have an alternative system because we cannot control Health Service costs, which are somehow spiralling out of control. It is true that costs are increasing, but that is partly because of the large number of elderly people. We should welcome that as an advance. I welcome the fact that my parents have been able to live to a ripe old age. I want to live to a ripe old age, and I want my children to do so. That should be welcomed as an advance in health and well-being, and should not be complained about by Conservative Members as being a problem. Costs have increased because of medical advance. We should be welcoming that rather than complaining and wishing to return to a system in which we cannot treat people and send them home without hope.

No lessons can be learnt from abroad about curtailing cost increases. The free-market or insurance-based system has a far greater rate of increase in costs. Last year, in the United States—in one year alone—costs rose by seven times more than the rate of inflation. Germany, which was given as an example by the right hon. Member for Chingford, has similar problems with runaway costs.

Alternative foreign systems are more expensive and less subject to cost control. If the Government are looking for alternatives to control costs, they are barking up the wrong tree.

Mr. Tebbit

rose—

Mr. Dennis Skinner (Bolsover)

What are you doing, Mr. Speaker, letting the moonlighter in?

Mr. Tebbit

If the hon. Gentleman did a little moonlighting he might learn something. With a bit of luck, he might find someone willing to employ him.

Mr. Speaker

Order. Questions to the Front Bench, please.

Mr. Tebbit

Is it the hon. Lady's premise that we have nothing to learn from anyone overseas—that our system is perfect, we know it all, we know it better, we have got it all right and they have got it all wrong? Is she willing to learn something from other people's experience?

Ms. Harman

What I have learnt from other people's experience is that other systems are more expensive, more unfair, more bureaucratic and more costly.

The Government say that we need an alternative to the Health Service because it is bureaucratic. It has been described as a bureaucratic monster, but a certain amount of administration is necessary for a system to run properly. We want doctors and nurses to be free to care for patients, not to be bogged down with administration.

The Health Service demands less in administration than other systems abroad because it is simpler. We spend 6 per cent. of our health budget on administration. France, in which there is a large insurance element in its health service, spends 12 per cent. on administration—double the amount that we spend—and America spends 21 per cent. of its health budget on administration.

Mr. Whitney

Will the hon. Lady quote the source of that remark? She will know, if she has read anything about the matter, that academic studies show that the administrative costs of the United States health service account for 10 per cent. of its health budget. Our figure is so low because it does not include the cost of collection and because we have a centralised system. I invite the hon. Lady to tell the House where she obtained that figure of 21 per cent., which is one of the many bogus statistics that she is reading from her schoolgirl essay.

Ms. Harman

I am quoting internationally recognised OECD statistics. In some states of America the administrative costs amount to 30 per cent.

I should like to give the example of a friend of mine in America who took her son to hospital because he had to have a grommet placed in his ear. His operation was due at 9 am, but he was called in at 6 am so that staff could do three hours of administration and paper work. That is the way the system runs.

In Britain the private health care companies are far more expensive to administer than the NHS. Compared with the 6 per cent. that is spent by the NHS on administration, BUPA spends 10 per cent.. Therefore, the message is clear: insurance-based schemes are far more expensive to run than the NHS.

Another idea promoted by the Government is that the NHS is inefficient. It is true that underfunding is starting to reduce the efficiency of the Health Service and to cause unit costs to increase. Of course it is a waste of capital resources to have 50 per cent. of operating theatres—valuable capital resources — lying idle. Of course unit costs are increased if wards are closed and beds in wards are closed. Of course it increases staff costs to allow the nursing work force to decline to such a level that hospitals must increasingly rely upon expensive agency nurses. But that is not to say that we do not think that we should have a continuous review of performance within the NHS. Of course we want value for money because we want value for patients.

All the evidence suggests that insurance-based or open-market systems of health care are far less efficient than the NHS in allocating resources. The absence of any coherent planning framework in the United States has led to an oversupply of hospital beds. It is estimated that between one in three and one in two of American hospital beds are surplus to requirements.

The medical director of BUPA in this country recently backed the idea that the Health Service is a good mechanism for planning and use of resources. He said: Due to the structure of the NHS, the distribution of health services is reasonably good and there is relatively little waste—particularly when this is compared to America. Perhaps the most important question is the access to care and the quality of care delivered by our Health Service compared with foreign systems. It is relatively well understood in Britain that the poor get a third-rate health care service in America. When an ambulance arrives at an accident in the United States, what the team is really interested in when deciding whether or where a victim should be treated is not where the nearest hospital is or where the appropriate facilities are available, but whether the person has got insurance.

There is no doubt that less well off people in the United States suffer because they delay seeking treatment and discharge themselves dangerously early because of the cost of health care. That is widely understood in Britain. It is also beginning to be understood that an insurance system is bound to allow gaps. It is estimated that more than 40 million people in the United States have no health insurance because insurance companies will not accept them because they are too old, because they have a chronic illness or because they are regarded as being an AIDS risk.

It is not as though someone is home and dry if he has an insurance policy, because there are also gruesome stories of insurance running out. When insurance runs out against a person's medical interest, he must move to a cheaper hospital. What is less well known, but extremely chilling, is that it is not only the poor who are the victims of the American health care system. The rich are also the victims of that system. It is a commercial system, and the doctors do what is profitable rather than what is medically necessary. For example, a doctor will not make much money from telling a patient with a headache to take an aspirin and lie down in a darkened room for an hour. Big money is made if the doctor starts brain and neurological investigations.

My hon. Friend the Member for Strathkelvin and Beardsden (Mr. Galbraith) has said that medicine in the United States is distorted by the profit motive. An American woman is three times more likely to have her womb removed than a British woman. An American man is four times more likely to have his prostate removed than a British man. An American is three times more likely than a Briton to have a hernia operation and twice as likely to have his tonsils removed. That is what happens in a health system in which the profit motive comes into play. An American woman is twice as likely as a British woman to give birth by caesarean section than by spontaneous delivery. A Congressional study estimated that 2.4 million surgical procedures had been carried out unnecessarily and that 11,900 deaths had been caused by unnecessary intervention.

That cannot be explained away by reference to different medical traditions or legal systems—although different medical traditions and different legal systems there are — because parallel differences exist in this country between the Health Service and the commercial medical sector. A woman in a private hospital is twice as likely to give birth by caesarian section as her counterpart in a National Health Service hospital. The alternatives that we are being offered by the Government are more expensive, more bureaucratic and more wasteful. They are unfair to the poor and they do no favours to the rich.

The central question is whether we want health care on the basis of people's ability to benefit from treatment or on the basis of their ability to pay for the treatment. The Health Service is fairer and more humane than commercial, insurance-based, profit-motivated systems. To any Government interested in acting sensibly, the obvious course of action would be to give the National Health Service a reasonable and fair allocation front public funds. We could then release all the enthusiasm and commitment that remain among doctors, nurses and other Health Service staff—enthusiasm and commitment that have not been stifled—who not only want to do more of what they are doing now but want to push back the boundaries of medical science, to make breakthroughs with new diagnostic techniques and treatments and so to improve our Health Service.

The Government and Conservative Back Benchers tell us that the money is available but that the Government are simply unwilling to use it for the Health Service. They prefer, as a matter of priority, to use it for tax cuts. The Government are considering abolishing the top rate of tax, which will benefit only 4 per cent. of people in this country but with a windfall of £850 million. They are considering abolishing inheritance tax, which will benefit only 35,0(10 people, but to the tune of £1 billion. The Government are considering plans to abolish capital gains tax to give a further windfall of £1.3 billion. Those amounts total more than £3 billion. While the Government pursue the theory that cuts in taxes encourage the rich to work harder, cuts in the Health Service are threatening people's lives.

In the year of the 40th anniversary of the Health Service, people will be paying particular attention to the Chancellor's treatment of the Health Service in his Budget. The real choice is not between the National Health Service and foreign systems, but between tax cuts and a soundly-based, well-resourced Health Service. Instead of forcing the Health Service to resort to flag-day finance, the Budget should use public finance to relieve the pain and suffering of the growing number of patients on the waiting lists. The Secretary of State tells the presidents of the royal colleges that the Health Service should get more money. The Chief Secretary to the Treasury says that it will not. People are expecting Budget day to be Health Service day. On 15 March, the eyes of all who care about a fair and effective health care system will be on the Chancellor.

9.38 pm

The Minister for Health (Mr. Tony Newton)

In many ways, this has been a more thoughtful and constructive debate than most of us expected at the outset—at least until the last few moments. The hon. Member for Peckham (Ms. Harman) appeared to be setting up nine-pins of her own making simply to knock them down. However, with that exception, hon. Members on both sides of the House have recognised—that recognition may be strategically significant in terms of the whole political debate on the NHS—the complexity of the problems and pressures involved in the controversies and arguments that surround the National Health Service.

I want to comment on some of those themes and on the constructive points that have been made. However, before I come to what I take to be the central theme of the debate, it is right for me to comment on some of the specific points raised by right hon. and hon. Members from the Opposition Front Bench and by hon. Members of all parties, although inevitably I shall be unable to take up every point, especially some of the local ones.

I give an undertaking to the hon. Member for Livingston (Mr. Cook) that I shall not rehearse all the statistics that obviously leave him uneasy. One striking thing about his speech was what I took to be his extremely defensive comments when he sought to suggest that the statistics were not presenting a true picture of what is happening in the Health Service. Without seeking to repeat the statistics which my right hon. Friend the Secretary of State set out clearly in his opening speech, I challenge the hon. Gentleman to provide me with any significant measure of the outputs of the Health Service in terms of patient care which do not show the marked and dramatic increase that has taken place during the eight years that this Government have been in office.

However, I must challenge the hon. Member for Livingston on some statistics that I understood him to take from the report of the Select Committee on Social Services. I say in the presence of my hon. Friend the Member for Macclesfield (Mr. Winterton)— —[Interruption.] —unfortunately, he is not here — that I normally have the greatest respect for that Committee. However, I challenge the hon. Gentleman's statistics about the effect of demography on the pattern of Health Service expenditure in recent years because, in my judgment, there has been persistent misrepresentation of the position on the basis that the picture has remained steady and that a regular 1 per cent. per year has been needed to cope with demographic pressures. So much of the attack on our suggestions and our view that there has been a real increase in expenditure on the National Health Service rests on that statistic, and, frankly, it rests on a misapprehension. The run of statistics—

Mr. Robin Cook

rose—

Mr. Newton

May I first finish my point?

The run of statistics, which I can go through although I had not intended to, shows marked variations, down as low as 0.3 per cent., for example, for demographic factors in 1981–82. Over the period as a whole, the average is significantly less than 1 per cent. It is important that people should recognise that fact when making some of the wilder generalisations about the real increase in Health Service funding.

Mr. Cook

I invite the Minister to contemplate the answer that he gave to the House on 13 July 1987 when he set out the annual increase in the pressure of demographic change on the hospital sector alone. He is absolutely right —it is not 1 per cent. per annum; the figure varies. Over the period at which the Select Committee looked, there was a 4–3 per cent. additional requirement on the hospital sector. The Select Committee estimated the increase in the volume terms of expenditure on the hospital sector as 3.2 per cent.—a clear 1.2 per cent. less. For next year it is a clear 2 per cent. less. That is why our hospitals cannot meet the demand on them. That is why they are in crisis and are turning away patients.

Mr. Newton

As I understand it, at least we agree that the 1 per cent. figure is an exaggeration as an average over the period concerned. Just as the hon. Gentleman and the hon. Member for Peckham have persistently refused to take account of the gains in efficiency in the service, so did the Select Committee. When account is taken of those factors, the increase in resources for the hospital and community health services represents a real increase which can be seen in the increases in patient care which all the statistics demonstrate.

I should like to make one other point to the hon. Member for Livingston, on a purely statistical issue. He referred to the representation of the British Cardiac Society about the number of cardiologists, quoting the society's reported view that some 10 million people were living in districts without the appropriate cardiological consultant care.

The number of consultant cardiologists has increased from 110 in 1979 to 152 on the latest available figure, an increase of more than 50 per cent. Although I have not been able to do all the maths involved, if 10 million people were living in districts without such consultants in 1986, that is a whole lot fewer than were living in such districts in 1979.

Mr. Nigel Griffiths

What consolation are those statistics to parents whose children are dying because of shortages?

Mr. Newton

Their consolation is that the increased resources for the hospitals and services involved create for their children a very much better chance of proper health care than they had eight years ago, when the Government came to office.

As the hon. Member for Edinburgh, South (Mr. Griffiths) has incited me, let me give one more statistic. —[Interruption.] Let him listen: he raised the subject. Let me give the hon. Gentleman the statistics for the number of hole-in-the-heart operations carried out on youngsters under one year old. In 1978, there were 333; in 1985—this is the latest figure that I have — there were 469. That is the scale of the increase.

I can give the House, and the hon. Member for Peckham, some helpful, up-to-date information. In the course of several references to nurses, the hon. Lady implied that the number had been falling. As it happens, I placed in the Library of the House yesterday the latest figures on NHS staff. I am glad to be able to tell the hon. Lady and the House that, in the year from September 1986 to September 1987, the number of nurses employed—excluding agency staff— rose by a further 3,400. That reflects the continuing increase that has taken place in the lifetime of the present Government.

There will always be legitimate public discussion and debate about the balance between expenditure and taxation at any one time, and about the balance in that expenditure between different desirable objectives —whether in health, education, housing or, for that matter, matters other than social policy such as defence, law and order or any other objective to which we attach collective importance. What is not in doubt, however, is the commitment that the Government have shown by their decisions since 1979—

Mr. D. N. Campbell-Savours (Workington)

What about nurse training?

Mr. Newton

The hon. Gentleman wishes me to go into the subject of nurse training, which was raised by the hon. Member for Cynon Valley (Mrs. Clwyd) in an intervention. The hon. Lady is right to say that there has been a modest decline in the total expenditure on nurse training over the past few years. There are two reasons for that. One is that there has been a reduction in the number of nurses leaving training before they complete that training which obviously tends to reduce the costs.

Mr. Campbell-Savours

Why?

Mr. Newton

There has been a reduction in the wastage. Why? Because no doubt they find it more attractive to be nurses now than they did when this Government came to office. Other factors are involved as well.

The Government have demonstrated by their decisions since 1979 the commitment they have to the Health Service, not only in the fact that expenditure has risen by 33 per cent. in real terms but that Health Service expenditure as a proportion of total public expenditure has risen by 2 per cent. in that period and, as my right hon. Friend said at the outset of the debate, the percentage of public expenditure on health in relation to the gross domestic product has risen from 4.7 per cent. to 5.4 per cent., after falling when the Labour party was in office.

The other point that has so far attracted less attention than I might have expected is that during the present year it is likely that health expenditure and personal social services expenditure, taken together, will overtake defence as the second largest item in Government expenditure after social security.

Mr. Anthony Beaumont-Dark (Birmingham, Selly Oak)

Before my right hon. Friend moves away from the main thrust. can he help many of us who are genuinely his friends— [Laughter.]—that is true—because many of us are perplexed? In Birmingham we are surrounded by great hospitals, good surgeons and good physicians who tell us — unless they are charlatans and liars, which I doubt but the Minister may convince me otherwise—that they are short of resources, that cancer beds are being closed and that kidney dialysis is rationed to those under 55 years of age. Either there are enough resources, or there are not. Who is right? Are those at the sharp end of public health right or is the Minister right?

Mr. Newton

The statistics that I have used —relatively few — and the figures that my right hon. Friend gave in his opening speech measure the increase in funds which has gone throughout the Health Service and not least to the West Midlands regional health authority, which has consistently gained under the process of resource allocation.

Mr. Campbell-Savours

Answer the question.

Mr. Newton

One point that I wish to deal with, because it is part of the core of the problem which both sides of the House face in talking about and dealing with these issues is that—

Mr. Campbell-Savours

Answer the question.

Mr. Speaker

Order. The Minister is trying to answer a question which has been put to him. It is no good the hon. Gentleman shouting across the Chamber at him.

Mr. Newton

I recognise that there is always more that people would like to do whether they are Health Service workers, Ministers or those to whom my hon. Friend has been speaking in Birmingham.

Whatever view is taken of spending, whether capital or current, present or past, one thing that should surely be clear to everyone who has participated in the debate is that there is no single, simple answer in anything that the lion. Member for Livingston suggested or, dare I say, in any of the many suggestions from hon. Members on both sides of the House.

It is right that we should examine the extent to which some of the proposals may be able to contribute, as indeed we are doing and will continue to do. The inescapable conclusion outlined by my right hon. Friend the Secretary of State is that the pattern of steadily rising demand, from factors that he described and above all from a combination of rising numbers of elderly people and the rapid pace or medical advance, is that we need to pursue steadily and consistently a range of measures of the sort that we have already embarked upon, not as a substitute for proper support from taxpayers nor a retreat from the responsibilities of Government, but in straightforward and practical recognition of the fact that, however much is contributed by taxpayers, there will always be more that all of us who are concerned with health would like to do.

Mr. Roland Boyes (Houghton and Washington)

A man came to my office recently to canvas my support to raise cash for Freeman hospital in Newcastle. He had written to a number of people, one of whom was the Prime Minister, to raise £50,000. He had a letter back from an aide to the Prime Minister, saying, in effect, "Find enclosed an autographed photograph of the Prime Minister, which has been used by many organisations to raise a considerable amount of money." How many autographed photographs does it take to run a Health Service?

Mr. Newton

Mention of Newcastle reminds me of my visit there, when I saw at the Freeman hospital undoubtedly the finest heart transplant unit in this country. It was designated and paid for by funds allocated by this Government since 1979.

The sad thing about the debate today is that the Opposition have not only sought to deny their past, but have resolutely ignored the real issues and practical problems that must be faced. A smile came to my face—

Mr. Campbell-Savours

rose—

Mr. Newton

No, I shall not give way to the hon. Gentleman. A smile came to my face when I heard the hon. Member for Livingston challenge us on the basis that no problems had occurred in the Health Service under the previous Labour Administration. I have in my hand copies of some headlines from newspapers in 1978 —[Interruption.] In March 1978, the headlines were: Patients sent home early to release beds, doctors say; NHS morale falling, MPs told; Minister told of threat to nursing standards; Big injection of money essential to resuscitate National Health Service, doctors told; Heart patients will die, warning in hospital dispute". Then, most telling of all, there is a headline from The Times of August 1978 in the "Home News", which says: NHS in crisis; doctors complain of chronic under-financing. That was what happened under the previous Labour Government. If we do not go down the track that they urge of taking yet more money from taxpayers, it is because we are conscious that down that track lies the same failure to fund the Health Service properly that marked the whole of their period in government. What we can and will do is to build on the expansion that we have already brought about.

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

The House divided: Ayes 233, Noes 338.

Division NO. 144]	[10 pm
AYES
Abbott, Ms Diane	Dewar, Donald
Adams, Allen (Paisley N)	Dixon, Don
Allen, Graham	Dobson, Frank
Alton, David	Douglas, Dick
Archer, Rt Hon Peter	Dunnachie, James
Armstrong, Ms Hilary	Dunwoody, Hon Mrs Gwyneth
Ashdown, Paddy	Eadie, Alexander
Ashley, Rt Hon Jack	Eastham, Ken
Ashton, Joe	Ewing, Harry (Falkirk E)
Banks, Tony (Newham NW)	Ewing, Mrs Margaret (Moray)
Barnes, Harry (Derbyshire NE)	Fatchett, Derek
Barnes, Mrs Rosie (Greenwich)	Faulds, Andrew
Barron, Kevin	Fearn, Ronald
Battle, John	Field, Frank (Birkenhead)
Beckett, Margaret	Fields, Terry (L'pool B G'n)
Beith, A. J.	Fisher, Mark
Bell, Stuart	Flannery, Martin
Benn, Rt Hon Tony	Flynn, Paul
Bennett, A. F. (D'nt'n & R'dish)	Foot, Rt Hon Michael
Bermingham, Gerald	Forsythe, Clifford (Antrim S)
Bidwell, Sydney	Foster, Derek
Blair, Tony	Foulkes, George
Blunkett, David	Fraser, John
Boyes, Roland	Fyfe, Mrs Maria
Bradley, Keith	Galbraith, Samuel
Bray, Dr Jeremy	Galloway, George
Brown, Gordon (D'mline E)	Garrett, John (Norwich South)
Brown, Nicholas (Newcastle E)	Garrett, Ted (Wallsend)
Brown, Ron (Edinburgh Leith)	George, Bruce
Bruce, Malcolm (Gordon)	Gilbert, Rt Hon Dr John
Buchan, Norman	Godman, Dr Norman A.
Buckley, George	Golding, Mrs Llin
Caborn, Richard	Gordon, Ms Mildred
Callaghan, Jim	Grant, Bernie (Tottenham)
Campbell, Ron (Blyth Valley)	Griffiths, Nigel (Edinburgh S)
Campbell-Savours, D. N.	Griffiths, Win (Bridgend)
Canavan, Dennis	Grocott, Bruce
Carlile, Alex (Mont'g)	Hardy, Peter
Clark, Dr David (S Shields)	Harman, Ms Harriet
Clarke, Tom (Monklands W)	Hattersley, Rt Hon Roy
Clay, Bob	Haynes, Frank
Clelland, David	Healey, Rt Hon Denis
Clwyd, Mrs Ann	Heffer, Eric S.
Cohen, Harry	Hinchliffe, David
Coleman, Donald	Hogg, N. (C'nauld & Kilsyth)
Cook, Robin (Livingston)	Holland, Stuart
Corbett, Robin	Home Robertson, John
Corbyn, Jeremy	Hood, James
Cousins, Jim	Howarth, George (Knowsley N)
Cox, Tom	Howell, Rt Hon D. (S'heath)
Crowther, Stan	Howells, Geraint
Cryer, Bob	Hoyle, Doug
Cummings, J.	Hughes, John (Coventry NE)
Cunliffe, Lawrence	Hughes, Robert (Aberdeen N)
Dalyell, Tarn	Hughes, Roy (Newport E)
Darling, Alastair	Hughes, Simon (Southwark)
Davies, Rt Hon Denzil (Lianelli)	Illsley, Eric
Davies, Ron (Caerphilly)	Ingram, Adam
Davis, Terry (B'ham Hodge H'l)	Janner, Greville

John, Brynmor	Radice, Giles
Jones, Barry (Alyn & Deeside)	Randall, Stuart
Jones, leuan (Ynys M6n)	Redmond, Martin
Jones, Martyn (Clwyd S W)	Rees, Rt Hon Merlyn
Kaufman, Rt Hon Gerald	Reid, John
Kilfedder, James	Richardson, Ms Jo
Kinnock, Rt Hon Neil	Roberts, Allan (Bootle)
Kirkwood, Archy	Robertson, George
Lamble, David	Robinson, Geoffrey
Lamond, James	Rooker, Jeff
Leadbitter, Ted	Ross, Ernie (Dundee W)
Leighton, Ron	Ross, William (Londonderry E)
Lestor, Miss Joan (Eccles)	Rowlands, Ted
Lewis, Terry	Ruddock, Ms Joan
Litherland, Robert	Salmond, Alex
Livingstone, Ken	Sedgemore, Brian
Livsey, Richard	Sheerman, Barry
Lloyd, Tony (Stretford)	Sheldon, Rt Hon Robert
Lofthouse, Geoffrey	Shore, Rt Hon Peter
Loyden, Eddie	Short, Clare
McAllion, John	Skinner, Dennis
McAvoy, Tom	Smith, Andrew (Oxford E)
McCartney, Ian	Smith, C. (Isl'ton & Fbury)
McCusker, Harold	Smith, Rt Hon J. (Monk'ds E)
Macdonald, Calum	Smyth, Rev Martin (Belfast S)
McKelvey, William	Snape, Peter
McLeish, Henry	Soley, Clive
Maclennan, Robert	Spearing, Nigel
McNamara, Kevin	Steel, Rt Hon David
McTaggart, Bob	Steinberg, Gerald
McWilliam, John	Stott, Roger
Madden, Max	Strang, Gavin
Mahon, Mrs Alice	Straw, Jack
Marshall, David (Shettleston)	Taylor, Mrs Ann (Dewsbury)
Marshall, Jim (Leicester S)	Taylor, Matthew (Truro)
Martin, Michael (Springburn)	Thomas, Dafydd Elis
Martlew, Eric	Thompson, Jack (Wansbeck)
Maxton, John	Turner, Dennis
Meacher, Michael	Vaz, Keith
Meale, Alan	Walker, A. Cecil (Belfast N)
Michael, Alun	Wall, Pat
Michie, Bill (Sheffield Heeley)	Wallace, James
Millan, Rt Hon Bruce	Walley, Ms Joan
Mitchell, Austin (G't Grimsby)	Wardell, Gareth (Gower)
Molyneaux, Rt Hon James	Wareing, Robert N.
Moonie, Dr Lewis	Welsh, Andrew (Angus E)
Morris, Rt Hon A (W'shawe)	Welsh, Michael (Doncaster N)
Morris, Rt Hon J (Aberavon)	Wigley, Dafydd
Mowlam, Marjorie	Williams, Rt Hon A. J.
Mullin, Chris	Williams, Alan W. (Carm'then)
Nellist, Dave	Wilson, Brian
Oakes, Rt Hon Gordon	Winnick, David
O'Brien, William	Wise, Mrs Audrey
Orme, Rt Hon Stanley	Worthington, Anthony
Patchett, Terry	Young, David (Bolton SE)
Pendry, Tom
Pike, Peter	Tellers for the Ayes:
Powell, Ray (Ogmore)	Mr. Frank Cook and
Primarolo, Ms Dawn	Mr. Allen McKay.
Quin, Ms Joyce
NOES
Adley, Robert	Beaumont-Dark, Anthony
Aitken, Jonathan	Bellingharn, Henry
Alexander, Richard	Bendall, Vivian
Alison, Rt Hon Michael	Bennett, Nicholas (Pembroke)
Allason, Rupert	Benyon, W.
Amery, Rt Hon Julian	Bevan, David Gilroy
Amess, David	Biffen, Rt Hon John
Amos, Alan	Biggs-Davison, Sir John
Arbuthnot, James	Blackburn, Dr John G.
Arnold, Tom (Hazel Grove)	Blaker, Rt Hon Sir Peter
Ashby, David	Body, Sir Richard
Aspinwall, Jack	Bonsor, Sir Nicholas
Atkins, Robert	Boswell, Tim
Atkinson, David	Bottomley, Peter
Baker, Rt Hon K. (Mole Valley)	Bottomley, Mrs Virginia
Baker, Nicholas (Dorset N)	Bowden, A (Brighton K'pto'n)
Baldry, Tony	Bowden, Gerald (Dulwich)
Batiste, Spencer	Bowis, John

Boyson, Rt Hon Dr Sir Rhodes	Gow, Ian
Braine, Rt Hon Sir Bernard	Gower, Sir Raymond
Brandon-Bravo, Martin	Greenway, Harry (Eating N)
Brazier, Julian	Greenway, John (Rydale)
Bright, Graham	Gregory, Conal
Brittan, Rt Hon Leon	Griffiths, Sir Eldon (Bury St E')
Brooke, Rt Hon Peter	Griffiths, Peter (Portsmouth N)
Brown, Michael (Brigg & Cl't's)	Grist, Ian
Browne, John (Winchester)	Ground, Patrick
Bruce, Ian (Dorset South)	Grylls, Michael
Buchanan-Smith, Rt Hon Alick	Hamilton, Neil (Tatton)
Buck, Sir Antony	Hampson, Dr Keith
Budgen, Nicholas	Hanley, Jeremy
Burns, Simon	Hannam, John
Burt, Alistair	Hargreaves, A. (B'ham H'll Gr')
Butcher, John	Hargreaves, Ken (Hyndburn)
Butler, Chris	Harris, David
Butterfill, John	Haselhurst, Alan
Carlisle, John, (Luton N)	Hawkins, Christopher
Carlisle, Kenneth (Lincoln)	Hayes, Jerry
Carrington, Matthew	Hayward, Robert
Carttiss, Michael	Heathcoat-Amory, David
Cash, William	Heddle, John
Channon, Rt Hon Paul	Heseltine, Rt Hon Michael
Chapman, Sydney	Hicks, Mrs Maureen (Wolv' NE)
Chope, Christopher	Hicks, Robert (Cornwall SE)
Churchill, Mr	Higgins, Rt Hon Terence L.
Clark, Hon Alan (Plym'th S'n)	Hill, James
Clark, Dr Michael (Rochford)	Hind, Kenneth
Clark, Sir W. (Croydon S)	Hogg, Hon Douglas (Gr'th'm)
Clarke, Rt Hon K. (Rushcliffe)	Holt, Richard
Colvin, Michael	Hordern, Sir Peter
Conway, Derek	Howard, Michael
Coombs, Anthony (Wyre F'rest)	Howarth, Alan (Strat'd-on-A)
Coombs, Simon (Swindon)	Howarth, G. (Cannock & B'wd)
Cope, John	Howe, Rt Hon Sir Geoffrey
Cormack, Patrick	Howell, Ralph (North Norfolk)
Couchman, James	Hughes, Robert G. (Harrow W)
Cran, James	Hunt, David (Wirral W)
Currie, Mrs Edwina	Hunt, John (Ravensbourne)
Curry, David	Hunter, Andrew
Davies, Q. (Stamf'd & Spald'g)	Irvine, Michael
Davis, David (Boothferry)	Irving, Charles
Day, Stephen	Jack, Michael
Devlin, Tim	Jackson, Robert
Dickens, Geoffrey	Janman, Timothy
Dicks, Terry	Johnson Smith, Sir Geoffrey
Dorrell, Stephen	Jones, Gwilym (Cardiff N)
Douglas-Hamilton, Lord James	Jones, Robert B (Herts W)
Dover, Den	Kellett-Bowman, Mrs Elaine
Dunn, Bob	Key, Robert
Durant, Tony	King, Roger (B'ham N'thfleld)
Emery, Sir Peter	Kirkhope, Timothy
Evennett, David	Knapman, Roger
Fallon, Michael	Knight, Greg (Derby North)
Farr, Sir John	Knight, Dame Jill (Edgbaston)
Favell, Tony	Knowles, Michael
Fenner, Dame Peggy	Knox, David
Field, Barry (Isle of Wight)	Lamont, Rt Hon Norman
Finsberg, Sir Geoffrey	Lang, Ian
Fookes, Miss Janet	Latham, Michael
Forman, Nigel	Lawrence, Ivan
Forsyth, Michael (Stirling)	Lawson, Rt Hon Nigel
Forth, Eric	Lee, John (Pendle)
Fowler, Rt Hon Norman	Leigh, Edward (Gainsbor'gh)
Fox, Sir Marcus	Lennox-Boyd, Hon Mark
Franks, Cecil	Lester, Jim (Broxtowe)
Freeman, Roger	Lightbown, David
French, Douglas	Lilley, Peter
Fry, Peter	Lloyd, Sir Ian (Havant)
Gale, Roger	Lloyd, Peter (Fareham)
Gardiner, George	Lord, Michael
Gill, Christopher	Luce, Rt Hon Richard
Gilmour, Rt Hon Sir Ian	Lyell, Sir Nicholas
Glyn, Dr Alan	McCrindle, Robert
Goodhart, Sir Philip	Macfarlane, Sir Neil
Goodlad, Alastair	MacKay, Andrew (E Berkshire)
Goodson-Wickes, Dr Charles	Maclean, David
Gorman, Mrs Teresa	McLoughlin, Patrick
Gorst, John	McNair-Wilson, M. (Newbury)

McNair-Wilson, P. (New Forest)	Shepherd, Richard (Aldridge)
Madel, David	Shersby, Michael
Major, Rt Hon John	Sims, Roger
Malins, Humfrey	Skeet, Sir Trevor
Mans, Keith	Smith, Sir Dudley (Warwick)
Maples, John	Smith, Tim (Beaconsfield)
Marland, Paul	Soames, Hon Nicholas
Marlow, Tony	Speed, Keith
Martin, David (Portsmouth S)	Speller, Tony
Mates, Michael	Spicer, Sir Jim (Dorset W)
Mawhinney, Dr Brian	Spicer, Michael (S Worcs)
Mayhew, Rt Hon Sir Patrick	Squire, Robin
Mellor, David	Stanbrook, Ivor
Miller, Hal	Steen, Anthony
Mills, Iain	Stern, Michael
Miscampbell, Norman	Stevens, Lewis
Mitchell, Andrew (Gedling)	Stewart, Allan (Eastwood)
Mitchell, David (Hants NW)	Stewart, Andrew (Sherwood)
Moate, Roger	Stokes, John
Monro, Sir Hector	Stradling Thomas, Sir John
Montgomery, Sir Fergus	Sumberg, David
Moore, Rt Hon John	Summerson, Hugo
Morris, M (N'hampton S)	Tapsell, Sir Peter
Morrison, Sir Charles (Devizes)	Taylor, Ian (Esher)
Moss, Malcolm	Taylor, John M (Solihull)
Mudd, David	Taylor, Teddy (S'end E)
Neale, Gerrard	Tebbit, Rt Hon Norman
Nelson, Anthony	Temple-Morris, Peter
Neubert, Michael	Thompson, D. (Calder Valley)
Newton, Rt Hon Tony	Thompson, Patrick (Norwich N)
Nicholls, Patrick	Thorne, Neil
Nicholson, David (Taunton)	Thornton, Malcolm
Nicholson, Miss E. (Devon W)	Thurnham, Peter
Onslow, Rt Hon Cranley	Townend, John (Bridlington)
Page, Richard	Townsend, Cyril D. (B'heath)
Paice, James	Tracey, Richard
Parkinson, Rt Hon Cecil	Tredinnick, David
Patnick, Irvine	Trippier, David
Patten, Chris (Bath)	Trotter, Neville
Patten, John (Oxford W)	Twinn, Dr Ian
Pattie, Rt Hon Sir Geoffrey	Vaughan, Sir Gerard
Pawsey, James	Waddington, Rt Hon David
Peacock, Mrs Elizabeth	Wakeham, Rt Hon John
Porter, Barry (Wirral S)	Waldegrave, Hon William
Porter, David (Waveney)	Walden, George
Portillo, Michael	Walker, Bill (T'side North)
Price, Sir David	Walker, Rt Hon P. (W'cester)
Raff an, Keith	Waller, Gary
Raison, Rt Hon Timothy	Walters, Dennis
Rathbone, Tim	Ward, John
Redwood, John	Wardle, C. (Bexhill)
Renton, Tim	Warren, Kenneth
Rhodes James, Robert	Watts, John
Rhys Williams, Sir Brandon	Wells, Bowen
Riddick, Graham	Wheeler, John
Ridley, Rt Hon Nicholas	Whitney, Ray
Rifkind, Rt Hon Malcolm	Widdecombe, Miss Ann
Roberts, Wyn (Conwy)	Wiggin, Jerry
Roe, Mrs Marion	Wilkinson, John
Rossi, Sir Hugh	Wilshire, David
Rost, Peter	Winterton, Mrs Ann
Rowe, Andrew	Winterton, Nicholas
Rumbold, Mrs Angela	Wolfson, Mark
Ryder, Richard	Wood, Timothy
Sackville, Hon Tom	Woodcock, Mike
Sayeed, Jonathan	Yeo, Tim
Scott, Nicholas	Young, Sir George (Acton)
Shaw, David (Dover)	Younger, Rt Hon George
Shaw, Sir Giles (Pudsey)
Shaw, Sir Michael (Scarb')	Tellers for the Noes:
Shelton, William (Streatham)	Mr. Robert Boscawen and
Shephard, Mrs G. (Norfolk SW)	Mr. Tristan Garel-Jones.
Shepherd, Colin (Hereford)

Question accordingly negatived.

Questin, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments):—

The House divided: Ayes 336, Noes 236.

Division No. 145]	[10.15 pm
AYES
Adley, Robert	Davis, David (Boothferry)
Aitken, Jonathan	Day, Stephen
Alexander, Richard	Devlin, Tim
Alison, Rt Hon Michael	Dickens, Geoffrey
Allason, Rupert	Dicks, Terry
Amery, Rt Hon Julian	Dorrell, Stephen
Amess, David	Douglas-Hamilton, Lord James
Amos, Alan	Dover, Den
Arbuthnot, James	Dunn, Bob
Arnold, Tom (Hazel Grove)	Durant, Tony
Ashby, David	Emery, Sir Peter
Aspinwall, Jack	Evennett, David
Atkins, Robert	Fallon, Michael
Atkinson, David	Farr, Sir John
Baker, Rt Hon K. (Mole Valley)	Favell, Tony
Baker, Nicholas (Dorset N)	Fenner, Dame Peggy
Baldry, Tony	Field, Barry (Isle of Wight)
Batiste, Spencer	Finsberg, Sir Geoffrey
Beaumont-Dark, Anthony	Fookes, Miss Janet
Bellingham, Henry	Forman, Nigel
Bendall, Vivian	Forsyth, Michael (Stirling)
Bennett, Nicholas (Pembroke)	Forth, Eric
Benyon, W.	Fowler, Rt Hon Norman
Bevan, David Gilroy	Fox, Sir Marcus
Biffen, Rt Hon John	Franks, Cecil
Biggs-Davison, Sir John	Freeman, Roger
Blackburn, Dr John G.	French, Douglas
Blaker, Rt Hon Sir Peter	Fry, Peter
Body, Sir Richard	Gale, Roger
Bonsor, Sir Nicholas	Gardiner, George
Boswell, Tim	Gill, Christopher
Bottomley, Peter	Gilmour, Rt Hon Sir Ian
Bottomley, Mrs Virginia	Glyn, Dr Alan
Bowden, A (Brighton K'pto'n)	Goodhart, Sir Philip
Bowden, Gerald (Dulwich)	Goodlad, Alastair
Bowis, John	Goodson-Wickes, Dr Charles
Boyson, Rt Hon Dr Sir Rhodes	Gorman, Mrs Teresa
Braine, Rt Hon Sir Bernard	Gorst, John
Brandon-Bravo, Martin	Gow, Ian
Brazier, Julian	Gower, Sir Raymond
Bright, Graham	Grant, Sir Anthony (CambsSW)
Brittan, Rt Hon Leon	Greenway, Harry (Ealing N)
Brooke, Rt Hon Peter	Greenway, John (Rydale)
Brown, Michael (Brigg & Cl't's)	Gregory, Conal
Browne, John (Winchester)	Griffiths, Sir Eldon (Bury St E')
Bruce, Ian (Dorset South)	Griffiths, Peter (Portsmouth N)
Buchanan-Smith, Rt Hon Alick	Grist, Ian
Buck, Sir Antony	Ground, Patrick
Budgen, Nicholas	Grylls, Michael
Burns, Simon	Hamilton, Neil (Tatton)
Burt, Alistair	Hampson, Dr Keith
Butcher, John	Hanley, Jeremy
Butler, Chris	Hannam, John
Butterfill, John	Hargreaves, A. (B'ham H'll Gr')
Carlisle, John, (Luton N)	Hargreaves, Ken (Hyndburn)
Carlisle, Kenneth (Lincoln)	Harris, David
Carrington, Matthew	Haselhurst, Alan
Carttiss, Michael	Hawkins, Christopher
Cash, William	Hayes, Jerry
Channon, Rt Hon Paul	Hayhoe, Rt Hon Sir Barney
Chapman, Sydney	Hayward, Robert
Chope, Christopher	Heathcoat-Amory, David
Churchill, Mr	Heddle, John
Clark, Hon Alan (Plym'th S'n)	Heseltine, Rt Hon Michael
Clark, Dr Michael (Rochford)	Hicks, Mrs Maureen (Wolv' NE)
Clark, Sir W. (Croydon S)	Hicks, Robert (Cornwall SE)
Clarke, Rt Hon K. (Rushcliffe)	Higgins, Rt Hon Terence L.
Colvin, Michael	Hill, James
Conway, Derek	Hind, Kenneth
Coombs, Anthony (Wyre F'rest)	Hogg, Hon Douglas (Gr'th'm)
Coombs, Simon (Swindon)	Holt, Richard
Cope, John	Hordern, Sir Peter
Cormack, Patrick	Howard, Michael
Couchman, James	Howarth, Alan (Strat'd-on-A)
Cran, James	Howarth, G. (Cannock & B'wd)
Currie, Mrs Edwina	Howell, Ralph (North Norfolk)
Curry, David	Hughes, Robert G. (Harrow W)
Davies, Q. (Stamf'd & Spald'g)	Hunt, David (Wirral W)

Hunt, John (Ravensbourne)	Pawsey, James
Hunter, Andrew	Peacock, Mrs Elizabeth
Irvine, Michael	Porter, Barry (Wirral S)
Irving, Charles	Porter, David (Waveney)
Jack, Michael	Portillo, Michael
Jackson, Robert	Price, Sir David
Janman, Timothy	Raffan, Keith
Johnson Smith, Sir Geoffrey	Raison, Rt Hon Timothy
Jones, Gwilym (Cardiff N)	Rathbone, Tim
Jones, Robert B (Herts W)	Redwood, John
Kellett-Bowman, Mrs Elaine	Renton, Tim
Key, Robert	Rhodes James, Robert
King, Roger (B'ham N'thfield)	Rhys Williams, Sir Brandon
Kirkhope, Timothy	Riddick, Graham
Knapman, Roger	Rifkind, Rt Hon Malcolm
Knight, Greg (Derby North)	Roberts, Wyn (Conwy)
Knowles, Michael	Roe, Mrs Marion
Knox, David	Rossi, Sir Hugh
Lamont, Rt Hon Norman	Rost, Peter
Lang, Ian	Rowe, Andrew
Latham, Michael	Rumbold, Mrs Angela
Lawrence, Ivan	Ryder, Richard
Lawson, Rt Hon Nigel	Sackville, Hon Tom
Lee, John (Pendle)	Sainsbury, Hon Tim
Leigh, Edward (Gainsbor'gh)	Sayeed, Jonathan
Lennox-Boyd, Hon Mark	Scott, Nicholas
Lester, Jim (Broxtowe)	Shaw, David (Dover)
Lightbown, David	Shaw, Sir Giles (Pudsey)
Lilley, Peter	Shaw, Sir Michael (Scarb')
Lloyd, Sir Ian (Havant)	Shelton, William (Streatham)
Lloyd, Peter (Fareham)	Shephard, Mrs G. (Norfolk SW)
Lord, Michael	Shepherd, Colin (Hereford)
Luce, Rt Hon Richard	Shepherd, Richard (Aldridge)
Lyell, Sir Nicholas	Shersby, Michael
McCrindle, Robert	Sims, Roger
Macfarlane, Sir Neil	Skeet, Sir Trevor
MacKay, Andrew (E Berkshire)	Smith, Sir Dudley (Warwick)
Maclean, David	Smith, Tim (Beaconsfield)
McLoughlin, Patrick	Soames, Hon Nicholas
McNair-Wilson, M. (Newbury)	Speed, Keith
McNair-Wilson, P. (New Forest)	Speller, Tony
Madel, David	Spicer, Sir Jim (Dorset W)
Major, Rt Hon John	Spicer, Michael (S Worcs)
Malins, Humfrey	Squire, Robin
Mans, Keith	Stanbrook, Ivor
Maples, John	Steen, Anthony
Marland, Paul	Stern, Michael
Marlow, Tony	Stevens, Lewis
Martin, David (Portsmouth S)	Stewart, Allan (Eastwood)
Mates, Michael	Stewart, Andrew (Sherwood)
Mawhinney, Dr Brian	Stokes, John
Mayhew, Rt Hon Sir Patrick	Stradling Thomas, Sir John
Mellor, David	Sumberg, David
Miller, Hal	Summerson, Hugo
Mills, lain	Tapsell, Sir Peter
Miscampbell, Norman	Taylor, Ian (Esher)
Mitchell, Andrew (Gedling)	Taylor, John M (Solihull)
Mitchell, David (Hants NW)	Taylor, Teddy (S'end E)
Moate, Roger	Tebbit, Rt Hon Norman
Monro, Sir Hector	Temple-Morris, Peter
Montgomery, Sir Fergus	Thompson, D. (Calder Valley)
Moore, Rt Hon John	Thompson, Patrick (Norwich N)
Morris, M (N'hampton S)	Thorne, Neil
Morrison, Sir Charles (Devizes)	Thornton, Malcolm
Moss, Malcolm	Thurnham, Peter
Mudd, David	Townend, John (Bridlington)
Neale, Gerrard	Townsend, Cyril D. (B'heath)
Nelson, Anthony	Tracey, Richard
Neubert, Michael	Tredinnick, David
Newton, Rt Hon Tony	Trippier, David
Nicholls, Patrick	Trotter, Neville
Nicholson, David (Taunton)	Twinn, Dr Ian
Nicholson, Miss E. (Devon W)	Vaughan, Sir Gerard
Onslow, Rt Hon Cranley	Waddington, Rt Hon David
Page, Richard	Wakeham, Rt Hon John
Paice, James	Waldegrave, Hon William
Parkinson, Rt Hon Cecil	Walden, George
Patten, Chris (Bath)	Walker, Bill (T'side North)
Patten, John (Oxford W)	Walker, Rt Hon P. (W'cester)
Pattie, Rt Hon Sir Geoffrey	Waller, Gary

Walters, Dennis	Winterton, Mrs Ann
Ward, John	Winterton, Nicholas
Wardle, C. (Bexhill)	Wolfson, Mark
Warren, Kenneth	Wood, Timothy
Watts, John	Woodcock, Mike
Wells, Bowen	Yeo, Tim
Wheeler, John	Young, Sir George (Acton)
Whitney, Ray	Younger, Rt Hon George
Widdecombe, Miss Ann
Wiggin, Jerry	Tellers for the Ayes:
Wilkinson, John	Mr. Robert Boscawen and
Wilshire, David	Mr. Tristan Garel-Jones.
NOES
Abbott, Ms Diane	Dobson, Frank
Adams, Allen (Paisley N)	Doran, Frank
Allen, Graham	Douglas, Dick
Alton, David	Dunnachie, James
Archer, Rt Hon Peter	Dunwoody, Hon Mrs Gwyneth
Armstrong, Ms Hilary	Eadie, Alexander
Ashdown, Paddy	Eastham, Ken
Ashley, Rt Hon Jack	Evans, John (St Helens N)
Ashton, Joe	Ewing, Harry (Falkirk E)
Banks, Tony (Newham NW)	Ewing, Mrs Margaret (Moray)
Barnes, Harry (Derbyshire NE)	Fatchett, Derek
Barnes, Mrs Rosie (Greenwich)	Faulds, Andrew
Barron, Kevin	Fearn, Ronald
Battle, John	Field, Frank (Birkenhead)
Beckett, Margaret	Fields, Terry (L'pool B G'n)
Beith, A. J.	Fisher, Mark
Bell, Stuart	Flannery, Martin
Benn, Rt Hon Tony	Flynn, Paul
Bennett, A. F. (D'nt'n &, R'dish)	Foot, Rt Hon Michael
Bermingham, Gerald	Forsythe, Clifford (Antrim S)
Bidwell, Sydney	Foster, Derek
Blair, Tony	Foulkes, George
Blunkett, David	Fraser, John
Boyes, Roland	Fyfe, Mrs Maria
Bradley, Keith	Galbraith, Samuel
Bray, Dr Jeremy	Galloway, George
Brown, Gordon (D'mline E)	Garrett, John (Norwich South)
Brown, Nicholas (Newcastle E)	Garrett, Ted (Walisend)
Brown, Ron (Edinburgh Leith)	George, Bruce
Bruce, Malcolm (Gordon)	Gilbert, Rt Hon Dr John
Buchan, Norman	Godman, Dr Norman A.
Buckley, George	Golding, Mrs Llin
Caborn, Richard	Gordon, Ms Mildred
Callaghan, Jim	Grant, Bernie (Tottenham)
Campbell, Ron (Blyth Valley)	Griffiths, Nigel (Edinburgh S)
Campbell-Savours, D. N.	Griffiths, Win (Bridgend)
Canavan, Dennis	Grocott, Bruce
Carlile, Alex (Mont'g)	Hardy, Peter
Clark, Dr David (S Shields)	Harman, Ms Harriet
Clarke, Tom (Monklands W)	Hattersley, Rt Hon Roy
Clay, Bob	Haynes, Frank
Clelland, David	Healey, Rt Hon Denis
Clwyd, Mrs Ann	Heffer, Eric S.
Cohen, Harry	Hinchliffe, David
Coleman, Donald	Hogg, N. (C'nauld & Kilsyth)
Cook, Robin (Livingston)	Holland, Stuart
Corbett, Robin	Home Robertson, John
Corbyn, Jeremy	Hood, James
Cousins, Jim	Howarth, George (Knowsley N)
Cox, Tom	Howell, Rt Hon D. (S'heath)
Crowther, Stan	Howells, Geraint
Cryer, Bob	Hoyle, Doug
Cummings, J.	Hughes, John (Coventry NE)
Cunliffe, Lawrence	Hughes, Robert (Aberdeen N)
Dalyell, Tam	Hughes, Roy (Newport E)
Darling, Alastair	Hughes, Simon (Southwark)
Davies, Rt Hon Denzil (Lianelli)	Illsley, Eric
Davies, Ron (Caerphilly)	Ingram, Adam
Davis, Terry (B'ham Hodge H'l)	Janner, Greville
Dewar, Donald	John, Brynmor
Dixon, Don	Jones, Barry (Alyn & Deeside)

Jones, leuan (Ynys Môn)	Radice, Giles
Jones, Martyn (Clwyd S W)	Randall, Stuart
Kaufman, Rt Hon Gerald	Redmond, Martin
Kilfedder, James	Rees, Rt Hon Merlyn
Kinnock, Rt Hon Neil	Reid, John
Kirkwood, Archy	Richardson, Ms Jo
Lambie, David	Roberts, Allan (Bootle)
Lamond, James	Robertson, George
Leadbitter, Ted	Robinson, Geoffrey
Leighton, Ron	Rooker, Jeff
Lestor, Miss Joan (Eccles)	Ross, Ernie (Dundee W)
Lewis, Terry	Ross, William (Londonderry E)
Litherland, Robert	Rowlands, Ted
Livingstone, Ken	Ruddock, Ms Joan
Livsey, Richard	Salmond, Alex
Lloyd, Tony (Stretford)	Sedgemore, Brian
Lofthouse, Geoffrey	Sheerman, Barry
Loyden, Eddie	Sheldon, Rt Hon Robert
McAllion, John	Shore, Rt Hon Peter
McAvoy, Tom	Short, Clare
McCartney, Ian	Skinner, Dennis
McCusker, Harold	Smith, Andrew (Oxford E)
Macdonald, Calum	Smith, C. (Isl'ton & F'bury)
McKelvey, William	Smith, Rt Hon J. (Monk'ds E)
McLeish, Henry	Smyth, Rev Martin (Belfast S)
Maclennan, Robert	Snape, Peter
McNamara, Kevin	Soley, Clive
McTaggart, Bob	Spearing, Nigel
McWilliam, John	Steel, Rt Hon David
Madden, Max	Steinberg, Gerald
Mahon, Mrs Alice	Stott, Roger
Marshall, David (Shettleston)	Strang, Gavin
Marshall, Jim (Leicester S)	Straw, Jack
Martin, Michael (Springburn)	Taylor, Mrs Ann (Dewsbury)
Martlew, Eric	Taylor, Matthew (Truro)
Maxton, John	Thomas, Dafydd Elis
Meacher, Michael	Thompson, Jack (Wansbeck)
Meale, Alan	Turner, Dennis
Michael, Alun	Vaz, Keith
Michie, Bill (Sheffield Heeley)	Walker, A. Cecil (Belfast N)
Millan, Rt Hon Bruce	Wall, Pat
Mitchell, Austin (G't Grimsby)	Wallace, James
Molyneaux, Rt Hon James	Walley, Ms Joan
Moonie, Dr Lewis	Wardell, Gareth (Gower)
Morley, Elliott	Wareing, Robert N.
Morris, Rt Hon A (W'shawe)	Welsh, Andrew (Angus E)
Morris, Rt Hon J (Aberavon)	Welsh, Michael (Doncaster N)
Mowlam, Marjorie	Wigley, Dafydd
Mullin, Chris	Williams, Rt Hon A. J.
Nellist, Dave	Williams, Alan W. (Carm'then)
Oakes, Rt Hon Gordon	Wilson, Brian
O'Brien, William	Winnick, David
Orme, Rt Hon Stanley	Wise, Mrs Audrey
Patchett, Terry	Worthington, Anthony
Pendry, Tom	Young, David (Bolton SE)
Pike, Peter
Powell, Ray (Ogmore)	Tellers for the Noes:
Primarolo, Ms Dawn	Mr. Frank Cook and
Quin, Ms Joyce	Mr. Allen McKay.

Question accordingly agreed to.

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

Resolved, That this House applauds the achievement of the National Health Service in providing a record level of patient care; recognises that this achievement rests on the substantial additional funds from the taxpayer which a strong economy has made possible and which has supported the dedicated work of the National Health Service staff; and welcomes the Government's continued commitment to the most effective use of all the Service's growing resources to bring about a further rise in the standard of health care, both in hospitals and in the community.