National Health Service

HC Deb 18 April 1989 vol 151 cc201-44

Mr. Speaker

I must announce to the House that I have selected the amendment in the name of the Prime Minister.

4.22 pm

Dr. David Owen (Plymouth, Devonport)

I beg to move, That this House rejects the Government's White Paper on the National Health Service as the basis for legislation; notes the rejection and reservations expressed by the Royal College of General Practitioners, the Royal College of Nursing, the Royal College of Surgeons and the Royal College of Physicians through the Joint Consultants Committee, the British Medical Association, the health service unions and the Institute of Health Services Management; believes that practice budgets for general practitioners and self-managing hospitals will lead to financial restrictions being imposed on the doctors' right to prescribe medication and treatment for patients on the basis of what is clinically necessary, to the separation of general practitioners and hospital consultants irrevocably damaging the growing links between home and hospital care and reducing the quality of the overall service available to patients; urges the Government to conduct pilot studies and experiments in relation to these proposals before introducing legislation and thereby to leave time for extensive consultations with the medical and nursing professions which did not take place before the White Paper was published; and also demands that the Government announce that they will not further extend tax allowances for private health insurance or allow the cost of private medical and surgical treatment to be offset against tax since these measures would lead towards a two-tier system of health care. The National Health Service is an issue which goes to the heart of the vast majority of the people of this country. This is therefore no ordinary debate and no ordinary subject. Ninety-five per cent. of the people of this country use their family practitioner services; in any one day, nearly two thirds of a million people consult their doctors. An issue as important as this must therefore concern all Members of this House. It is also, of course, important that more than a million people are employed by the National Health Service.

It is not new for Governments to be in conflict with the medical profession, but it is extremely rare for a Government to find themselves at odds with such a very large group of people concerned with the National Health Service. A White Paper was introduced at the start of this year without any consultation with any of the professional bodies in the National Health Service. That in itself is unique. It is thus not unduly surprising that there has been criticism—what is serious, however, is the level of the criticism.

The royal colleges, which speak for the profession not in terms of salaries but in terms of education and science and professional ethical standards, are not notorious for political criticism and most Governments have been able to find some support among the royal colleges when dealing with the National Health Service. On this occasion, however, all the royal colleges—including the Royal College of General Practitioners, the Royal College of Surgeons and the Royal College of Physicians through the joint consultants' committee—have criticised the proposals. Indeed, they have gone further and rejected them as a basis for legislation for the future of the National Health Service. The British Medical Association and the Health Service unions have also criticised the proposals. The Health Service managers have also criticised them, although in somewhat muted terms.

Taken at face value, the Government's proposals are supposed to benefit patients, but all the patients' organisations have expressed serious concern about them. It is a matter of pride and pleasure to the Social Democratic party to have the first debate on the proposals, although no doubt it is but the first of many. Hon Members of all parties have been confronted in their constituencies with a level of criticism and concern about the Government's proposals which has led Conservative Members to be deeply worried about them. I should be surprised, although perhaps not too surprised, if Conservative Members were able to support the Government amendment to the motion. The Government seem incapable of realising the depth of opposition to their proposals.

I want first to consider the central objections to the proposals. I do not believe that the Government are proposing a genuine internal market. If they were, I should be more enthusiastic about them. Rightly or wrongly, inadvertently or otherwise, the Government have produced proposals for the commercialisation of health care in its entirety. They are not even privatising it—they are commercialising it. Furthermore, they are creating not an internal market, but an open market.

The criticism of the proposals which is heard from every lip is that they involve the fragmentation of health care. Over the decades during which the NHS has operated, an important aspect of the service has been the way in which general practitioners and hospital consultants have gradually come together to provide an integrated pattern of care from home to hospital and from hospital to home. Until the White Paper was produced, it appeared to be common ground among the political parties to support that process of integration of health care—of doctors involving nurses and nurses working in hospitals and in the community, integrating community care and hospital care as part of a continuum. Suddenly, however, without any consultation, the Government have produced proposals which separate hospital health care from family practitioner care.

The proposals refer to the "self-governing" hospital. The Government seem to be trying to incorporate in the Health Service the same principles as they have applied to schools. The terminology is similar, with references to "opting out", and the marketing arrangements are also similar. But a hospital cannot be regarded as a self-contained unit. Let us examine the parallel with schools. A comprehensive school caters for pupils aged from 11 to 16 and often to 18. The school knows what is coming through, so it can plan and project, but it is impossible for a hospital to do that. It is also extremely wasteful to consider acute hospitals as separate entities.

One of the most important developments recently has been the policy to use acute hospitals intensively and on occasions to transfer patients from acute hospitals to community hospitals as a halfway house before going home. The services provided in the home—meals on wheels, health visitors, practitioner nurses and community nurses—are also an important part of the continuum of care. If provision in those areas is insufficient, people have to stay longer in hospital. If there is high-quality care in the community and at home, it is possible to have more day surgery—something that is increasing all the time—and shorter stays in hospital, thus cutting costs.

One of the absurdities of debates about the National Health Service that is all too often apparent in the House are the great boasts about the number of people treated in hospital. The number has increased significantly, of course, because we have been able to increase the throughput in hospitals and to shorten the time that patients spend there. That is highly desirable, but it adds to hospital costs and additional hospital personnel are needed.

It is essential to see the Health Service in the round, as a whole. This is where the fundamental flaw in the Government's proposals arises. They have us talking about the self-governing hospital, when what we should be talking about is the self-governing district health authority because it is the district health authority which provides the continuum of care. We talk about general practice budgets as though the budget of the general practitioner could be separated, as though it existed in isolation from hospital costs and social services costs. When in the past such distinctions have been proposed there has been sufficient flexibility in the Health Service to take account of them.

For example, some years ago it was decided that a cash limit should be placed on hospital prescribing—I remember this because I was actually prescribing in hospitals at the time—so instead of the epileptic clinic prescribing for three months for a person being seen on a three-month cycle, one prescribed for two or three days and shunted the rest of the bill off to the general practitioner. The patient did not mind tremendously, although the general practitioner objected slightly, and we overcame the problem simply by shuffling the hospital pharmacy budget on to the general practitioner. In reality, it cost the Health Service more because hospitals prescribed cheaper drugs bought in bulk, while general practitioners prescribed drugs from the local pharmacy.

Mr. John Redwood (Wokingham)

The right hon. Gentleman is being rather negative. Can he tell us how his internal market would work? How is it possible to have an internal market without doctor choice as to consultants, without patient choice, and without some differentiation in style of hospital?

Dr. Owen

I will deal with that when I come to it in the course of my argument. I prefer to develop first the logical case that general practice costs cannot be separated from hospital costs and that hitherto there has been a thoroughly reputable movement to bring the two together, rather than to separate and fragment them.

To return to the analogy of pharmaceutical costs, if a limit is put on the family practitioner's budget as well as on the hospital budget, there will be no way out because there will be no flexibility. That is rightly seen by general practitioners as limiting their clinical freedom to choose the type of treatment that they think best for the individual patient, so if the Government insist on it they will be starting to challenge a very fundamental aspect of medical practice.

These ill-thought-out proposals come at a moment when a large part of the Health Service agrees that there is a need for medical audit. There is now not only a great deal of consent to medical audit within hospitals but a growing recognition of a need for medical audit within general practice and of the need for the medical profession to be held accountable for the costs that it incurs. It is beginning to be recognised that one cannot have a narrow concept of medical freedom—freedom to prescribe exactly what one wants, and to treat exactly as one wants—because that works back. As there is an overall limit to the amount of money that any Government will put into the Health Service, one has to accept some restriction on one's freedom to treat all patients as ideally as one would wish.

Medical audit—the concept of being held accountable for costs—is accepted by the medical and nursing professions and there is a growing understanding of the techniques involved, so why have the Government brought in a blunderbuss in the form of the White Paper? Why do they seek to legislate for those proposals to be applied across the board without a pilot study for a practice budget or any real understanding of self-governing hospitals other than that gained from six experiments, which have wisely been undertaken, in resource management in hospitals?

It is important to remember that, in five out of six hospitals, those responsible for the experiment in resource management have all said that it is far too early to move to self-governing hospitals and that many more lessons need to be learned. They have asked that their hospitals should continue with the experiment and not be diverted by the question of self-governing hospitals. It is not surprising that those five hospitals—the exception is Guy's —which have pioneered new techniques and want to continue the experiment, and which are going with the trend of modern medicine and modern management, should be coming out in criticism of the Government's proposals. Those who manage the Health Service say that the Government's proposals are ill thought out, with consequences that are difficult to foresee, most of them deeply damaging to the NHS.

It is not as though that was always what the Government intended. The proposition for an internal market, which the hon. Member for Wokingham (Mr. Redwood) asked me to discuss, was put into the public domain by Professor Alan Enthoven of Stanford university more than six years ago. Those proposals were bitterly criticised, often by the Department itself, as impractical and undesirable.

It is well known that the Social Democratic party thought that there was considerable merit in the application of an internal market as proposed by Professor Enthoven, but he did not propose self-governing hospitals or general practice budgets—he suggested that district health authorities should be given far greater autonomy to manage the district health authority, free from regional control, and that there should be a modest market between the district health authorities, with some element of patient choice.

We argued then, as we argued today, that the first step towards an internal market is for patients to be given choice so that, faced with a long waiting list in a district health authority—as sadly happens all too frequently, particularly in elective surgery—they should have the right to go to another district health authority with a shorter waiting list, confident in the knowledge that the bill for that will not be taken up by the district health authority which has reduced its waiting list but by the district health authority whence the patients came. That gives an incentive to districts with shorter waiting lists to take patients from other districts, and acts as a financial discipline on district health authorities with long waiting lists.

If a district health authority decides that it does not wish to build up its expertise or be self-sufficient in a particular speciality, it will be prepared to accept the cost, knowing what that cost will be. In such a system, the money really does follow the patient. The patient makes the choice, advised by the general practitioner who will need information about waiting lists in neighbouring district health authorities.

Not every patient can move. To put a young mother in a hospital 50 or 60 miles from her home creates a major social problem, quite apart from the considerable costs involved. Although that is the most effective way of dealing with the immediate problem of waiting lists, introducing a welcome measure of patient choice, to be realistic for poorer families it must be accompanied by generous help with the cost of going to hospital and of a minimum visiting programme. We already encounter that problem with perinatal care. Where there are not full facilities for dealing with the highly specialised treatment of prematurely born children, the mother and child have to be taken to a specialised unit. The family then faces very heavy costs for a period of six weeks or more with practically no financial support. That aspect must be dealt with.

Such a system, which is the true internal market that has been discussed for the last five years and criticised by the Department of Health, is now being thrown out of the window as being of no significance and we suddenly have a new proposal for self-governing hospitals. Where did the proposal come from? What great genius created it?

If, as is clear, the medical profession objects, as does the Royal College of Nursing, and if the Institute of Health Services Management foresees considerable problems, do the Government still intend to shunt the proposals through? Are we to have the Official Secrets Act all over again? Will Tory Members behave like Lobby fodder and vote for the proposals? There will be a test of that later today.

How can any Conservative genuinely vote for the Government amendment? Perhaps I should read it out to them. It seeks to leave out from 'House' to end and add expresses full support for the proposals set out in the White Paper 'Working for Patients' and believes that these will lead to a Health Service that is more responsive to the needs of patients". I hope that general practitioners in the constituencies of Conservative Members who vote for the amendment will ask a few questions tomorrow. If consultation is to mean anything, surely the Government could have phrased it better and said: expresses the belief that this forms a reasonable basis on which to progress, in consultation with the medical profession". We are already being told by the Minister of State that there are to be no Dr. Noes and no change in the proposals. We are told that they are to be pushed through. [Interruption.] The Minister has been widely reported as saying that there will be no Dr. Noes. If he did not say that, I am only too delighted.

The Government need to face the fact that there are serious problems in the Health Service. It has caused deep resentment in the Health Service that the White Paper did not in any section address underfunding. By any standards, that must be one problem. I agree that the medical profession always wants more money. The Government cannot blame it for that. The teaching profession always wants more money, too. Everybody always wants more money. But it is a fact of life that in comparison with the service in almost any other industrial democratic nation, our National Health Service is asked to carry on with a lower percentage of GDP devoted to it.

The figure in this country is 6 per cent. The average for OECD countries is 7.5 per cent. In the United States the figure is 11 per cent., and in France and Germany it is 8 per cent. to 9 per cent. We are told that the White Paper is to bring about the most radical change in health services since the National Health Service Act 1946. Yet it does not even address financial under-investment. It is no wonder that people who work in the Health Service are asking themselves, "Can the Government really be serious about these proposals?"

Only a few days ago, Bassetlaw district health authority produced an interesting proposal. Instead of asking for its hospital to be part of a self-governing unit, it put in a detailed proposal to the Ministry that it should be allowed to form a National Health Service trust and that, within the National Health Service, the whole district—hospital and community care—should be allowed to be self-governing. It also proposed that the regional health authority should hold the budget and should be the accounting officer. The district health authority went to Price Waterhouse for an assessment of its capacity to do that.

That is the internal market that is really being suggested, and I believe that a pilot study should be conducted into it. Although I am deeply committed to the whole concept of an internal market, the SDP has always argued that it cannot be introduced overnight, that pilot studies must be carried out to prove that it can be done and that the information system on which the management of an internal market critically depends does not exist in the NHS at present. We have argued that it will take many years to develop to its true sophistication before we have an internal market, such as that which I suggested at district level, operating throughout the country. Despite that, however, the Government have introduced proposals for self-governing hospitals, which people do not want. The Government want 200 to 300 of them operating by 1992. What world are they living in? It is certainly not the world in which the majority of people using and operating the NHS live.

There are technical issues. The problem with the White Paper is that of an underlying dogma which is far more ominous. With the Finance Bill we are seeing the first step towards the more dogmatised, ideological basis of the Government's reforms—health insurance tax relief for those aged over 60. Many Conservative Members voted for that proposal, but I hope that before it is implemented, and later extended to the whole of the working population, they will think through the implications. Since the original Tory opposition to the 1948 legislation, it has been a Right-wing dream to have tax relief on health insurance.

One of the more amusing issues in recent months has been the criticism of the doctors. Department of Health Ministers have claimed that if the doctors had had their way originally there would not have been a National Health Service. They forget to mention that if the Conservative party had had its way, there would not have been an NHS either because Tory Members of the day voted against the legislation.

Mr. Ray Whitney (Wycombe)

How does the right hon. Gentleman explain the 1944 White Paper which set out the basic principles on which the NHS was founded? The Health Minister at the time was a Conservative.

Dr. Owen

Mr. Brown's White Paper, initially in 1943, followed by the actions of Henry Willink in 1944, was one of the best examples of a coalition Government that we have seen. The social legislation of the 1940s, on education, and so on—R. A. Butler's measure—was important, and if one cares to do so, one can go back in the history of the NHS to the Socialist Medical Association of the early 1930s. Even the British Medical Association had moved its position by the late 1930s. As with most radical changes, a considerable breadth of consensus was needed. It was surprising that when the original NHS Bill came forward from Aneurin Bevan, Sir Winston Churchill and the Tory party opposed it with great vigour. Fortunately, the Conservatives did not overturn the Act in 1951 when they were returned to office.

Since 1948, the NHS has had the unanimous support of all political parties in Britain and, by and large, that has been sustained across the transfers of Government. Now, however, the Government have introduced their White Paper, and there is no question but that if there were a further extension of tax relief for private health insurance covering the whole working population, we would inexorably be heading for a two-tier health service and the American system of health care. If that were buttressed by the demands, of which we hear and about which we read in the newspapers, for tax relief on the cost of private medical treatment or in respect of private surgical treatment—we gather that that is being demanded by some Conservative Back Benchers—the movement towards a two-tier system would be very rapid indeed.

Against that philosophical background, we must consider the other aspects of the White Paper. The Prime Minister is among the small percentage of the population who do not use the NHS. She seems genuinely to believe that if one can pay for private insurance, one almost has a moral obligation to opt out of the NHS, freeing resources for use elsewhere in the service. But the NHS is based on a different concept. It is based on the principle of "count everyone in"—that everyone has insurance cover, that the service is provided for the whole of the population and that nobody, rich or poor, need opt out. There are great advantages in a health care system in which rich and poor participate and all are treated the same, with the judgment being made on the basis of clinical need. We would be taking a major step if we encouraged people to feel that they had a moral obligation to opt out of health care purely and simply because they had enough money to pay for private health insurance.

Let us look at the Government's proposals for self-governing, autonomous hospitals. It is very nice perhaps for teaching hospitals to opt out, but one of the problems of the teaching hospitals, particularly in London, is that they are already opting out of some of their community health responsibilities. If the Minister were to tell us that a particular hospital specialised in orthopaedic work, such as hip replacement operations, and was doing virtually nothing else and that there was a case for the hospital being autonomous and run as a self-managing unit, people would say that we ought to try it and would feel that such a move was not unreasonable, since the hospital was not providing a district service and was not part of the health care pattern. If the Government were to encourage that hospital or some other specialised hospital to opt out as an experiment, no one would get very upset about it. Our objection is to taking out the district general hospital—the very core of our intergrated health care—and managing and financing it separately.

Let us take another example. It is suggested that the hospital trusts should have different terms of employment. There is much to be said for a district health authority being the employing authority, having the freedom to employ and making its own contracts. Hospital consultants should have contracts not with the region but with the district health authority. The family practitioner committees should come under the district health authority. If one integrated the district with the family practitioner health service one would create what is, in American terms, a health maintenance organisation, and one would be much better able to achieve some of the benefits that the Government are trying to achieve with the general practitioners contract.

Many of the preventive health measures in the new GP's contract are beneficial to medicine and, operating within the concept of a district health authority, could be of great benefit. But in fact the GP practice is to be fragmented and regarded as a separate unit. That will not work, or, if it does work, it will damage the overall integrated health care pattern.

On top of this, we have been waiting for years for proposals on the community health services, but they have not yet been brought forward. How on earth is it possible to legislate for the National Health Service and to formulate views on the family practitioner service and on the hospital service without any idea how the Government intend to handle the community health service? Those concepts are not separate abstractions—they are closely integrated.

Let us take, for example, the question of joint funding which I introduced when I was Minister of Health. Its prime purpose was to bring the social services, hospital services and family practitioner services together, and to provide some money to grease the wheels for integration. How can one consider this White Paper in the absence of any provision for community health? I hope that in this debate the Government will listen to the views of their own Back Benchers—to whom they listen more readily, I fear, than to Opposition Members.

Mr. Stephen Day (Cheadle)

Will they?

Dr. Owen

We must take a realistic view of these matters. I am sad about it. I should like to believe that every word that we spoke would be taken with the utmost seriousness in the Department of Health, but I suspect that four or five speeches of opposition from Conservative Back Benchers might have more impact on No. 10 Downing street, if not on the Department of Health.

This debate is our first real opportunity to flag tip that the basis of the White Paper will not provide legislation which will carry the Health Service workers with the Government or carry the country with the Government but will do grave damage to the National Health Service. The question is how to get the Government off the hook.

That is the issue that Conservative Back Benchers should be worrying about. Here there are some real possibilities that I should like to encourage the House to consider.

First, it would be much better to get the question of the GP contract out of the way as quickly as possible—"Give 'em the money, Barney" used to be the expression, or "Stuff their mouths with gold," as Aneurin Bevan put it. I admit that at one moment when we were in office and when it looked as though we had the hospital doctors, the junior hospital doctors and the general practitioners all opposed to us, we found a way of paying GPs for contraceptive advice. I felt that that was part of the contract of general practitioners and I was bitterly opposed to paying it, but I am afraid that I paid up, so it would not be the first or the last time that Governments have paid up.

That is not, however, what is necessary now because most of the criticisms of the GPs' contract can be overcome by a modification of some of the objections which are fairly soundly based. For example, the criticism made of the immunisation percentage is a real one, although I cannot for the life of me see why we do not put an obligation on parents, when their children enter school or when they claim child benefit, to show that they have participated in an immunisation programme. Making it all a responsibility of general practitioners is wrong. Parents have a responsibility to see that the immunisation programme is undertaken and it is part of the general practitioner's contract to see that it is done or done by the school health service.

Similarly with the cervical cancer smear service, the percentage figure is very high and people have reasonable objections to that. In dealing with the withdrawal of seniority payments, it is necessary to protect pension rights. Something can also be done about payment for night calls. It is not beyond the wit, certainly of the Secretary of State, if he sets his mind to it, to resolve these problems. He is obviously worried that if he makes a few concessions here the British Medical Association will come back asking for more and he will have to negotiate it.

Let the Government settle the issue of the contract in the next couple of months and then deal with the substantive problem, the National Health Service review. Having done that, let them get the GPs to accept medical audit to the extent that hospital consultants have accepted it. Let them extend resource management in the Health Service from the six hospitals that operate it now to 100 hospitals, and gradually build up an information system. Then let them conduct some experiments or pilot studies.

If, for example, a few hospitals are highly specialised and not part of the district health authority, let us have a look at running them autonomously. If there are a few people with large practices who are keen to run a practice budget, let them have a go at it. Legislation is not needed for any of that.

Mr. Day

That is exactly what is being said.

Dr. Owen

No, it is not exactly what is being said. The Government have been arguing for more than 200 hospitals to be operated as autonomous, self-governing units within a short period.

As regards practices, the Government are saying that it is up to the general practitioner—

Mr. Day

It is voluntary.

Dr. Owen

No, it is not voluntary. The Government have so changed the other arrangements for general practitioners that they are giving a considerable incentive to go for practice opt-outs. This is what the Royal College of General Practitioners and the General Medical Services Committee object to. If it were a free choice—

Mr. Day

It is.

Dr. Owen

It is not. Hon. Members must look at the proposals carefully and, I suggest, talk to a few of their local general practitioners. They will find that the criticism of the proposal is not that they are allowed to take an "opt out" decision for their own particular practice. What GPs object to is that the structuring of general practice payments and arrangements makes it difficult for them not to go in that direction. There is not just an incentive but a stick pushing them in that direction. That is what they object to, and they are quite right to object.

It is in any case not the right direction. The right direction is to integrate the family practitioner committees with the district health authority, and to try to produce a system of incentives that will encourage preventive medicine and health maintenance. In keeping down the costs of hospitalisation of a patient, the GP works with the consultant and both have an incentive to keep the patient in hospital for as short a time as possible. That saves money for the district health authority, and they all benefit in consequence. That is not fragmenting care—it is integrating care. It is getting cost-effectiveness through a much better provision of care by bringing hospital and home care together.

That is the direction in which the Secretary of State should proceed if he is wise. His problem is that overshadowing it all is the Prime Minister, who wishes to change the National Heath Service fundamentally. We should be under no illusions about this. The Prime Minister wants a two-tier health service, and she openly admits it in the House. She wants a system under which those who can pay private health insurance will do so. She thinks that it is quite right that the 40 per cent. of people who can afford to do so should operate within a broadly private health system. They would have a safety net so that if they were hit by a car on the M4 they would be taken to the local hospital. However, broadly speaking, the health care of such people will be taken outside the National Health Service.

For the other 60 per cent. of the population, the Prime Minister accepts that there should be a safety net and a health care system that is as good as can be afforded. Her Government would not spend too much money on that because it will be public sector money.

There is nothing new about such a system—it operated in this country in the 1920s and 1930s. It was rejected by the people when the National Health Service was created in 1948, and many of us are determined that it should not be reintroduced through either the front or the back door. Such a system underlies many of these proposals and it will be introduced unless they are rejected.

Sir Michael McNair-Wilson (Newbury)

Does the right hon. Gentleman think that consultants should opt to work in either the National Health Service or the private sector, or that the present position should continue?

Dr. Owen

I have reluctantly come to the conclusion over many years that we shall have to accept the Aneurin Bevan compromise in which doctors work in both the public and private health service, and we have a mixed provision of health care. Ideally, I should like doctors to work full time in the National Health Service, as I did. Had I stayed, I should always have worked full time in the NHS. However, we have to live with the system under which doctors cherish the right to practise privately part of the time. [HON. MEMBERS: "That is a two-tier system."] It is not a two-tier system at all. The private health care system that operates in this country is a small part of the overall health care system—a safety valve. It operates—and has done so under successive Governments—without serious detriment to the National Health Service.

If there was a serious attack on NHS waiting lists, they could be reduced, and then much of the motivation to expand the private sector would be withdrawn. There will always be some people who would like to have the freedom to choose their own doctor, but we cannot offer that choice to the whole population. It produces only a minor distortion of the system and, provided it operates at a fairly low level, it can be tolerated as part of the mixed health care system. However, that is not a two-tier system, or the one which we had before the National Health Service. Many of us are determined to ensure that it is not introduced.

Having listened to the debate I realise that a number of Conservative Members need to discuss these matters a bit more with some of their constituents if there are not to be many tears over the next few years. Nobody should underestimate the extent and depth of feeling against the proposals. The nursing profession is now almost more important than the medical profession to the successful running of the Health Service. There is a reasonable surplus of doctors, but there is an acute shortage of nurses, who have to be encouraged to return and stay in the Health Service. We cannot, therefore, dismiss the view of the nurses, let alone the views of the medical profession. Above all, we should not exclude the views of the patients.

The Government should be able to come forward with some level of support for their proposals from the people whom the proposals are meant to serve. If there is merit in them, it should be possible to point to patients who want them, but I have found no evidence of popular demand for any of the substantive proposals—which have been criticised—put forward in the White Paper.

Mr. Day

Does the right hon. Gentleman agree that while there is much feeling against the White Paper it is against the myths surrounding it rather than the actual proposals? The myths are largely created by organisations such as the British Medical Association.

Dr. Owen

The BMA is bound to be in conflict with the Ministers. I am reminded of the story of David Lloyd George, who went to the BMA when he was Chancellor of the Exchequer. When he came out of the meeting he said that he felt "like Daniel leaving the lion's den, the only difference being that those lions knew their anatomy." A mauling of Health Ministers by the British Medical Association is par for the course, but it is not par for the course for them to receive a mauling from the royal colleges of physicians, surgeons, general practitioners, obstetricians, gynaecologists and from the Royal College of Nursing. The degree of opposition that the White Paper has roused within and without the National Health Service, and the total lack of support from patients, is not commonplace.

When Aneurin Bevan had trouble with the BMA, at least he had the patients on his side. It is clear from this debate that nobody—apart from Tory Members—seems prepared to vote for the Government's splendid amendment to the effect that everything in the garden is fine. Here is an opportunity for Conservative Members to abstain—to disappear quietly so that they are not here to vote for the Government's self-congratulatory amendment. In doing so, they may do themselves a great service. In voting with the Government they will be doing the Opposition a great service.

5.7 pm

The Minister of State, Department of Health (Mr. David Mellor)

I beg to move, to leave out from 'House' to the end of the Question and to add instead thereof: `expresses full support for the proposals set out in the White Paper "Working for Patients" and believes that these will lead to a Health Service that is more responsive to the needs of patients, and will enable those hospitals which best meet the needs of patients to get the money to do so, will reduce waiting times, improve the quality of care, help family doctors to develop the services they provide for their patients, improve the effectiveness of National Health Service management, and ensure that all those concerned with delivering health care make the best use of the resources available to them.'. I am glad that we have had the opportunity of debating this matter today. I wondered when an Opposition Supply day would be devoted to the topic. It is interesting that, whatever the Labour party may have to say about the White Paper, it has not been enthusiastic to table such a motion. Apart from the hon. Member for Peckham (Ms. Harman), who has to be here, there is only one other Labour Member in the Chamber. Admittedly, it is always a pleasure to hear from the hon. Member for Halifax (Mrs. Mahon) on these matters.

It may be that the Labour party lacks enthusiasm for a full-scale debate because it would not be long before its threadbare thinking on the need for positive change in the NHS would be revealed. Into that vacuum, in a rather unexpected way, has moved the right hon. Member for Plymouth, Devonport (Dr. Owen) and his motion. We heard a typically self-indulgent performance, expanding over 43 minutes, from the right hon. Member. Perhaps in future two-and-a-half-hour debates the right hon. Gentleman will use notes so that he might be able to deliver his speech a little quicker and more accurately. What he said was full of misconceptions about the White Paper.

One thing which could always be said of the right hon. Gentleman was that if he thought that the Government had a point—or even half a point—he was always prepared to acknowledge it. The interesting point about his contribution to this debate is the uneasy way—often resorting to making distinctions on the head of a pin—in which he seeks to distinguish between the Government's concept of an internal market in the NHS and the one that he claims to have popularised.

I suspect that the right hon. Gentleman—intoxicated, as his last remarks made clear by the thought that every man's hand was against the proposals, which is far from the case—has fallen into the trap of the lowest common denominator of Opposition. He would have done himself a greater service if he had acknowledged that much of the thinking in the White Paper reflects a number of issues that obviously occurred to him when he wrote his book and when the SDP published its document.

The best I can find to say about the motion is that it could have been drafted by the Labour party. The right hon. Gentleman used not to be pleased to hear such words. However, he knows full well that, in his book, he makes it clear that he is interested in a more consumerist NHS, wants an internal market to be developed and a national health authority with substantial autonomy. He makes it clear that he wants improved resource management with measures to improve the cost awareness of professionals. He makes it clear that he understands the case for management of the NHS to be much freer and at a lower level.

It is astonishing that the right hon. Gentleman should base his objections to the Government's proposals on the distinction between self-governing hospitals and semi-independent district health authorities. Bassetlaw may well have snookered him by producing proposals at which we are looking with great interest.

The right hon. Gentleman knows full well that the concepts set out in the White Paper reflect an awareness at which everyone except members of the Labour party must surely arrive: if the NHS is to meet the challenge of the next decade it must be more cost-effective in its delivery of services. The "Green Paper"—presumably the right hon. Gentleman not only wrote it but cut down the trees to pulp the paper, given its one-man-band nature—states: The SDP believes that the introduction of an internal market into the National Health Service would yield a number of benefits. Firstly, health managers would be able to use resources in a more effective manner. They would be free to buy services from other suppliers who offered good value, and by careful investment of their own resources attract income from other health authorities. The move to an internal market would provide an incentive to develop a more sophisticated financial management and information system. It would also provide a strong incentive to review existing methods of service delivery … Funding will in effect follow the patient, bringing an important transfer of power in favour of patients. It is regrettable that the right hon. Gentleman has failed to accept that such notions—whether they embody his own concept of an internal market, which no doubt he would be bound to admit was less than fully argued through in his book and presented very sketchily today, or our kind of concept—start from a common root of recognition that unless the NHS becomes more consumerist and is managed more effectively lower down the scale—unless there is some freedom for finance to cross the arbitrary district boundaries that now inhibit the proper delivery of care—we shall not meet the challenge of the next decade. It is regrettable that the right hon. Gentleman has seen fit to kow-tow in this way, notably in the article that he produced in the Daily Express on Saturday. I do not know whether any other hon. Members have read it.

Although the article went on at some length, no one reading it would have dreamt for a moment that the right hon. Gentleman had ever thought about internal markets. Of course, it contained much good advice. It called my right hon. and learned Friend the Secretary of State "insouciant", and told him what wise heads would do— which, in the light of the right hon. Gentleman's political career, is a bit like King Farouk telling people how to run a kingdom.

Mr. Nicholas Soames (Crawley)

Or Roy Jenkins.

Mr. Mellor

The right hon. Gentleman says: when you are in a hole, stop digging. Who better than he to formulate such advice?

The right hon. Gentleman knows only too well that when he was in office he was not deflected by opposition from groups that he considered to be standing up for more vested interests than for progress. He has conceded in most of his subsequent writings that what he proposed then was wrong. But the idea that the doctors, or indeed any other group within the NHS, should be the final arbiters of a change in what is actually the patients' service strikes me as a further retreat from the principle of which the right hon. Gentleman should be less than proud.

Let me make a positive case for the concepts in the review. I shall do so as briefly as possible, so that the maximum number of hon. Members will have an opportunity to speak—more than 40 minutes having been taken, quite unnecessarily in my respectful judgment, to open the debate.

The first crucial point is that the past 10 years have been years of expansion for the NHS, in which funding has increased considerably. Had we merely continued the level of funding that existed 10 years ago, this year the NHS would be spending just under £19 billion at 1989–90 prices. In fact, it will be spending more than £26 billion. We know that nearly 1.5 million more in-patients a year are being treated by the NHS than were treated 10 years ago, while 3.25 million more out-patients and 500,000 more day cases are being dealt with.

Those statistics are familiar; I need not go over them. However, the expansion of the NHS has not, in truth, made the service any easier to run in 1989 than it was in 1979. If we had dared to predict such expansion 10 years ago, people would have thought first that a tripling of cash expenditure within a decade was not possible, and secondly that if it were possible—imagining that signing a large cheque is the fundamental way of dealing with the NHS—we would be in an easier position. We are not. The job of balancing priorities will become more rather than less difficult in the years ahead.

The reason is clear: demand for the NHS is growing, and will continue to grow inexorably. That is partly for demographic reasons: we are an aging population, and, important and good though that is, it imposes large costs on the NHS. Secondly, the frontiers of medical science are being continually pushed forward, mostly into expensive, high-technology developments. Thirdly, people are no longer content, for instance, to wear a body support for a hernia or a surgical stocking for varicose veins; they require an operation. People's thresholds for seeking treatment are being constantly lowered, which is not unreasonable. The service is there and people want to use it.

Finally, people are no longer content for the NHS to be simply a service for sickness. They want it to be a service for health. They want more prevention techniques, and they want the full benefit of primary health care to go to those who think that they are healthy but who may not be, so that they can be screened for conditions that can be dealt with at an early stage. Such things are possible in this decade. They were not possible in the decade during which the right hon. Gentleman had custody of the NHS, because he spent most of his time having to argue that the NHS could not be protected from funding problems.

I know that what I am saying is not palatable to the right hon. Gentleman, but I listened to most of his speech, and I feel that he could at least do me the courtesy of listening to mine. The right hon. Gentleman is not always alone in having a valuable contribution to make to a debate, and having started this one he should, I think, listen to what the rest of us have to say.

The right hon. Gentleman knows that in the current decade the 20 per cent. increase in the number of general practitioners, and the 50 per cent. increase in the number of support staff for them—including the doubling of practice nurse members—have made possible primary care teams that could not have been dreamt of in the 1970s. As a consequence a great gap has been opened between those who are providing that full range of services and those who are not.

The task of Government is not to sit back and say, "Chacun à son goût; let any doctor do what he chooses", but to try to ensure, through the contract and in other ways, that health care reaches high standards everywhere, and that the contract not only rewards effort but stimulates further effort. To my mind there is not too much difference between that kind of consumerist approach and that which, until it became politically expedient not to do so, the right hon. Gentleman supported.

The gravamen of the right hon. Gentleman's charge when the debate was announced was his hostility to the "commercialisation" of the NHS, whatever that may mean. But unless the NHS is prepared to use the techniques of cost-effectiveness that have been so successful elsewhere it will be incapable of meeting those demands, even within the rising budget that we all want. Let us take, for instance, competitive tendering. I do not know whether in his present mode the right hon. Gentleman would consider that commercialisation, but we have saved nearly £110 million simply by not accepting that the way in which things have always been done is the way in which they should be done in the future.

Interestingly, 85 per cent. of the contracts that were reconsidered went in-house, showing that there were savings to be made if only people could be bothered to try. All that £110 million has gone back into the service. To put it another way, the equivalent of one and a half Great Ormond street hospitals have been saved by the service tightening up on washing and cleaning costs.

Mrs. Alice Mahon (Halifax)

rose—

Mr. Mellor

If the hon. Lady does not mind I will not give way: I am trying to be quick.

The same is true of a range of other efficiency savings. Some £740 million has been allocated elsewhere in the system. A tighter view has been taken of prescribing. Most people now admit that all the fuss over the limited list was based on two entirely false premises—damage to patients and that savings would not be made. We said that £75 million a year would be saved, and £75 million has been saved for four years now. Some £300 million that was being spent on over-priced branded cough mixtures on prescription is now going into the "front end" of patient care.

Mr. Michael Latham (Rutland and Melton)

I hope that my hon. Friend will concede that at the end of the consultation period the limited list was three times longer than it was at the beginning of the consultation period, because his predecessors listened to hon. Members on all sides of the House. I hope that he will assure the House that he will do the same in regard to the doctors' contracts.

Mr. Mellor

Another unfairness in the speech of the right hon. Member for Devonport was that he suggested, by distorting phrases ripped out of context from my speeches and those of my right hon. and learned Friend the Secretary of State for Health, that we were seeking to ram those changes willy-nilly down the throat of the profession. My right hon. and learned Friend the Secretary of State has made it clear that the Government have a duty to set the direction in which the service should go. The publication of the working papers, the intensive discussions that are taking place and the invitation to co-operate that lies at the heart of all our proposals are designed to work with the grain of the system.

Of course, as we receive representations, whether they are about details of the contract or suggest ways in which we can better apply the financial principles in the resources management initiative, their voices will be heard and we shall not hesitate to change our minds. That is what we have been saying throughout the process. I am glad to say that the media who first wanted to report war-war have belatedly become interested in jaw-jaw and are reporting passages from my speeches saying that the proposals were not tablets of stone. We are looking for a genuine dialogue and we are only too ready to alter course and change practical details if that is required. We have a duty to lay down the basic thrust of the proposals and to carry them forward because they are right.

The right hon. Gentleman's house was built on sand. He based his case on the fact that we were compelling GPs to have practice budgets and hospitals to become self-governing. But only general practices of a certain size are being invited to apply for practice budgets, and those who do not wish to do so do not have to. Pilot schemes are a practical way of testing whether budgeting will work. The practices concerned will open negotiations—and plenty of them are ready to do so—if the negotiations flourish they will accept the budget and if the negotiations are unsuccessful they will walk away. No one is being compelled to take a budget. If the system works it will grow, and if it does not, as I said on the radio, it will be consigned to history. What could be fairer than that?

The same applies to self-governing hospitals. Of course we are entitled to say that we hope that the majority of acute hospitals will follow up but it is entirely their choice and there is no shortage of interest. What is meant by self-governing hospitals? Far from the right hon. Gentleman's uncharacteristic sloppiness in suggesting that the proposal was carried across from the education reforms, we have never used the words "opting out". We are saying that in the interest of good Health Service management it should be reduced to the lowest level consistent with being able to develop the best patient care. Given the calibre of people interested in becoming involved in special health authorities in London, the attractions of self-governing hospitals with the politics removed—attracting the best people from the community and the best managers to deliver the best service—are clear.

Mr. Brian Wilson (Cunninghame, North)

In referring to opting out or self-governing hospitals, the Minister repeatedly said, "It is entirely their choice." To whom was he referring?

Mr. Mellor

The hon. Gentleman knows well that the White Paper makes it clear that it is for various interested groups to come forward with proposals, and for the Secretary of State to determine whether those proposals should be implemented. I have told the hon. Gentleman what the White Paper states on that.

The White Paper is based on concepts which every patient and everyone concerned with the NHS wants—quality, responsiveness and value for money. As the Institute of Health Services Management has made clear in regard to the present funding of the NHS hospital service, a good unit that gets through its list and carries out more operations than average, runs into financial difficulties nine or 10 months into the financial year, while a unit that coasts along and does not extend itself is funded on exactly the same basis for ever and a day and, of course, does not run into financial difficulties. With money following the patient, something that the right hon. Gentleman used to advocate—well might he hold his head in his hands—those units that are good are allowed to reach their proper level. Surely that is in the best interest of patients.

We want a more consumerist Health Service. We are beyond the point at which, after the great battle to establish the Health Service, it was possible for the profession or anyone else to say that the NHS was doing the public a favour simply by allowing people to pass through its portals. It was regarded as deeply radical by some general practitioners that there should be an appointments system, but now it is accepted. Why should hospitals not be the same? Why should patients turn up at 9.30 and be seen at 12.30? Why should the conditions for many out-patients be so disgraceful?

Mr. Simon Hughes (Southwark and Bermondsey)

Because of the lack of funding.

Mr. Mellor

I have already mentioned the increase in funding. The problems to which I referred often relate to priorities and attitudes rather than money. The idea that everyone should be acquitted of any dereliction of duty by the parrot cries about funding is typical of how spurious NHS debates often become. We all know that it relates to attitudes. We all hope that when cash follows the patient, NHS patients will become as valuable commodities to the medical profession and others as private patients. That day is long overdue.

Finally, I turn to value for money. Given the demands on the Health Service in the next decade, unless we can deliver health care efficiently and effectively, we shall not meet the increased pace of demand. Sometimes the argument is satirised as if it is simply a matter of making cuts or signing a large cheque, but the argument is about providing a quality of care that meets the demands of patients. Even within an expanding budget it will be a struggle. Value for money—a good quality of care at a sensible cost—is the way forward.

We all know that there are hospitals capable of carrying out operations on a day care basis. I visited one in Burton where 50 per cent. of the operations were carried out on a day care basis. In many other parts of the country people are in-patients for two to three days. Conducting operations on a day care basis is not selling the patient short. Most patients do not want to stay overnight in hospital and do so only because the present system demands it. Our proposals are based on straightforward concepts that have been carried through to beneficial effect elsewhere in the economy. The NHS must not become a mausoleum to outdated managerial practices. The NHS is in the forefront of medical advance and should be in the forefront of financial and other management if we are to have the NHS that we need.

It will be interesting to hear other speeches in the debate and to find out whether any other parts of the House are capable of yielding up positive proposals such as those in the White Paper. People should be concerned not merely to stir up easy points by suggesting that the profession is against one proposal and the public are worried about another, but to find some way of ensuring that we deliver health care more effectively. At the moment, only the Conservative party is rising to that very real challenge.

5.27 pm

Ms. Harriet Harman (Peckham)

It is highly significant, and will be greeted with dismay by the public and the professions outside the House, that the Minister failed to address any of the very real concerns that have been raised about the White Paper. He did not address any of the concerns that were well articulated by the right hon. Member for Plymouth, Devonport (Dr. Owen).

When will the House have a full debate on the White Paper? While I welcome the opportunity provided by this brief debate to begin discussion on the White Paper, it is quite wrong that the country should be discussing the White Paper yet the House has not had the opportunity to have a full debate. It is particularly wrong because the Government are already progressing with their plans, and have even gone so far as to appoint finance managers to run hospitals which have yet to opt out under system which has yet to be debated in the House. I should have thought that the Secretary of State should come forward urgently to discuss those plans in the House. The House is the only place in which the Government are likely to hear any support for their proposals, largely thanks to the Government Whips.

It is in keeping with the way in which the review has been dealt with from the outset that we have not had a chance to debate it fully in the House. The review was not, of course, a response to public concern about the shortage of resources in the Health Service. The original idea of the review was to give Ministers a breathing space and to sweep the issue under the carpet. It gave Ministers something to say when, week by week, day after day, they had to respond at the Dispatch Box to the concerns about lengthening waiting lists and cancelled operations.

But away from public involvement and any professional advice, the review has unfortunately mutated into a monster which aims to inflict on us the same chaos and misery that the American health care system inflicts on the American people. If there had been any public or professional consultation during the review process, it is inconceivable that the Government could have come up with the commercialisation of the National Health Service.

There is a broad and deep consensus about the Health Service, which only the Government stand outside. People understand that the commercialisation of health care will drive down the quality of health services, drive up costs by saddling the Health Service with a monstrous bureaucracy and undermine the doctor-patient relationship by putting a price tag on each patient's head. It is clear to everybody that the Government are interested not in a healthy patient, but only in a healthy bank balance.

Doctors', nurses' and health workers' unions have all warned that the White Paper proposals will cut down patient choice, not increase it, and will reduce our chance of developing preventative health services. The proposals will hit hardest those who need help the most—the chronically sick, the disabled and the elderly. The fact that the weight of public opinion is overwhelmingly against the proposals and that the weight of professional opinion is unanimously against them must be a grave disappointment to the Government, especially as they have invested a great deal of public money—more than £1.25 million —in a shameful attempt to mislead the public and health professionals about what the proposals constitute. I challenge the Minister to name even one reputable, independent organisation that knows anything about the issue which supports the proposals. There is none.

Sir Michael McNair-Wilson

Seven million pounds has been spent in opposing the White Paper. Does the hon. Lady think that the British Medical Association should use general practitioners' surgeries as a way of putting across its propaganda to the sick and the elderly?

Ms. Harman

It is for the British Medical Association to decide what it does with its members' money. What the Government do with taxpayers' money is a matter for all of us. It is a pity that the hon. Gentleman cannot tell the difference.

The Secretary of State and his Ministers have become angry about the fact that they have not been able to buy public or professional opinion, so they have resorted to smear tactics: they have said that the doctors are simply reaching for their wallets and that the nurses are merely a vested interest who must be overridden. The Government remain determined not to listen to argument, not to consider the evidence and not to respond to public concern. Nothing in the Minister's speech suggested that he has listened to the points made so strongly.

The evidence is clear: we need more resources in the Health Service. It seems that even that message has not got through to the Minister. We spend less per head on health care than most other European countries and only a little more than half what Americans spend for an inferior system.

The other important piece of evidence to which the Government do not want to listen is that competition actually drives down quality. When hospitals compete, they cut corners so that they can cut costs, and that increases the mortality rate. The fiercer the competition, the higher the mortality rate. Evidence of that has been established clearly in the United States, even when dealing with not-for-profit hospitals. I am not talking about profit driving down quality, but the fact that competition for patients results in a lowering of quality. That was reported in The New England Journal of Medicine.

Ironically, people were safer being treated in a small town where there was only one hospital than in a big city, where many hospitals were competing for patients, and therefore cutting costs and corners. Yet that is what the Government's proposals for opted-out hospitals competing with each other will mean. Standards will be driven down and mortality rates will rise. The internal market would also drive up administrative costs.

Mrs. Mahon

Before my hon. Friend comes on to competition, will she agree that the competition introduced through the tendering of services has been damaging to the quality of the Health Service? Most of us regularly see headlines about that in our local press. I have here an article describing how food inspectors have told a local authority to clean up and to improve hygiene standards in the hospital in which I worked for 11 years. It was a very clean hospital until it was forced to accept the in-house tender, which cut domestic services in half and reduced the standard of hygiene, leading to a dangerous situation.

Ms. Harman

My hon. Friend's example is a testimony to the Government's obsession to cut the cost of public services and never mind the quality.

When the Secretary of State gave evidence to the Select Committee on Social Services and was asked about the effect of the internal market on administrative costs, it was extraordinary that he could say that he had no idea of what the extra administrative costs would be. He was unable to give even the roughest estimate. When one considers that he is going headlong into proposals which, by all other estimates, will have considerable expenditure implications, it is extraordinary that he has no estimates or pilot scheme.

Resources will be diverted from patient care in a veritable paper chase of bills and billing procedures. Bills will go from hospital to hospital, from district health authority, to hospital, from GP to community service and from GP to one district health authority or another. That is what happens in the United States already and it is a pity that we cannot learn from the experience there, instead of simply recreating the mistakes. If one has a hospital appointment there for 9.30 am, one often has to turn up at 6 am to complete three hours of paper work before being admitted to hospital, so complicated has the system become. It is no wonder the American administrative costs are about 20 per cent., whereas ours in the Health Service are far lower.

I hoped that the Minister would deal with a number of important points of criticism raised outside the House and by the right hon. Member for Plymouth, Devonport (Mr. Owen). First, there is the question of patient choice. At present, a GP can refer patients either within the district or outside it, and within or outside the region. We have a genuinely national Health Service in that respect. If we look at the figures for cross-boundary flow, we can see that we do not need an internal market to free up the system and to enable patients to cross district boundaries. They already have the freedom and cross boundaries as a routine matter. The only impediments to that cross-boundary flow are spending restrictions, which have led some major hospitals to say that they will not treat out of district patients. That is a resource problem, not a problem of the system.

Therefore, the Government are making a completely bogus offer when they say that they are offering us a White Paper so that patients can travel across district boundaries, because GPs already have the opportunity to refer their patients to wherever they and the patient think that the treatment is best and most convenient for that individual patient.

Although the right hon. Member for Devonport talked about what he regarded as the internal market, I did not see anything of the market in what he was saying. He said that we should have freedom of cross-boundary flows, which we already have, and activity-based budgeting. I do not see anything wrong with that, but there is nothing of the market in it.

Under the White Paper, the freedom of GPs, together with their patients, to make the choice about where the patient will be treated, will disappear. Instead, the decision will be made on a block basis at the beginning of the year by managers, by people who have no contact at all with patients, let alone with the individual patient who is seeking treatment. The decision will be made to place the contract and spend the money where the service is cheapest, not where it is most convenient for the individual patient, not where the service or the treatment is best, let alone where the individual patient chooses. The decision will be made not in response to individual patients as at present—the decision now rests with the GP and the patient—but on the basis of contract negotiations at the beginning of the year.

A major problem with that is that managers do not have accurate measurements of outcome and quality. All they have are accurate measurements of costs. Therefore, a powerful incentive is being put into the system for managers to negotiate contracts on block bookings for patients where the service is cheapest, rather than where the service is best. At this stage, medical audit does not help us, because the science of medical audit is still underdeveloped in terms of giving indications of outcome and quality.

At the moment, the people who know most about the quality of service in different hospitals and the effectiveness of the treatment and its outcome are the GPs who see their patients coming back from hospitals, and the hospital doctors who see the patients in hospital. However, they will not be consulted. They will not be the ones to make the decision on each individual patient. That decision will be made by means of a block booking by managers who know everything about cost, but nothing about quality and outcome.

That is why it is a travesty to continue to say that the White Paper will extend choice. Choice will be taken away from the patient and the GP and given to managers. It is true that in one respect more choice will be given—more choice will be give to the managers. It will be they who will benefit from more choice; it will certainly not be the GP or the patient.

The Minister said that GPs will not be forced to hold their own budgets. However, they will be forced to do so if that is the only way in which they can save referral rights for themselves and their patients. That is the stick to which the right hon. Member for Devonport rightly referred. The only way in which GPs can keep choice for themselves and their patients is if they opt to hold their own budgets.

However, when GPs do opt to hold their own budgets, they will be going out of the frying pan into the fire. Although they will have the choice of where to refer their patients, when they consult a patient, they must think not only about what the patient needs, but about what their practice's budget can afford. That is why GPs are, justifiably, so angry about the proposals and that is why the public are justifiably afraid.

Mr. Day

On what basis does the hon. Lady justify the implication that the budgets for such practices will be under-funded—because that is the implication of what she is saying?

Ms. Harman

At the moment, the proposals are that the region will decide on the budget for particular GPs. If the hon. Gentleman had read the working papers, as I have —I suspect from his question that he has not—he would have seen that they state that the region will not underwrite too high referral practices. It is clear that GP's budgets are part of an attempt—a blunt instrument—to hold down referral rates, not to make sure that referrals are appropriate when they are made and that when they are not made that, too, is an appropriate decision, because overall the Government want to see referral rates and spending on prescribing go down, irrespective of the effect on the quality of care and irrespective of the effect on the patient.

Having seen the effect that spending restrictions have had on hospitals, surely the effect that such restrictions would have on GPs is obvious to anybody. In the debate on the Health and Medicines Act 1988 it was clear that the Government wanted cash limits on GPs because they thought that GPs were spending too much money. Wherever one looks, the Government's true aims are self-evident.

The second point that I was disappointed that the Minister did not deal with was the question of the number of patients that each GP has. The trend, supported by successive Governments, has been to reduce the number of patients of each GP. There is good reason for that. The idea is to improve the quality of care; to be able to give each patient more time to make a better diagnosis; to discuss more deeply with their patients the treatment and effect; and to increase the opportunity for preventive work and screening. Increasing the capitation element of GPs' pay is a direct incentive for GPs to increase their number of patients. It is a direct disincentive and financial penalty for those GPs who want their patient list to reduce.

I turn now to the opting-out proposals. Again, the Minister tried to fudge this issue. Why does he not come clean and admit that it is the Secretary of State who will decide whether a hospital opts out? Indeed, it will not have been necessary for anybody at local level to have been interested in the proposals. A hospital can be selected by the region without consultation with anybody, and it can be offered up as a sacrifice to the Secretary of State. It is absolutely clear in the White Paper that the Secretary of State will decide and that the region will recommend. No account need be taken of the views of the community which depends on that hospital or those of the people who work in it.

The right hon. Member for Devonport was right in saying that, when a hospital opts out, it will become a self-interested institution. It will be dislocated from the community that it should be serving. It will not be possible to plan services when a whole load of competing institutions are all trying to keep their heads above water in a dog-eat-dog situation. That is the very opposite of the integration of the services and the planning for future services which, hitherto, everybody agreed was so important.

The way in which the Government have gone about the process of trying to spur people into being in favour of opting out is disgraceful. There has been a mixture of threats and promises. To doctors who are desperately worried because of the years of under-funding, the Government have said, "If you're good boys and girls and if you're one of the first to opt out, we'll see you all right" —with a nudge and a wink. I advise those who are being cajoled in that fashion to be careful, because, although it might be part of the Government's plan to ensure that the first opters out survive and that they, the Government, have successful examples to hold before the public at the next general election, the Government do not plan to carry on like that. The Government will then cut those hospitals loose with their enormous debts of interest charges. Rather than a dash for freedom, opting out might end up as financial suicide.

The right hon. Member for Devonport said that it might be very nice for teaching hospitals to opt out. Well, it will not be very nice for teaching hospitals in London, because of the value of their sites and buildings. If, as the Government plan under the capital charges White Paper, St. Thomas's hospital had to pay interest charges on its sites, it would have to pay an extra £40 million a year. Guy's hospital, which is just a stone's throw down the river, would have to find an extra £27 million per year to service its huge interest charge. Therefore, those hospitals will have to compete for patients to bring in the resources to service their enormous capital debts. They will end up doing what the private sector does to make money—more and more cold surgery.

Therefore, the teaching base and the centre of excellence will be lost in a war of attrition between hospitals which are on sites of high value and are close together. At the end of the day, when one of them goes bust, the Government will say, "It's not our fault; it's the market. There must have been over-provision." I warn those in the teaching hospitals to be careful, because a trap is being laid. I believe that many of them understand that.

What the Government must explain most of all—what the Minister failed to mention—is the tax subsidy to commercial medicine. That is an extraordinary way to allocate public money. It is unfair, because it goes to only those who can afford private medical insurance or to those who can get someone else to take it out on their behalf. It will not go to those who have the greatest need. The point about private medical insurance is that it is about insurance and not about medicine. The insurance companies want to insure a healthy person who is unlikely to claim, not a sick person who is likely to claim.

Why should the Government subsidise private medicine? The Government appear to be in a lather of enthusiasm for private medicine, but they have no idea what is happening in the private sector. When I asked a series of questions about activity rates and bed occupancy in the private sector, the Government's answer was, "We haven't a clue." Therefore, my hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith) conducted a survey of the private sector, and we are grateful for its response.

The survey showed that the private sector has a lower bed occupancy and has higher administrative costs. It costs more to do operations and it is being increasingly taken over by the Americans. Why are the Government pushing us towards a system where the well-off will get treatment that they do not need, because it is profitable for doctors, but poor sick people will not get the treatment they need, because they will not be able to get insurance?

No one believes that the National Health Service is perfect. Of course we need more emphasis on community services, a better complaints procedure, a better system for compensating for mistakes and a reorientation of management and of those who work in hospitals towards the people who are using those hospitals. We need to develop the as yet primitive science of measuring and comparing the quality and outcome of the service, to further integrate acute and community services and primary services; and we need more resources to get the waiting lists down. No one is saying that the National Health Service is perfect, but what everyone is saying, apart from the Government, is that it is the best possible base on which to build.

The Government are trying to browbeat everyone by saying—the Minister denied this today—"Whatever you think, we shall go ahead with these plans, so you might as well shut up and learn to live with them." I do not believe that. Public and professional opposition remains enormously important. Because the plans are unjust as well as unworkable, the aim of everyone with any sense is to be part of a campaign to ensure that those plans remain plans and are never put into practice.

When will we receive the Government's response to the Griffiths report? It was rumoured before Easter that it would be soon after Easter. However, when giving evidence to the Select Committee, the Secretary of State said that he did not know when it will be. It appears to have drifted off the political horizon altogether. It is more than a year since Griffiths reported. There has been a huge increase in public spending on private care. It has increased by more than 8,000 per cent. since the Government came to power. Many people have grave reservations about the appropriateness of the sort of care and the standards of care that are being provided at public expense in the private sector. When will the Government get their act together and take hold of the situation? Or will they simply let the situation drift and leave thousands of frail, disabled and vulnerable people in the lurch, as is happening now?

5.53 pm

Dame Jill Knight (Birmingham, Edgbaston)

A fool has infinite capacity for self-deception and a knave has infinite capacity for deceiving others. Far be it for me to accuse the British Medical Association of being either of those things, but I cannot understand why it has chosen to misinform, to mislead and to misquote the Government's review to its own members and to the country. The BMA's version of "Working for Patients"—I have read it carefully several times—is a travesty both of the Government's report arid of the true situation. I shall not say what I think, but I shall say what is in the BMA's review and point out where it contrasts clearly with what is in the Government's plan.][n several places the BMA's review speak as though underfunding is normal. If the facts are repeated often enough everyone will believe them. The BMA speaks of the underfunding of the Health Service—we have heard that again today—when we are pouring money into the Health Service like Croesus, Midas and the IMF all rolled into one.

We heard again from the hon. Member for Peckham (Ms. Harman) that tired old fable that more money is being spent on the continent than is being spent here. If we do not add the amount of money that people are spending on their own health and are not receiving from the taxpayer at all, one can happily come up with an answer like that, but it is not an accurate answer.

In fact, our expenditure and our plans for putting more money into the Health Service are following a far steeper graph than anywhere else on the continent. We are doing much more for health care. I am proud to mention that, and even to boast about it. I know that Opposition Members hate hearing this, but when we came into office expenditure was £7,000 million per annum and it is now more than £26,000 million per annum. That is a large sum in anyone's language—except the BMA, which does not even notice it. Despite that immense increase, all that the BMA talks about is underfunding. I sometimes wonder whether the BMA would consider any sum worth mentioning as even adequate.

In paragraph 2.4 of the document the BMA goes even further. It keeps up its reputation for frightening old ladies by saying that the Government's main proposals in the White Paper are to reduce the level of public expenditure for health care. I was horrified to read such an accusation. I searched the Government White Paper from cover to cover, from back to front, upside down and inside out, and there is not one word to indicate any such thing. It is a lie. Does it even make sense?

Mr. Alex Salmond (Banff and Buchan)

rose—

Dame Jill Knight

No, I shall not give way. I am trying not to be too long and I give notice that I shall not give way to anyone.

The BMA's version of "Working for Patients" says that doctors will run out of money to treat patients. That is utter nonsense. The BMA says that doctors will have to take on more patients than they can possibly cope with. That is absolute rubbish.

Mr. Allen McKay (Barnsley, West and Penistone)

It is true.

Dame Jill Knight

The hon. Gentleman might do the Government the courtesy of reading the White Paper, which says what the plans are. It is no use Opposition Members talking about what they would like it to say. They will have to read what it says. Conservative Members are not fools. Could anyone in his right mind imagine us doing anything to harm the National Health Service? [HON. MEMBERS: "Yes."] I am glad to have had that extraordinary reaction from Opposition Members—it shows that they do not know anything.

Mr. Brian Wilson (Cunninghame, North)

Will the hon. Lady give way?

Dame Jill Knight

No, the hon. Lady will not give way.

It would be sheer suicide for anyone in Government to destroy the Health Service. Apart from that, we care a great deal about it and, as our efforts have shown, we have repeatedly given more and more money to it. That is how we shall continue.

The paper published by the BMA speaks of the present uniform distribution of specialist services throughout the UK". What "uniform distribution"? Where has the BMA been all this time? There is ample evidence of a wide variety of services up and down the country. Why does the BMA pretend otherwise? Why does it give us this rubbish about present uniform distribution of specialist services"? The Government are anxious to achieve such a uniform distribution of specialist services, which will be available to everyone. The Government are working towards that goal, not jettisoning it.

In paragraph 2.7 the BMA states: Extreme pressure is being put on health service managers, consultants and other hospital staff to seek self governing status for hospitals That is another lie. No pressure is being exerted on hospital managers or consultants. If the Government were exerting pressure, extreme or otherwise, why on earth would they include conditions? One cannot exert extreme pressure and then say, "but the conditions are this, that and the other." The White Paper makes it absolutely plain that there is no question of pressure being exerted. Hospitals will be able to choose what they want to do. If the Government intended to exert pressure, why does the White Paper say that hospitals must be interested in achieving self-government? One cannot have it both ways. The Government have made it plain that before any decision is made about self-government the option must be wanted by the particular hospital. That is not equivalent to forcing hospitals to adopt self-governing status.

There is no more pressure on hospitals to go independent than there is on general practitioners to become budget holders, as the BMA suggests. Recently a banner headline in a west midlands newspaper said proudly: Birmingham family doctors will refuse to carry out the Government's plans All along, the Government have made it perfectly clear that doctors are entirely free to decide whether they wish to become budget holders. The hon. Member for Peckham was wrong—there is no hidden pressure on doctors. That is not to say that their expenditure will not be monitored, and so it should be.

Some doctors prescribe 50 per cent. more drugs than others with exactly the same case load. Some doctors send 20 times more patients to hospital than others, again with the same case load. What is wrong with monitoring doctors and asking why a particular doctor sends so many more patients to hospital? I know of a young woman who was put on valium by her doctor and stayed on it for seven years without any medical examination at any time. She was simply given repeat prescriptions. [Interruption.] Opposition Members may not like what I am saying, but that is a ludicrous situation and it must be stopped. The Opposition clearly do not want to do anything about it. It is right to monitor the amounts of money spent by different doctors and the reasons for that expenditure. It would be thoroughly irresponsible of the Government not to try to get all practices to run as efficiently as the best ones. The best ones are extremely good, but I am appalled at what some of the bad ones do.

In this connection, I draw the attention of the House to a leaflet which has been distributed in Poole. A copy of it was brought to the House by my hon. Friend the Member for Poole (Mr. Ward). Hon. Members should know that there is a skull and cross-bones at the top of the leaflet. I thought it had something to do with pirates, but dear me no—it is a health warning. It says: The Government is about to force dangerous changes on the National Health Service. They are going to put strong financial pressure on family doctors to give you fewer medicines, give you cheaper medicines, cut down on your hospital tests, cut down on your hospital treatment"— [HON. MEMBERS: "That is true."] If the Opposition believe there is a scintilla of truth in that, they are out of their tiny minds. It continues: Dangerous illnesses will be discovered and treated too late. People will die. That has been published by a profession which has already said that it will not agree to advertising. Yet it apparently agrees with handbills which contain lies being directed at sick, old and frightened people. That is monstrous, and it is all of a piece with the deplorable BMA document.

In one respect, my right hon. and learned Friend the Secretary of State has brought trouble on his own head and contributed to the misunderstandings. I was astonished by accusations in the BMA paper that the Government are "rushing through" far-reaching and complicated reforms. The reforms are far-reaching and complicated, but they are not being rushed through. We all know that we shall not see a Bill until November or December at the earliest.

I have tracked down the source of some doctors' concern about this. In the first of the working papers the Government say that they intend to complete discussions by May. The whole thrust of the BMA's Luddite paper is to put the worst possible interpretation on the proposals and to suggest that the Government are rushing them through. That is not true, of course, but I wish that those words had not been used in the working paper as they suggest a lack of consultation.

Consultations are taking place. I know of no hon. Friend who is not having meetings every week with doctors or consultants in his constituency. We want to hear everything and we want to listen—that is what I call consultation. There is no question of rushing anyone as we have plenty of time. The BMA's interpretation of the proposals suggests to its members that the BMA's interpretations are fact. The words "might", "maybe", "possible" and "perhaps" are used right through the document—in one paragraph there were four "coulds" and a "might". It is infinitely better to have statements of fact than interpretations of the worst possible kind.

Another part of the BMA paper expresses concern that family practitioner committees might be filled by individuals with no experience of the primary health care services". Why on earth would we be likely to appoint such people, especially as the paragraph directly opposite complains that the Government intend to appoint health authority members who reflect 'the strength of skills and experience' that the member could bring to the work of the health authority". The BMA cannot have it both ways, but by golly it certainly tries.

I will take on a fair and honest political battle any day of the week. What I deplore about the BMA's misleading attitude and actions is that it knows perfectly well what the Government are driving at. It even acknowledges in some parts of the document that those objectives are absolutely right. The BMA forgets itself several times in the document and it says that the Government's objectives are right—[Interruption.] Opposition Members should be careful. They have obviously not noticed how much of the White Paper the BMA considers is a good idea. That is made plain in its document. That is in there, too.

The worst part of all this is that members of the BMA are obviously being encouraged to mislead and frighten their patients. Our reforms have nothing to do with privatising, starving or ending the Health Service; they are about strengthening, extending and financing—

Mr. Alistair Darling (Edinburgh, Central)

Private practice.

Dame Jill Knight

I do not give a damn about private practice. What I do give a damn about is that people outside this place should have the freedom to spend their money in the way that they wish. If they want to spend their money on health care, what has that to do with the hon. Gentleman? Why should he poke his nose into the way they choose to spend their money? What we are interested in is that there should be the best possible Health Service for sick people who need it, whether they can afford to pay for it or not—and it is because those are the aims of the Government that they will succeed, come what may from the Opposition.

6.10 pm

Mrs. Alice Mahon (Halifax)

I am happy to follow the hon. Member for Birmingham, Edgbaston (Dame Jill Knight), and I hope I can put her right on one or two things which are certainly not the case. Her interpretation of what the BMA says is not the same as mine.

This White Paper is not working in the interests of patients. Indeed, organisations working for the National Health Service have all told me that they are quite insulted by the title of the White Paper, in that it implies that they are not working for patients now. Nothing could be further from the truth, and many of these organisations have worked under a great deal of stress, thanks to Government policies over the last 10 years on the National Health Service.

This White Paper is not just another reorganisation, it is something quite different. My hon. Friend the Member for Peckham (Ms. Harman) said it has turned out to be a monster, and that is absolutely true. She has been to America and studied in detail the system there, so she knows what the effect of the White Paper will be on the future of the National Health Service. It is about ending the National Health Service as we know it. [HON. MEMBERS: "Rubbish."] Oh, yes it is. It does not address the real problems of the National Health Service: under-funding, waiting lists, and the disgraceful segregation of the elderly which has gone on over the last 10 years.

We have seen wholesale privatisation of the care of the elderly, something that hon. Members opposite should be deeply ashamed of. The White Paper does not address the lack of care for the mentally ill and mentally handicapped. In fact, the disgusting emphasis of the White Paper is on competition, markets, buying, selling, incentives and assets —dehumanising terms when talking about care, but certainly reflecting the Government's values.

What is missing from the White Paper is any notion of the National Health Service as we would like to see it, as it once was, and as it was envisaged by its founders: care and compassion, the alleviation of pain, and an end to suffering, regardless of the ability to pay. Most of it is focused on ending the basic character of the National Health Service. It is an extremely obvious prelude to full privatisation after 1992, and we on the Opposition Benches are not fooled at all; should a Conservative Government be elected then, that is what we will get.

Looking at the detail of the White Paper, I am shocked by the absence of local control and planning, because the district health authorities will essentially disappear. Paragraph 3.20 of the White Paper virtually announces the end of district health authorities. As the acute hospitals become self-governing, we are told that it will be the responsibility of those placing contracts to monitor their performance in providing agreed services. That is absolute nonsense, because the reality is that most district health authorities will possibly go, and where one remains in existence, it will be seriously weakened, and no monitoring of any authority is built into the White Paper.

I have read all the discussion documents, and it is only the training of junior doctors which will be monitored by the royal colleges. There is talk of questionnaires and follow-up surveys, but it is misleading to talk about monitoring by health authorities, because they will be either extinct or seriously weakened.

As my hon. Friend the Member for Peckham said, the capital arrangements are quite dangerous for some hospitals which might be tempted to opt out. The claim in the Prime Minister's introduction that the National Health Service will be financed mainly by general taxation looks like a very flexible and unreliable commitment. The delegation of operational money and increasingly large capital schemes to trust hospitals will encourage opting out, despite the Minister saying it is not true. There really is an arm-twisting operation going on, with lots of carrots being dangled; offers of a great share of the new market in hips and hernias and the like are being made.

I put it to the Minister that these trusts may be called the National Health Service but that that will soon become meaningless; despite what the hon. Member for Edgbaston said in her passionate address, hospital services will be subject to jungle law, because the hospitals which compete less successfully will slowly but surely lose patients, funds, reputations and staff, and communities will lose their hospitals.

One cannot have a free-standing accident and emergency department. I asked the Prime Minister and the Minister of Health for an assurance that Calderdale area health authority will not lose its accident and emergency service, and I received wriggling and sleight-of-hand answers, which is the technique this Government use when they do not want to be frank. But, reading those answers, it is clear that there is no guarantee that Calderdale will retain its accident and emergency service and the health authority or hospital trust may have to buy that service from Bradford or Burnley, thus putting life and limb at risk.

We may have thought that the arrangements under which schools and housing might be permitted to opt out were bizarre and undemocratic, but if we consider paragraph 3.15 in the original document, which mentions that a group of staff or people from the local community might initiate the process or respond to any initiative taken by the Secretary of State to form a hospital trust, we realise what a sham any democratic consultation about these hospitals is. Paragraph 3.19, which talks about adequate publicity for trust formation, really does not comply with any notion of consultation as we all understood it.

My district health authority is under the direction of a politically appointed chairman, a Government lackey, who does the bidding of the Government on every instruction to cut and has done for years, and a district manager, a redundant manager from British Steel, who was thrust upon us and has proved an unmitigated disaster for our local health services. Any of these people can say to the Secretary of State, "We want to opt out," and the Secretary of State himself, as I understand it, can say, "I believe you should opt out." There is absolutely no sense of fairness or democracy in that at all.

This is not their Health Service. What right has a redundant steel manager, who now manages our local health service—very badly, in my opinion—to say that he will move us on the road to privatisation? He has no right. I worked for the Health Service for 13 years and I have more right than he to take decisions about our local services. I at least put my blood, sweat and toil into the Health Service. I cared very much for it. The bizarre and quite undemocratic notion of opting out will meet great opposition. The public will perceive it as so unfair that it will be a non-starter.

The hon. Member for Edgbaston referred to the BMA and what she thought were its unfair objections to the White Paper. As a member of the National Union of Public Employees, I worked actively for the benefit of staff in the National Health Service for many years. I was also an auxiliary nurse in the NHS. I did not often find myself on the same side as the BMA. Mostly the BMA is on the Government's side, not on the side of the rest of us in political terms. However, there is nothing iffy about the objections voiced by the BMA in Halifax to the White Paper: A large proportion of patients will not be able to travel to hospitals outside their locality. Many patients and their relatives cannot afford to pay for fares involved; they will certainly find it highly inconvenient. For hospitals to provide a competitive 'quote' for any service, corners will be cut, for example, skimping on investigations or reducing in-patient times increasing the likelihood of problems for the patient. If a patient has been investigated at one hospital, but the treatment is cheaper at another hospital, will the patient need to be transferred?

Many questions are raised about patient care. With regard to general practitioner services the Halifax division of the BMA states: Concern was expressed that no pilot-study had been carried out, or is proposed, to see if the GP budget-holding is feasible. It continues: Reduction of the basic practice allowance is likely to cause fewer vacancies for women doctors, who commonly work less than full-time while they have a young family. The proposed budget-holding GPs will have no incentive to screen patients as any pathology found might cost some of his/her budget. Patients on expensive treatments might find doctors reluctant to accept them because of the financial implications. GP budget-holders will have difficulty controlling their budget because of the open-ended nature of GP services. GPs cannot refuse service to patients on financial grounds. There are many more specific objections from the BMA.

The idea that GPs require a different structure to provide them with incentives to practise better medicine is abhorrent and insulting. The emphasis of the White Paper is clearly on finance instead of patient care.

Cash-limiting primary health care will be hugely disadvantageous to the people who really need help—the old and the chronically sick. Far from criticising the BMA, GPs, nurses, hospital workers, consultants and all the other decent organisations which have put patient care first and objected to the proposals, the Opposition applaud those people roundly and soundly.

The National Health Service is suffering from starvation caused by under-funding. If Conservative Members were not blind, they would see the headlines in the press about this. On 13 April, I read a headline which stated: Patients are dying because Calderdale does not have its own specialist heart unit. The report continued: the inevitable delays mean that many die, according to a report by Bradford Cardiologists. The report states that roughly 11 per cent. of people waiting for an operation die.

If the Government were really serious about doing something about the Health Service, they should address that obscenity. They should not be trying to restructure something which does not require restructuring. The White Paper has little if anything to do with organisation or restructuring. The Health Service has been kept going, while the Government have been bleeding it to death, by the motivation of individuals and the dedication of those who work for it.

The Guardian said that the White Paper has met a wall of professional opposition which begins to look more impregnable day by day. I believe that the opposition will grow. This is just the start. I welcome the debate and I believe that the White Paper will be defeated because it is about ending the National Health Service. The public have rumbled that.

6.25 pm

Mr. Ray Whitney (Wycombe)

This is a very sad day for what remains of the Social Democratic party. In its very short history it has had many sad days, but I believe that the contribution from the right hon. Member for Plymouth, Devonport (Dr. Owen) who sadly cannot be with us any longer, marked the nadir of that party's troubled life. Possibly that has something to do with the right hon. Gentleman's personal history. However, it is particuarly sad because when that party was formed many Conservative Members, without any temptation to join it, welcomed it because it might offer an alternative to the tired Socialism and faded Marxism of today's Labour party. We hoped that it would offer open minds and new ideas. However, today we heard a speech from one of the most closed minds on this issue. The speech was totally lacking in new ideas.

The right hon. Member for Devonport suffers from what across the Channel might be called a professional deformation. That is to say, as a professional medical man, he shares the short-sightedness which sadly seems to afflict so many professional medical people in this country. They seem to be wilfully ignorant of the standards and what is being achieved in other parts of the world. They are totally cocooned and complacent about what the National Health Service can or should offer. When they look overseas, they choose only the worst of the American experience, and ignore the very impressive best. They also ignore the enormous gaps growing in many areas between the standards on the continent and the standards which we can offer here now, with the great impact of the resources which the Government have invested in health care over the past 10 years.

The hon. Member for Devonport also suffers from a personal sense of guilt. He attacked fiercely the fact that we now spend—I believe he said "only"—6 per cent. of our national GDP on health. He seemed very anxious to forget the fact that when he was a Minister with responsibility for health, we spent 4.8 per cent. of a very much smaller GDP. That takes a lot of living down for someone who had any responsibility for the Health Service.

The right hon. Member for Devonport also made great play about the present flurry from the medical profession, including the royal colleges. Although he admitted that such flurries had happened before, he suggested that they were happening now at absolutely unprecedented level. A short time ago, the presidents of the royal colleges and the deans of the medical faculties issued a statement which said: The ills within the NHS are serious and by threatening standards threaten the health and well-being of the community. There is a real danger of standards deteriorating to a point from which recovery will be impossible within a foreseeable term. That statement was issued by the presidents of the royal colleges and the deans of the faculties in October 1974, when the right hon. Member for Devonport was a Minister responsible for health. Therefore, he should understand that this is not a new problem. It is a problem that has been developing. Indeed, it has been developing during the past 10 years, despite the resources that we have provided. I will not rehearse our record yet again, but it is a proud record—a record of commitment to a comprehensive, universal Health Service.

But, clearly, more and more funding is not enough. On the Jimmy Young show about 12 months ago, the hon. Lady said: We need perhaps another £200 million, and then the problems of the health service will all be over. Since the hon. Lady said that, we have produced billion after billion after billion, and, of course, we still have the problems. We know why. My hon. Friend the Minister of State, Deparment of Health enumerated the problems: the aging of the population, technical innovations and their resource implications, and rising expectations and aspirations.

These are serious problems that have to be dealt with seriously, but they are not being dealt with at all by members of the Opposition parties. Those Members are applying closed minds, totally ignoring what we have done and the fact that, in addition to more funds, which are coming forward thanks to the strength of the economy, we need structural and organisational changes. It is monstrous that, after 40 years, including the period when the right hon. Member for Devonport had some say in these matters, the sensitivity for resource management in the National Health Service should be virtually non-existent.

Happily, in recent years, we have had the resource management initiatives, the Korner report, and one or two other things, but we have a long way to go. But we cannot go that way unless mechanisms are put in place, and that: is precisely what the reforms now proposed are intended to do. The suggestion that this involves the break-up of the National Health Service is nonsense. What it involves is doctors, nurses and others concerned taking a much more concrete interest themselves in the disposal of the available resources.

The right hon. Gentleman did at least have the grace to recognise that resources are finite. I will not say that demand is infinite, but certainly it can never seriously be contained. It is much more sensible that judgments about the allocation of resources should be made not at the level of the Chief Secretary to the Treasury or the Secretary of State for Health, but, to the best possible extent, in the surgery by the general practitioner, by the professional who knows. It is the professional who has the greatest insight, the best judgment and the most experience. Likewise, he must be much better equipped to judge which hospital his patient should go to. This is the essence of the proposals, which will bring great benefits to the consumer —and I do insist that we are consumers and customers, not just patients.

One of the unfortunate features of the Health Service, great though it is in many respects, is that in too many areas patients are pushed around. They have to wait here and wait there. This is the wrong atmosphere. Consumerism is growing and developing in so many other areas of life. Indeed, the Social Democratic party would consider that it is in the van of consumerism—but not in respect of the sacred cow of health, because it lacks the political courage to tackle the problems, as, of course, do all the other parties opposite.

I urge my right hon. and hon. Friends on the Front Bench not to be discouraged by the extraordinary performance of the British Medical Association. They should take comfort from the fact that there are many historical precedents. Every time a Government in this country have sought to improve the National Health care system, they have been opposed by the medical professions and their organised bodies. Those people opposed Lloyd George's National Insurance Act 1911, until they discovered two years later that it benefited them. They were the only people who opposed the coalition White Paper put forward by Henry Willink, the Conservative Minister of Health in 1944. We all know that their opposition to the Aneurin Bevan proposals were silenced only when, as we have been reminded, their mouths were stuffed with gold. Most of us in this House remember their ferocious opposition to the 1984 selected list, which we all now know is a great success. In all those cases, after fierce opposition for a year or two, the medical profession came round. I hope that it will not take so long this time.

6.34 pm

Mr. Simon Hughes (Southwark and Bermondsey)

I welcome this debate, and I welcome the opportunity to speak specifically to one aspect of it, in my role as the Member of Parliament representing Guy's hospital, which is thought to be the hospital with the strongest desire to become a self-governing hospital trust. It may interest the House to know that, when it comes to a vote tonight, there is not one thing in the motion as tabled by the right hon. Member for Plymouth, Devonport (Dr. Owen) with which my hon. and right hon. Friends and I do not agree. We shall therefore vote with the SDP and, as I understand it, the Labour party, at the end of this debate.

We shall be voting with the other Opposition parties because the people represented in those parties are the successors to those who supported the idea of the Health Service both in concept and in legislation, in the 1940s, when the Tories opposed it. We believe that the Tories' commitment then, which was noticeable by its absence, to the provision of a free Health Service—free at the point of delivery for all, without distinction—is matched by their lack of commitment now.

I would point out to the hon. Member for Birmingham, Edgbaston (Dame J. Knight) that the evidence for that is that there is not equal choice for all. This year, her Government have introduced tax incentives for people, if they are of pensionable age, to go to the private sector. Her Government have always allowed the private sector to benefit from training that is paid for out of the public purse. The reality is that, over and over again, it is the Tory Government who push towards the private sector people who would—given a fair choice—far rather remain in the public sector.

Dame Jill Knight

Will the hon. Gentleman give way?

Mr. Hughes

Not at the moment. If I have a moment later, I may give way.

Many of the people who may be contemplating going into self-governing hospitals as consultants are doing so not because they support the idea, but only, as the hon. Member for Peckham (Ms. Harman) said, because they believe that if they jump quickly, if they jump first, the Government will make sure that they are protected, whatever happens to the rest. They are doing so not out of conviction but out of concern for their self-preservation. That is a cynical—understandable, but cynical—way of justifying any argument that they support the Government's proposals.

It is not right to say, as the hon. Lady argued, that the Government are not encouraging people to move in the direction of being independent within the Health Service. The working paper on self-governing hospitals says: The Government believes that self-governing hospitals will have a major role to play in improving services to patients. It will therefore encourage as many hospitals as are willing and able to do so to seek self-governing status as NHS hospital trusts. The Government aims to establish a substantial number of trusts with effect from April 1991. There is no doubt that the Government will encourage, push and contrive to make sure that, if possible, there are at least some flagships sailing into the new sea of the private Health Service after the next election. Whether they succeed is yet to be determined.

I accept the argument of the hon. Member for Wycombe (Mr. Whitney) that in this sort of debate it is not necessarily best to pray in aid those who traditionally have been difficult to please when reform has been mooted for them and their profession. The BMA has argued against reforms in the past. Inevitably, it sees things from its professional point of view. I do not think that its members are necessarily the best people to cite as advocates for a case that one seeks to argue here. One has to argue from principle and from the point of view of the public at large.

I must tell those hon. Members who believe that the users of the Health Service will not represent the greatest patient difficulty that the enormous majority of them are strongly opposed to the Government's plans. They believe not that there is just a scintilla of truth in leaflets such as that which the hon. Member for Birmingham, Edgbaston (Dame J. Knight) cited as coming from Poole, but that there is a flotilla of truth in the allegations and assertions made in such documents. They believe that the Health Service is not safe in the Government's hands.

Mr. Day

rose—

Mr. Hughes

I shall give way in a moment if I have time.

Those who usually look to Guy's hospital as their local district hospital have specific reasons for concern. Many aspects of the White Paper are worrying, but those which worry people in south-east London most are those which are likely to change the nature of Guy's hospital and its quality of care. Guy's is at the forefront of those reported to be interested in becoming a self-governing hospital trust. However, many at Guy's, from the most senior to the most junior, are resolutely opposed to opting out. Many have written expressing their views. Even those who have said that they support the idea, among whom are some on the management board, have many crucial questions about self-governing yet to be answered by the Government. The Government have not yet convinced Guy's—far from it.

Just like the other five hospitals which are part of the resource management initiative, all of which have opposed the ideas in the White Paper, Guy's hospital has also not come out in support because it is not yet satisfied that its specific questions and concerns have been answered, some of which have even been put forward by advocates of the White Paper, one of whom was an adviser to the Prime Minister on these matters.

There is no guarantee that the introduction of market forces as proposed will in anyway improve care. On the contrary, there is evidence that unprofitable patients will become unpopular patients. In my area, where more than 25 per cent. of the community are pensioners, the probability is that in the long term Guy's will not be able to look after them and they will have to go much further away.

An increasing number of constituents in an inner city are likely to be elderly. On my last visit to Guy's I asked what would happen when they are admitted and could not he returned to their homes after an operation or treatment because they could not cope on their own. I was shown a graph of the profits to be made from the hospitalisation of an old person. After the initial operation or intensive care, profits begin to tail away to little or nothing. In order to prevent an old person blocking a bed, the hospital might, after about 10 days, have to impose a surcharge on the district for keeping the district's elderly, non-earning patients in hospital. The district would not have catered for that surcharge because it would have gone to Guy's because it offered the cheapest contract available. Therefore, the district will not be able to keep in hospital an elderly patient who has had an operation, but will have to move the patient out or look for somewhere else for that patient to go.

It is right that hospital beds intended for acute purposes should not necessarily be used for long-term convalescence, but in a place such as north Southwark there is nowhere else to go for long-term convalescence. We do not have nursing homes or long-term geriatric care facilities. If the last refuge, a bed in the local district general hospital, which also happens to be a regional national specialty, disappears, the Government will he saying to the elderly in a community such as that in south London and Southwark, "You must leave your community because we cannot pay for you here."

There is no profitable solution to the care of old people; there are only caring solutions or uncaring solutions. With the district health authority forced to enter contracts on the basis of what will be the most economical, there is no hope of the less profitable services being expanded. The only answer will be out-of-town homes where residents will be far away from friends and families, inaccessible to visitors, isolated and alone. Commercialisation always has losers and the losers are always the weakest and most vulunerable in our community.

But care of the elderly will not be the only area to suffer. Centralisation will be inevitable as one hospital becomes known for a certain specialty. District health authorities will be powerless to prevent the services that they want to purchase being discontinued at one hospital and will be forced to go elsewhere. It is a twisted sort of logic to think that choice can be widened simply by a provider becoming a purchaser.

Anyone who has visited their corner shop knows that it does not work by providing everything because market forces do not allow it to do so. The convenience of the consumer does not mean that every shop has every product for sale. It will be the patient who has to travel away from his or her home and who will not receive continuity of care from the same general practitioner and consultant who will suffer yet again. Patients may have to go to Walsall for eyes, Maidstone for hearts and Southampton for backs because of the contract that the district has entered into. Many doubts still centre on whether it will be profitable for a local hospital to give a comprehensive service. The reality is that it will not be, and comprehensive local care in one's local hospital will be a thing of the past.

What effects will the White Paper have on teaching? For Guy's to survive as a teaching hospital there needs to be a wide range of medical activity. What will happen if Guy's loses its core contract with the local health authority of Lewisham and north Southwark? In any year, market forces may determine that the contract goes somewhere else—to St. Thomas's, King's, Bart's, the London or elsewhere. Commercialisation will not provide the stable basis that is needed to give students a five or six-year medical degree course. What will happen to the future provision of skilled doctors if medical schools are struggling to provide adequate training in an uncertain environment? And will they spend a lot of money on training—an expensive commitment—which they will not easily be able to recoup?

Commercialisation means the end of a balanced service in other ways too. The good consultants will be bought by the hospitals that can afford them and other hospitals will become second class with second class staff. The test in 'the White Paper is what is cost-efficient, not what is best for care.

The White Paper speaks of consultants becoming more efficient managers. Nowhere does it speak of managers becoming more caring health providers. Everywhere profit will be the governing factor. The providers, the general practitioners and the health authorities, will not be able to rely on a consistently secure provision of services. The hospitals will not be able to rely on a consistently secure flow of patients. The patients will not be able to rely on consistently secure provision of care. The Opposition are right to be deeply cynical in their belief that the Government are intent on replacing care with profit as the motivating factor in the Health Service. I hope that Conservative Members will join us in voting for the motion tonight.

6.48 pm

Mrs. Gillian Shephard (Norfolk, South-West)

It is noticeable that the debate has been distinguished yet again by the continued inability of Opposition Members to give the Government credit for the record amounts now being spent on the Health Service. The nurses had an enormous pay award of almost £1 billion during the year, with an extra £2 billion being spent in the current financial year and an extra £2.5 billion planned for next year. The Government should give themselves credit for that extra spending and for the fact that our attention is now directed at the way in which those enormous sums of money are to be spent. I am sorry to note that Opposition Members apparently have no notion of the inequalities in the levels of provision across the country which the White Paper seeks to put right.

I mention in particular the new arrangement for the resource allocation working party. The abolition of RAWP will be welcomed in many rural areas with a high population growth, and especially in East Anglia, where the chairman of the regional health authority has said that that single measure will help East Anglian patients more than anything else in the shorter term. We hope that that wil be implemented rapidly.

The White Paper also seeks to remedy the poor quality of information about costings and quality of care within the Health Service, a matter frequently highlighted by the Select Committee. That too will be greatly welcomed by all the professionals working in the Health Service as a way of measuring the quality and evenness of care across the country.

In rural areas, patients are not always satisfied with the standard of service that they get from their general practitioners. Financial incentives will be given to general practitioners on a new basis for rural populations, for caring for elderly people amd for caring for children under five. Those and a great number of other incentives will do a great deal to bring the standard of service enjoyed by rural patients up to the best standard provided by GPs for their urban counterparts.

It may be of interest to Opposition Members to note that rural patients can perceive advantages in some of the provisions of the White Paper. If the new contract and the provisions of the White Paper can do anything to improve the attitude towards patients of a general practitioner who says that he does not need an appointments system because village people like talking to one another all morning, it will certainly have been worth while.

6.51 pm

Mrs. Rosie Barnes (Greenwich)

The debate has been set against a necessary Government review of the Health Service. The SDP has always welcomed the review. We were looking for a radical and imaginative overhaul of a system that has served us well for the last 40 years and that we want to serve us well for the next 40 years. We share many of the Government's objectives—at least the ones to which they pay lip service. We welcome an increase in patient choice, better rights for patients and a more consumer-related service. The SDP has long been committed to the internal market, but not necessarily the internal market that we see in the White Paper. We also welcome a better quality of service across the board, and structural and organisational changes.

The White Paper sets the wrong agenda. There is nothing on funding. In spite of the many protestations from the Government Benches, without proper funding for the Health Service, no amount of juggling or reorganisation will make it work. The Health Service is under-funded compared with our comparable European competitors. It has to receive a substantial influx of funds to make any subsequent reorganisation and restructuring work.

Also incorporated in the White Paper and in some of the Government's recent thinking is an erosion of the basic principles of free service at the point of use, funded entirely out of direct taxation. There are major gaps in what we have seen so far. There is no acknowledgment of the growing need of the elderly and no proposal to take account of how a Health Service that is already straining under pressure can cope with the increasing number of elderly in our midst.

One of the things that troubles me most about the review is the speed with which it is being implemented. Again, we have heard from the Government Benches that it is a leisurely process. I could not disagree more. We are looking at a radical review which is demanding new skills, new structures and new procedures. There are dangers in what will happen. We have heard the words "might", "may" and "possibly"—the changes might or may possibly have disastrous effects on the Health Service. One way to make sure that they do not is to pilot schemes and see how they work. The Government should proceed slowly, cautiously and carefully on the basis of proper information.

I have a document from a leading city management consultant which addresses some of the problems. It deals with what regional health authorities, district health authorities and general practitioners will have to do. It is an extensive list. Due to lack of time, I shall read only a few of the items that it lists in relation to district health authorities: establishing the likelihood of hospitals becoming self-governing; specifying the volume and standards of service which will be required to meet local health needs; setting up and evaluating contracts for both `core' and other services; establishing tight contractual arrangements within minimum and maximum service levels for the full range of services required by the DHA's population; establishing financial management systems which monitor contract expenditure and activity; establishing mechanisms by which quality of contract performance is monitored, and ensuring all providers have comprehensive quality assurance and medical audit programmes". The list goes on and on. It is a complex list of serious things that need to be done properly in order to get the service right.

We have before us not only an impossible time scale but a programme that is being implemented without proper consultation and without the good will and support of the innumerable tiers of staff who have to carry out the procedure. The White Paper has provoked at best quiet resentment and at worst open hostility.

Severe and major strategic changes, which should be implemented sequentiously, are proposed. We should ensure that the cost and quality information is available well in advance of the procedure starting. There is no point in saying that we will go ahead on the basis of incomplete or incompetent information and, if we get it wrong, so be it. We are dealing with people's lives and with a Health Service that has been built up over the years. I agree with some Government Back Benchers that the current debate is taking place against a background of many successes that have often been overlooked while we focused on the failures.

The time scale for the review should be five to 10 years. We should move slowly and surely to get it right. There is a need to develop business plans and to acquire and use marketing and contractual skills. There is also a need for capital accounting. The whole procedure will need new skills. For all that to be done within two and half years is nothing more than a joke.

I support the resource management initiative, clinical audit and the use of information technology, but the way it is all being picked out of a hat and offered to the Health Service as a panacea for all evils makes the whole process unrealistic when the people, the resources and the structures are not there. Information technologists are an expensive breed. Many hon. Members will have spoken to hospital technicians who can all double or even treble their salaries overnight outside the Health Service. This scheme will rely on those self-same experts being in the Health Service, with no extra resources to pay for them. It just cannot work.

I prefer to speak in terms of patients' rights when considering the internal market. The SDP's version of the internal market was triggered by patients. It was based on offering patients a choice of a faster service in another hospital or in another health authority. But it would be up to them to make the choice. Because it was a choice, it was a carrot rather than a stick. It was not a cheap option, it was not punitive and it was not a cost-cutting exercise. The review will have disastrous consequences for the NHS.

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

The House divided: Ayes 77, Noes 230.

Division No. 161]	[6.59 pm
AYES
Archer, Rt Hon Peter	Fields, Terry (L'pool B G'n)
Barnes, Harry (Derbyshire NE)	Fisher, Mark
Beckett, Margaret	Flannery, Martin
Beith, A. J.	Godman, Dr Norman A.
Boateng, Paul	Golding, Mrs Llin
Boyes, Roland	Gordon, Mildred
Campbell, Menzies (Fife NE)	Harman, Ms Harriet
Campbell-Savours, D. N.	Haynes, Frank
Carlile, Alex (Mont'g)	Heffer, Eric S.
Clark, Dr David (S Shields)	Howarth, George (Knowsley N)
Clay, Bob	Howell, Rt Hon D. (S'heath)
Clwyd, Mrs Ann	Howells, Geraint
Corbett, Robin	Hughes, John (Coventry NE)
Cryer, Bob	Hughes, Simon (Southwark)
Dalyell, Tam	Johnston, Sir Russell
Davies, Rt Hon Denzil (Llanelli)	Jones, Martyn (Clwyd S W)
Davis, Terry (B'ham Hodge H'I)	Kilfedder, James
Dixon, Don	Kirkwood, Archy
Duffy, A. E. P.	Livsey, Richard
Ewing, Mrs Margaret (Moray)	Lofthouse, Geoffrey
Fearn, Ronald	Loyden, Eddie

McFall, John	Salmond, Alex
McKay, Allen (Barnsley West)	Sheerman, Barry
Madden, Max	Short, Clare
Mahon, Mrs Alice	Skinner, Dennis
Meale, Alan	Soley, Clive
Michie, Bill (Sheffield Heeley)	Spearing, Nigel
Michie, Mrs Ray (Arg'l & Bute)	Steel, Rt Hon David
Morris, Rt Hon A. (W'shawe)	Taylor, Mrs Ann (Dewsbury)
Mullin, Chris	Taylor, Matthew (Truro)
Owen, Rt Hon Dr David	Wall, Pat
Parry, Robert	Wallace, James
Patchett, Terry	Wareing, Robert N.
Pike, Peter L.	Welsh, Andrew (Angus E)
Powell, Ray (Ogmore)	Wilson, Brian
Quin, Ms Joyce	Young, David (Bolton SE)
Rees, Rt Hon Merlyn
Richardson, Jo	Tellers for the Ayes:
Rogers, Allan	Mrs. Rosie Barnes and
Rooker, Jeff	Mr. John Cartwright.
Ruddock, Joan
NOES
Adley, Robert	Currie, Mrs Edwina
Aitken, Jonathan	Davies, Q. (Stamf'd & Spald'g)
Alexander, Richard	Davis, David (Boothferry)
Alison, Rt Hon Michael	Day, Stephen
Allason, Rupert	Dorrell, Stephen
Amess, David	Douglas-Hamilton, Lord James
Amos, Alan	Dover, Den
Arbuthnot, James	Dunn, Bob
Arnold, Jacques (Gravesham)	Durant, Tony
Arnold, Tom (Hazel Grove)	Emery, Sir Peter
Ashby, David	Favell, Tony
Aspinwall, Jack	Fenner, Dame Peggy
Atkinson, David	Fookes, Dame Janet
Baker, Rt Hon K. (Mole Valley)	Forman, Nigel
Baker, Nicholas (Dorset N)	Forsyth, Michael (Stirling)
Batiste, Spencer	Forth, Eric
Bellingham, Henry	Fox, Sir Marcus
Bennett, Nicholas (Pembroke)	Franks, Cecil
Benyon, W.	French, Douglas
Bevan, David Gilroy	Fry, Peter
Blackburn, Dr John G.	Gale, Roger
Body, Sir Richard	Garel-Jones, Tristan
Boscawen, Hon Robert	Gill, Christopher
Boswell, Tim	Goodhart, Sir Philip
Bottomley, Peter	Gow, Ian
Bottomley, Mrs Virginia	Greenway, Harry (Ealing N)
Bowden, A (Brighton K'pto'n)	Greenway, John (Ryedale)
Bowden, Gerald (Dulwich)	Griffiths, Sir Eldon (Bury St E')
Bowis, John	Hague, William
Braine, Rt Hon Sir Bernard	Hamilton, Neil (Tatton)
Brandon-Bravo, Martin	Hanley, Jeremy
Brazier, Julian	Hannam, John
Bright, Graham	Hargreaves, Ken (Hyndburn)
Brooke, Rt Hon Peter	Harris, David
Brown, Michael (Brigg & Cl't's)	Hayward, Robert
Browne, John (Winchester)	Heathcoat-Amory, David
Bruce, Ian (Dorset South)	Heddle, John
Buchanan-Smith, Rt Hon Alick	Heseltine, Rt Hon Michael
Budgen, Nicholas	Hicks, Mrs Maureen (Wolv' NE)
Burns, Simon	Hicks, Robert (Cornwall SE)
Burt, Alistair	Hill, James
Butcher, John	Hind, Kenneth
Butler, Chris	Hogg, Hon Douglas (Gr'th'm)
Butterfill, John	Holt, Richard
Carlisle, John, (Luton N)	Hordern, Sir Peter
Carlisle, Kenneth (Lincoln)	Howard, Michael
Carrington, Matthew	Howarth, Alan (Strat'd-on-A)
Carttiss, Michael	Howarth, G. (Cannock & B'wd)
Cash, William	Howell, Ralph (North Norfolk)
Chalker, Rt Hon Mrs Lynda	Hughes, Robert G. (Harrow W)
Chapman, Sydney	Hunt, David (Wirral W)
Clark, Hon Alan (Plym'th S'n)	Hunter, Andrew
Clark, Dr Michael (Rochford)	Irvine, Michael
Clarke, Rt Hon K. (Rushcliffe)	Irving, Charles
Conway, Derek	Jack, Michael
Coombs, Anthony (Wyre F'rest)	Janman, Tim
Coombs, Simon (Swindon)	Jessel, Toby
Cope, Rt Hon John	Johnson Smith, Sir Geoffrey

Jones, Robert B (Herts W)	Rhodes James, Robert
Kellett-Bowman, Dame Elaine	Riddick, Graham
Key, Robert	Ridley, Rt Hon Nicholas
King, Roger (B'ham N'thfield)	Ridsdale, Sir Julian
Knapman, Roger	Rifkind, Rt Hon Malcolm
Knight, Greg (Derby North)	Rost, Peter
Knight, Dame Jill (Edgbaston)	Rowe, Andrew
Knowles, Michael	Sackville, Hon Tom
Lang, Ian	Shaw, David (Dover)
Lawrence, Ivan	Shaw, Sir Giles (Pudsey)
Leigh, Edward (Gainsbor'gh)	Shaw, Sir Michael (Scarb')
Lester, Jim (Broxtowe)	Shersby, Michael
Lilley, Peter	Sims, Roger
Lloyd, Sir Ian (Havant)	Skeet, Sir Trevor
Lloyd, Peter (Fareham)	Smith, Tim (Beaconsfield)
Lord, Michael	Speed, Keith
Macfarlane, Sir Neil	Speller, Tony
MacKay, Andrew (E Berkshire)	Spicer, Michael (S Worcs)
Maclean, David	Stanbrook, Ivor
McLoughlin, Patrick	Steen, Anthony
McNair-Wilson, Sir Michael	Stern, Michael
Malins, Humfrey	Stevens, Lewis
Mans, Keith	Stewart, Allan (Eastwood)
Maples, John	Stewart, Andy (Sherwood)
Marlow, Tony	Stradling Thomas, Sir John
Martin, David (Portsmouth S)	Summerson, Hugo
Mates, Michael	Taylor, John M (Solihull)
Maude, Hon Francis	Taylor, Teddy (S'end E)
Mayhew, Rt Hon Sir Patrick	Tebbit, Rt Hon Norman
Mellor, David	Thompson, Patrick (Norwich N)
Meyer, Sir Anthony	Thorne, Neil
Miller, Sir Hal	Thurnham, Peter
Mills, Iain	Townend, John (Bridlington)
Mitchell, Andrew (Gedling)	Townsend, Cyril D. (B'heath)
Mitchell, Sir David	Tredinnick, David
Moate, Roger	Trippier, David
Montgomery, Sir Fergus	Trotter, Neville
Morrison, Sir Charles	Twinn, Dr Ian
Moss, Malcolm	Vaughan, Sir Gerard
Moynihan, Hon Colin	Waddington, Rt Hon David
Mudd, David	Wakeham, Rt Hon John
Needham, Richard	Walker, Bill (T'side North)
Neubert, Michael	Waller, Gary
Newton, Rt Hon Tony	Wardle, Charles (Bexhill)
Nicholls, Patrick	Watts, John
Nicholson, David (Taunton)	Wheeler, John
Onslow, Rt Hon Cranley	Whitney, Ray
Oppenheim, Phillip	Widdecombe, Ann
Page, Richard	Wiggin, Jerry
Paice, James	Wilkinson, John
Parkinson, Rt Hon Cecil	Wilshire, David
Patnick, Irvine	Winterton, Mrs Ann
Porter, David (Waveney)	Wolfson, Mark
Powell, William (Corby)	Wood, Timothy
Price, Sir David	Young, Sir George (Acton)
Raffan, Keith
Raison, Rt Hon Timothy	Tellers for the Noes:
Rathbone, Tim	Mr. David Lightbown and
Redwood, John	Mr. Michael Fallon.

Question accordingly negatived.

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

The House divided: Ayes 215, Noes 85.

Division No. 162]	[7.13 pm
AYES
Alexander, Richard	Baker, Rt Hon K. (Mole Valley)
Alison, Rt Hon Michael	Baker, Nicholas (Dorset N)
Allason, Rupert	Batiste, Spencer
Amess, David	Bellingham, Henry
Amos, Alan	Bennett, Nicholas (Pembroke)
Arbuthnot, James	Bevan, David Gilroy
Arnold, Jacques (Gravesham)	Blackburn, Dr John G.
Arnold, Tom (Hazel Grove)	Body, Sir Richard
Ashby, David	Boscawen, Hon Robert
Aspinwall, Jack	Boswell, Tim
Atkinson, David	Bottomley, Peter

Bottomley, Mrs Virginia	Janman, Tim
Bowden, A (Brighton K'pto'n)	Jessel, Toby
Bowis, John	Johnson Smith, Sir Geoffrey
Braine, Rt Hon Sir Bernard	Jones, Robert B (Herts W)
Brandon-Bravo, Martin	Kellett-Bowman, Dame Elaine
Brazier, Julian	Key, Robert
Bright, Graham	King, Roger (B'ham N'thfield)
Brooke, Rt Hon Peter	Knapman, Roger
Brown, Michael (Brigg & Cl't's)	Knight, Greg (Derby North)
Browne, John (Winchester)	Knight, Dame Jill (Edgbaston)
Bruce, Ian (Dorset South)	Knowles, Michael
Buchanan-Smith, Rt Hon Alick	Lang, Ian
Budgen, Nicholas	Lawrence, Ivan
Burns, Simon	Leigh, Edward (Gainsbor'gh)
Burt, Alistair	Lester, Jim (Broxtowe)
Butcher, John	Lilley, Peter
Butler, Chris	Lloyd, Sir Ian (Havant)
Butterfill, John	Lloyd, Peter (Fareham)
Carlisle, John, (Luton N)	Lord, Michael
Carlisle, Kenneth (Lincoln)	Lyell, Sir Nicholas
Carrington, Matthew	Macfarlane, Sir Neil
Carttiss, Michael	MacKay, Andrew (E Berkshire)
Cash, William	Maclean, David
Chapman, Sydney	McLoughlin, Patrick
Clark, Hon Alan (Plym'th S'n)	McNair-Wilson, Sir Michael
Clark, Dr Michael (Rochford)	Malins, Humfrey
Clarke, Rt Hon K. (Rushcliffe)	Mans, Keith
Conway, Derek	Maples, John
Coombs, Anthony (Wyre F'rest)	Martin, David (Portsmouth S)
Coombs, Simon (Swindon)	Mates, Michael
Currie, Mrs Edwina	Maude, Hon Francis
Davies, Q. (Stamf'd & Spald'g)	Mayhew, Rt Hon Sir Patrick
Davis, David (Boothferry)	Mellor, David
Day, Stephen	Meyer, Sir Anthony
Dorrell, Stephen	Miller, Sir Hal
Douglas-Hamilton, Lord James	Mills, Iain
Dover, Den	Mitchell, Andrew (Gedling)
Dunn, Bob	Mitchell, Sir David
Durant, Tony	Moate, Roger
Emery, Sir Peter	Montgomery, Sir Fergus
Favell, Tony	Morrison, Sir Charles
Fenner, Dame Peggy	Moss, Malcolm
Fookes, Dame Janet	Moynihan, Hon Colin
Forman, Nigel	Mudd, David
Forsyth, Michael (Stirling)	Needham, Richard
Forth, Eric	Neubert, Michael
Fox, Sir Marcus	Newton, Rt Hon Tony
Franks, Cecil	Nicholls, Patrick
Fry, Peter	Nicholson, David (Taunton)
Garel-Jones, Tristan	Onslow, Rt Hon Cranley
Gill, Christopher	Oppenheim, Phillip
Goodson-Wickes, Dr Charles	Page, Richard
Gow, Ian	Paice, James
Greenway, Harry (Ealing N)	Parkinson, Rt Hon Cecil
Greenway, John (Ryedale)	Patnick, Irvine
Griffiths, Sir Eldon (Bury St E')	Pattie, Rt Hon Sir Geoffrey
Hague, William	Porter, David (Waveney)
Hamilton, Neil (Tatton)	Raffan, Keith
Hanley, Jeremy	Raison, Rt Hon Timothy
Hannam, John	Rathbone, Tim
Hargreaves, Ken (Hyndburn)	Redwood, John
Harris, David	Rhodes James, Robert
Hayward, Robert	Riddick, Graham
Heathcoat-Amory, David	Ridley, Rt Hon Nicholas
Heddle, John	Ridsdale, Sir Julian
Heseltine, Rt Hon Michael	Rifkind, Rt Hon Malcolm
Hicks, Robert (Cornwall SE)	Rost, Peter
Hill, James	Rowe, Andrew
Hind, Kenneth	Sackville, Hon Tom
Hogg, Hon Douglas (Gr'th'm)	Shaw, David (Dover)
Holt, Richard	Shaw, Sir Giles (Pudsey)
Howard, Michael	Shaw, Sir Michael (Scarb')
Howarth, Alan (Strat'd-on-A)	Shersby, Michael
Howarth, G. (Cannock & B'wd)	Sims, Roger
Howell, Ralph (North Norfolk)	Smith, Tim (Beaconsfield)
Hughes, Robert G. (Harrow W)	Speed, Keith
Hunt, David (Wirral W)	Speller, Tony
Hunter, Andrew	Spicer, Michael (S Worcs)
Irvine, Michael	Stanbrook, Ivor
Jack, Michael	Steen, Anthony

Stern, Michael	Waddington, Rt Hon David
Stevens, Lewis	Walker, Bill (T'side North)
Stewart, Allan (Eastwood)	Waller, Gary
Stewart, Andy (Sherwood)	Wardle, Charles (Bexhill)
Stradling Thomas, Sir John	Watts, John
Summerson, Hugo	Wheeler, John
Taylor, John M (Solihull)	Widdecombe, Ann
Taylor, Teddy (S'end E)	Wiggin, Jerry
Tebbit, Rt Hon Norman	Wilkinson, John
Thompson, Patrick (Norwich N)	Wilshire, David
Thorne, Neil	Winterton, Mrs Ann
Thornton, Malcolm	Wolfson, Mark
Thurnham, Peter	Wood, Timothy
Townsend, Cyril D. (B'heath)	Young, Sir George (Acton)
Tredinnick, David
Trippier, David	Tellers for the Ayes:
Trotter, Neville	Mr. David Lightbown and
Twinn, Dr Ian	Mr. Michael Fallon.
Vaughan, Sir Gerard
NOES
Barnes, Harry (Derbyshire NE)	Dixon, Don
Barnes, Mrs Rosie (Greenwich)	Duffy, A. E. P.
Beckett, Margaret	Dunwoody, Hon Mrs Gwyneth
Beith, A. J.	Eadie, Alexander
Boateng, Paul	Ewing, Harry (Falkirk E)
Boyes, Roland	Ewing, Mrs Margaret (Moray)
Campbell, Menzies (Fife NE)	Fisher, Mark
Campbell-Savours, D. N.	Flannery, Martin
Carlile, Alex (Mont'g)	Fyfe, Maria
Cartwright, John	George, Bruce
Clark, Dr David (S Shields)	Godman, Dr Norman A.
Clay, Bob	Golding, Mrs Llin
Clelland, David	Gordon, Mildred
Clwyd, Mrs Ann	Hardy, Peter
Cohen, Harry	Haynes, Frank
Cook, Robin (Livingston)	Heffer, Eric S.
Corbett, Robin	Henderson, Doug
Corbyn, Jeremy	Hogg, N. (C'nauld & Kilsyth)
Dalyell, Tam	Howell, Rt Hon D. (S'heath)
Davis, Terry (B'ham Hodge H'I)	Howells, Geraint

Hughes, John (Coventry NE)	Quin, Ms Joyce
Hughes, Simon (Southwark)	Redmond, Martin
Johnston, Sir Russell	Rees, Rt Hon Merlyn
Jones, Martyn (Clwyd S W)	Richardson, Jo
Kilfedder, James	Rooker, Jeff
Kirkwood, Archy	Ruddock, Joan
Leighton, Ron	Salmond, Alex
Livsey, Richard	Sheerman, Barry
Lloyd, Tony (Stretford)	Short, Clare
Lofthouse, Geoffrey	Soley, Clive
Loyden, Eddie	Spearing, Nigel
McFall, John	Steel, Rt Hon David
McKay, Allen (Barnsley West)	Taylor, Mrs Ann (Dewsbury)
Madden, Max	Taylor, Matthew (Truro)
Mahon, Mrs Alice	Wall, Pat
Meale, Alan	Wallace, James
Michie, Bill (Sheffield Heeley)	Walley, Joan
Michie, Mrs Ray (Arg'l & Bute)	Wareing, Robert N.
Morris, Rt Hon A. (W'shawe)	Welsh, Andrew (Angus E)
Mullin, Chris	Young, David (Bolton SE)
Owen, Rt Hon Dr David
Parry, Robert	Tellers for the Noes:
Patchett, Terry	Mr. Dennis Skinner and
Pike, Peter L.	Mr. Bob Cryer.
Powell, Ray (Ogmore)

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

Resolved, That this House expresses full support for the proposals set out in the White Paper "Working for Patients" and believes that these will lead to a Health Service that is more responsive to the needs of patients, and will enable those hospitals which best meet the needs of patients to get the money to do so, will reduce waiting times, improve the quality of care, help family doctors to develop the services they provide for their patients, improve the effectiveness of National Health Service management, and ensure that all those concerned with delivering health care make the best use of the resources available to them.