§ Order read for resuming adjourned debate on Question [7 December] , That the Bill be now read a Second Time.
§ Question again proposed.
§ [Relevant documents: Eighth Report from the Social Services Committee, Session, 1988–89, Resourcing the National Health Service: the Government's plans for the future of the National Health Service, (House of Commons Paper No. 214-III, 1988–89), the Government's reply to that Report (Cm. 851), the Second Report from the Social Services Committee, Session 1984–85, Community Care with special reference to adult mentally ill and mentally handicapped people (House of Commons Paper No. 13-I 1984–85), the Government's reply to that Report (Cmnd. 9674), Community Care: Agenda for Action (1988 HMSO), and the White Paper Caring for People: Community Care in the next decade and beyong (Cm. 849).]
§ Mr. Speaker
I must announce to the House that I have not selected the amendment in the name of the right hon. Member for Yeovil (Mr. Ashdown), but the arguments that are advanced in that amendment can, of course, be made in the debate.
I must repeat what I have said: a large number of hon. Members wish to participate. I therefore propose to put a limit of 10 minutes on speeches between 6 and 8 o'clock. The hon. Member for Nottingham, North (Mr. Allen) raised a point about the time limit on speeches, but I have no authority to limit speeches to 10 minutes before 8 o'clock. Nevertheless, I hope that hon. Members who are called before and after that time will bear that limit in mind so that more hon. Members may be called to put their points of view.
§ The Secretary of State for Scotland (Mr. Malcolm Rifkind)
Today is the second day of debate on the Bill. Before I address myself to the major issues that are covered by the legislation, I want to report to the House a welcome development on the position of doctors in the rural and more sparsely populated parts of Scotland of which, I believe, the House will approve. In the White Paper "Working for Patients", the Government gave a guarantee that they would seek to protect the position of such doctors, and that has been a priority for us.
The new general practitioner contract already includes a transitional payments scheme which will help small practices to adjust to their new circumstances. However, the evidence that the Department of Health submitted to the doctors' and dentists' review body last week also stated that I intended to fulfil the undertaking given in chapter 10 of the White Paper by funding from Scottish block resources a scheme analogous to the transitional payments scheme, but on a long-term basis. Scottish doctors who are normally eligible for rural practice payments and who fulfil the obligations of the contract will have their level of income protected under the new contract. As a matter of practical convenience, the fund will be administered by the Scottish rural practices fund committee as the body best 682 placed to ensure that the payments are targeted to doctors who are entitled to receive them. I understand that the proposal has been welcomed by the British Medical Association and I am sure that it will be welcomed by the House as a whole.
I want to begin by giving what I hope will be seen as friendly advice to the hon. Member for Glasgow, Garscadden (Mr. Dewar), who will speak on behalf of the Opposition. On a previous occasion, he expressed some criticism of the fact that the Government's Scottish proposals are incorporated in a Great Britain Bill. I advise him, in the friendliest way, not to pursue that line of reasoning. If he does, he should bear in mind that in the 40 years since the National Health Service was founded, no fewer than 13 Bills affecting it have applied throughout Great Britain as a whole and only three, including a consolidation measure, have dealt with specific aspects in Scotland. As the Government's proposals apply throughout Great Britain, this is the proper approach to take.
Two debates are taking place in the House and in the country on the Government's National Health Service proposals. There is a bogus debate and a real debate. It is appropriate to address myself to both issues and I shall start with the bogus debate because I know that Opposition Members will be more interested in it as it dominates their thinking on the matter.
§ Mr. Rifkind
I hope that the hon. Lady will allow me to continue for a moment.
The bogus debate has taken three forms. It was begun by an assertion that the Government were seeking to destroy the NHS. It was then claimed that the Government's proposals were intended to lead to a reduction in NHS funding and, finally, it was suggested that the Government were putting profit before people and were seeking to commercialise the NHS. Let us address the evidence and see what justification those arguments have.
In its submission to the Government, the BMA states categorically that, in its view, the Government's proposals willdestroy the comprehensive nature of the existing service.The Labour party, in a document produced by the hon. Members for Kirkcaldy (Dr. Moonie) and for Strathkelvin and Bearsden (Mr. Galbraith), stated that the Government's proposals represent "opting out" of the NHS. The National and Local Government Officers Association, in its—as usual—constructive contribution to the NHS debate, suggested that the Government are proposing the "break-up" of the NHS. It is a compliment to the Government in a sense that, as the critics are unable to direct their attention and concern to the contents of the White Paper and of the Bill, they seek to divert attention from those matters by referring to matters that have never been the Government's intention.
One simply needs to quote from the White Paper, which says categorically and unequivocally:The NHS is, and will continue to be, open to all, regardless of income, and financed mainly out of general taxation.Those are the principles on which the NHS is based and on which it will continue to be based. The first assertion—that we intend to destroy the NHS—is of such manifest absurdity as not to justify further attention by the House.
683 No less a body than the BMA then suggested that the Government sought to reduce the funding of the NHS. In paragraph 2.4 of its submission, the BMA said:The Government's main proposals would appear to be to contain and reduce the level of public expenditure devoted to health care.That is a serious allegation from the BMA. I say to the BMA and to those who think similarly that when one puts forward such a proposition, it is proper to judge matters not by what people say, but by what they do. The achievements of the Government over the past decade make the falsity of that accusation undeniable.
Over the past 10 years no fewer than 67,000 more nurses have been working in the NHS; no fewer than 14,000 more doctors have been working in it; and expenditure on the Health Service has risen from £8 billion in 1979 to about £26 billion. Before I give way to the hon. Member for Moray (Mrs. Ewing), I want to give her a Scottish aspect to this discussion. In 1979 expenditure on the NHS for every man, woman and child in Scotland was about £385 which, in today's prices on a common price basis, has risen to £509. I hope that when I give way to her she will concede that that represents a fundamental and real increase in the resources available to the NHS. I hope that if she is as fair about that as she would wish to be seen to be, she will happily acknowledge the point.
§ Mrs. Margaret Ewing
The Secretary of State has raised so many points that it is difficult to include them all in a short intervention.
There is a difference between funding and meeting the task that lies ahead. The requirements in Scotland are so extensive that we shall need to examine the NHS budget carefully. I welcome what the right hon. and learned Gentleman said about rural practices, but what provision has been made for part-time women doctors in practices? What provision is being made for state-enrolled nurses who want to take bridging courses to meet the requirements of Project 2000? If these nurses do not want to take bridging courses, what provision will be made to safeguard their contracts?
§ Mr. Rifkind
I thank the hon. Lady for her welcome for my earlier remarks. We recognise the importance of those who want to work part time in the NHS—particularly female doctors and other female members of staff. For the first time a part-time contract is now available to them, and I am sure that the hon. Lady will welcome that.
The third assertion to which I referred some moments ago was the claim that the Government somehow want to put profit before people or, in the quaint phrase used by the hon. Member for Livingston (Mr. Cook) on Thursday, that we are seeking to commercialise the NHS. I presume that he was not suggesting that we are seeking to obtain value for money—no: the implication of his remarks was that the Government see the NHS as a profit-making body, or believe that it should become one, working in a commercial way without giving priority to the needs of patients.
I hope that the hon. Member for Garscadden will not associate himself with such a foolish argument. If the Government wanted to put profit before people they would hardly have brought forward these proposals, fundamental to which is the idea that any resources saved by a general practice budget will remain with the general practice to improve the quality of its service, and that any savings obtained by an NHS hospital trust will be 684 reinvested in that hospital for the benefit of its patients. In no circumstances can the Treasury or any doctor obtain financial benefit as a consequence of these changes. That adequately meets the point about the Government's priorities.
The bogus debate should not detain the House for more than a few moments, so I turn to the real issue that should attract the attention of the House and the country. The real issue in the NHS debate of the past few months is simple and straightforward. It is how, in a modern society, we should administer the vast resources—the £26 billion or £27 billion—that are required to run the NHS. Can we continue to administer it in a centralised bureaucratic way, or can we, through the benefits of modern information technology, adopt a decentralised method of administration for the benefit of the patients whom the NHS exists to serve?
In addition, we must examine the origins of the NHS and how it was administered when it was first set up. At the time of its inception some 40 years ago there was a basic belief, no doubt sincerely held, in the virtues of central planning and of a benign bureaucracy. There was undoubtedly a widespread belief, perhaps extending beyond the Labour party at the time, that the best way to administer resources of that scale was through a form of rigid, centralised planning which would then feed its way through the system to the benefit of the public as a whole. We did not see that approach only in the NHS; it was evident in various other sectors of the economy and our society. It was reflected in the great nationalised industry legislation of the Attlee Government. The assumption was that there should be nationalisation and many small concerns should be brought together into massive conglomerations and that would achieve the best use of resources. That view was shared in western and eastern Europe as well.
The hon. Member for Garscadden and his colleagues should appreciate that a structure established 40 years ago does not necessarily make sense in the dramatically changed circumstances in the 1980s and 1990s.
§ Mrs. Gwyneth Dunwoody (Crewe and Nantwich)
Does the Secretary of State accept that his Government have reorganised the NHS twice since then?
§ Mr. Rifkind
The hon. Lady is quite correct. Of course there have been changes. However, even today we still have an essentially centralised system administering vast resources. The Government have realised that we must change constantly as circumstances change and it is unfortunate that the Labour party appears to be caught in a timewarp and is attached to a system of administration of the resources which might have been relevant 40 years ago, but is certainly not relevant to the vast sums of money and the vastly changing circumstances at the moment.
It is also sad that the BMA, with its particular involvement in the NHS, should remain so resistant to change. It is resistant not because it is caught in a timewarp, but because it has a fundamental antipathy to change. The BMA opposed the NHS 40 years ago because setting up the NHS represented change. It opposes the Government's proposals today because they also represent change and that is something it cannot come to terms with.
If we consider the way in which circumstances have changed over the past 40 years, I do not believe that Labour Members can seriously suggest that we should not 685 take cognisance of those changes. We have seen a vast increase in resources dating back 40 years. When the NHS was first formed, the expenditure in 1948 was £270 million for the whole of the NHS. Today it is £26 billion. Even taking account of inflation over the past 40 years we have seen an increase in real terms under both Conservative and Labour Governments of 610 per cent. It beggars imagination to suggest that the system of administration of such vast resources can remain untouched by those changes.
It is not simply the scale of resources that has changed. In this country and elsewhere we have also seen a growing disillusionment with central planning and central control as a means of administering resources and getting the best benefit from the way in which we run the NHS. New information technology also offers an exciting opportunity. If we had wanted to decentralise control and the administration of NHS resources in the past, there would have been grave practical limitations on our ability to do that. Hospitals and health authorities did not have the information and could not have been expected to obtain information essential to making rational decisions between different priorities for resources.
§ Mr. Michael Foot (Blaenau Gwent)
If it was so evident to everyone that changes had to be made along the lines that the Government are now proposing, why did the Government make no mention of the proposition in their election promises to the country?
§ Mr. Rifkind
As the right hon. Gentleman knows, the scale of the resources has increased as the years have passed. If he wants to accuse us of being a little tardy in approaching the need for reform, perhaps we will plead guilty to that. However, the right hon. Gentleman should at least appreciate that the Government are serious in their attempt to ensure that resources are used for the maximum benefit of patients.
Perhaps the greatest single change since the inception of the NHS has been the extent to which both sides of the House now emphasise the virtue and importance of choice for patients as a crucial requirement for the way in which the system should be administered.
§ Mr. Rifkind
I will develop this point and then I will happily give way to the hon. Gentleman.
I am glad that the hon. Member for Garscadden agrees with me that the desire for choice has now been represented as common to the views of both sides of the House. In its document "Patients First", a discussion document on the NHS in Scotland, the Labour party actually goes so far as to say, in the most eloquent terms:The National Health Service should provide patients with treatment when they want it, where they want it, by whom they want it, and in suitable surroundings. In other words, choice. This choice must be available to all, and free at the time of need.The document goes on to refer toChoice in primary care … Choice in the hospital service … Choice of day and time of hospital appointments … Choice of consultant … Choice within hospitals and health boards and between health boards … Choice of date for in-patient treatment … Choice of in-patient accommodation.686 Those are fine words and fine sentiments, but the question to which the Opposition have so far failed to address themselves is how such fine aspirations can be translated into reality. We are dealing with a society of no fewer than 55 million men, women and children. How can individual men, women and children be provided with effective, meaningful choice without a dramatic decentralisation of the administration of our vast resources?
Not only will we require such a massive decentralisation, but, if individual citizens are to be given effective choice, we must ask ourselves where they will exercise that choice. Such people do not enter the Department of Health or the Scottish Home and Health Department; they do not enter the regional or the district health authorities. The point of contact with the NHS for the vast majority of ordinary citizens is a visit to either their GP or their local hospital. Only if we can give GPs and local hospitals more freedom in how they use the resources provided for them will it be possible for them to respond to the individual wishes of individual members of the public.
That is the crucial and fundamental point to which the Opposition have not yet addressed themselves. Fine words about choice, and marvellous sentiments about individual members of the public being able to determine which doctor or hospital they visit on which day, can have no hope of translation into reality unless those who provide the services—GPs and local hospitals—have sufficient autonomy in their use of their resources to be sensitive to individual wishes in any meaningful way.
§ Dr. Moonie
Will the Secretary of State tell us how it will improve choice for patients to implement a directive such as that sent out by the Scottish Home and Health Department last week to all health boards, instructing them that once the Food Safety Bill becomes law all chicken served in hospitals will have to be irradiated?
§ Mr. Rifkind
The hon. Gentleman knows perfectly well that the Government made some announcements about irradiation recently, and we shall no doubt have an opportunity to discuss that subject at an appropriate time.
If the hon. Gentleman, who has a medical background, does not believe in the need for proper standards of public health, he is a very surprising example of his profession. We are talking about a view that is common to both sides of the House, and one that was expressed in the hon. Gentleman's own document—for it was his document to which I referred. When I gave way to him, I hoped that the hon. Gentleman would put forward real, serious propositions on how sentiment could be translated into reality, other than through the granting of far more autonomy to individual general practices and hospitals.
§ Dr. Norman A. Godman (Greenock and Port Glasgow)
Has the Secretary of State seen the article in today's Glasgow Herald about the service offered by Yorkhill children's hospital? Serious allegations have been made there about delays in carrying out operations on young children. Will the Secretary of State give me an assurance that he will initiate an investigation into those allegations?
§ Mr. Rifkind
I, too, was concerned when I read the press reports this morning. I have already made inquiries, and I understand that there has been a recent increase in demand for intensive care beds in a number of specialties, leading to the unfortunate postponement of a number of planned operations. The board has already funded an 687 increase of two beds in the intensive care unit and I understand from the board that there is no question of money being transferred away from paediatric-cardiac surgery. The recent unfortunate cancellation is now the subject of a full investigation by the board. I am grateful to the hon. Gentleman for raising that matter.
I referred to the general agreement existing between hon. Members of all parties about the need for increased, meaningful choice for individual patients. However, the practical debate—the real debate—is about how one translates that sentiment into new administrative procedures that give the opportunity for effective choice rather than simply for splendid political rhetoric. Therefore, I turn now to the specific practical criticisms that the Opposition have sought to make about the Government's proposals. Essentially, when one removes the rhetoric and the emotional dimension to the Opposition's position, one comes down to allegations about two basic alleged failures in our proposals. First, the Opposition suggest that our proposals represent what they call a "fragmentation" of the National Health Service. Secondly, they seek to suggest that the effect of our proposals will be to reduce choice, rather than to increase it. Those are serious matters which represent the core of the serious part of this argument, rather than the wild political posturing on which I commented earlier.
With regard to the first accusation—that our proposals represent a "fragmentation" of the National Health Service—clearly the word "fragmentation" has not been chosen unconsciously. It is an emotional word which seeks to suggest something improper or undesirable—
§ Mr. Rifkind
The hon. Member for Garscadden says that it is a descriptive term, but if we are talking about fragments, that term is appropriate only if we refer to the size of the fragments with which we will end up. The hon. Gentleman should look at, for example, the proposals for National Health Service trusts, which are proposed—at least in the first instance—to apply to the large and acute hospitals. If the hon. Gentleman examines the budgets for such hospitals, he will find that they range between £10 million and £50 million per hospital. If that is fragmentation, it is a pretty substantial fragment, as I am sure the hon. Gentleman will agree.
§ Dame Elaine Kellett-Bowman (Lancaster)
My point has nothing to do with Scottish hospitals. On my right hon. and learned Friend's point about fragmentation, I must advise him that I have received one or two letters from constituents who are diabetics, and who are worried that treatment may become more fragmented, as between care in the hospital and care in the community. Will my right hon. and learned Friend or his hon. Friend the Minister of State deal with that point at some stage?
§ Mr. Rifkind
My hon. Friend is perfectly right to raise that matter. Clearly, it will be important for the health authority to continue to use its strategic role for ensuring provision of the services required by the public, including diabetic patients, in its locality. That is important when determining what contractual relations the health authorities should enter into with individual hospitals and others providing medical services. It is important that the needs of the community should continue to be identified 688 by the health authorities which will not, of course, provide resources unless they are satisfied that the services that are required will be met.
I should have more time for the Opposition's accusation about fragmentation if their own position and the proposals in their documents did not point in the same direction, at least in theory. I read with considerable interest the document entitled, "Working with Patients—A Critique", of which the hon. Member for Kirkcaldy was co-author. There is a section on the White Paper, entitled, "What's Good in the White Paper". Indeed, it may delight the House to know that the hon. Gentleman has found a number of things that are good in the White Paper and presumably, therefore, in the Bill. He stated that the quality of care proposals in the White Paper are good. Indeed, they must be good in his view because he claims that they were taken from the Labour party's White Paper and it is always a good sign if the Opposition have to fall back on that claim. The hon. Gentleman welcomed efficiency in the delivery of care and more information being made available to consultants and general practitioners. He also welcomed a flexible accounting system to reflect clinical-led doctor-patient choice.
However, most important of all, which is why I am drawing attention to this point, is the hon. Gentleman's particular welcome to what he describes asfurther devolution of management to hospital and unit level".Indeed, the hon. Gentleman comes close to the Government's thinking in a way that must alarm some of his hon. Friends on the Opposition Front Bench. He stated, "This should be done", and claimed that it is done already under the current structure.
The hon. Member for Kirkcaldy then went on to say what a Labour Government would do. This should he of particular interest to the House, because he said that a future Labour Governmentwould issue hospitals with their own budgets.—[HON. MEMBERS:"Oh."] We have suddenly discovered that, far from being antipathetic to hospitals having their own budgets, the Labour party, which spends half its time accusing the Government of creating an administrative shambles through such a scheme, is putting forward such a proposal itself. However, there is a qualification. Indeed, there is always a qualification and it is right that I should repeat it. The document states:We would issue hospitals with their own budgets, but only WITHIN health boards. Savings should go back to the health board for use in priority areas.We know what that means. It means that hospitals will be given their own budgets, encouraged and no doubt praised for making savings, but they will not be allowed to keep the savings. Savings will have to be returned to the health board. We know of the prospects of hospitals striving as hard as possible to make savings if they themselves are not going to have any benefit as a result of their success in so doing.
§ Dr. Moonie
I thank the Secretary of State for giving way again. Most of the debate seems to be about papers that were published last year. However, I should like to put two points to him. First, general management has been in place for only four years and the right hon. and learned Gentleman has not yet conducted an adequate evaluation of the success of that general management, which was established within an integrated community-based set-up, by which I mean involving both hospitals and the 689 community side. Does the right hon. and learned Gentleman recognise that it might have been better to evaluate the existing change in management before trying to bring in a separate structure?
Secondly, the right hon. and learned Gentleman rightly referred to hospital budgets and savings therefrom. Does he not agree that, when we are dealing with finite resources, savings should be allocated to the most appropriate area of need in a community?
§ Mr. Rifkind
On the hon. Gentleman's first point, his criticism would be valid if we were proposing that as from the enactment of the Bill every single hospital in Great Britain should be required to set up an NHS trust. However, we are not doing so. Not only is the proposal entirely optional, but inevitably there will be only a relatively modest number of participants to begin with and, depending on how matters then develop, that number will increase if the system is seen to be successful by those who have not so far volunteered. What better way could there be of moving towards a more decentralised system, which the hon. Gentleman claims in his document to support?
On the hon. Gentleman's second point, he must appreciate that what he says may sound fine in theory, but will not be realised in practice—[Interruption.] No, because the hon. Gentleman knows as well as I do the practical consequences of telling individual hospitals that they will have a budget and that if they do not use the whole of that budget, any excess will be taken away immediately. The only practical way in which one can achieve the benefits of which the hon. Gentleman claims to be a supporter is by giving hospitals generous budgets and if, by careful use of those resources, the hospitals find that not all their resources are required for the purpose for which they were given, telling them that they may use those extra resources to improve the quality of the provision in the individual hospitals to make them even more attractive to the general public.
§ Mr. James Couchman (Gillingham)
Does my right hon. and learned Friend know whether the budgets suggested by the hon. Member for Kirkcaldy (Dr. Moonie) will be cash-limited and, should a hospital overstretch its cash limit, what penalties will be exacted by the hospital board? That is an interesting line of thought because it accords with some of our thoughts on this matter.
§ Mr. Rifkind
My hon. Friend has asked a fair question, but I must advise him that we have not been blessed with such information. As is so often the case with Opposition proposals, generalised statements are made, but there is an unwillingness—or perhaps an inability—to expand on exactly what is meant. Perhaps the hon. Member for Garscadden, who is hoping to speak immediately after me, will be able to explain exactly the kind of budgets that the Labour party proposes to give to hospitals and will answer the relevant points raised by my hon. Friend.
§ Mr. Tam Dalyell (Linlithgow)
Before we leave the subject of new information, the Secretary of State for Health, who is sitting beside the right hon. and learned Gentleman, has rightly in my view, for what it is worth, 690 said that he would be casting his vote in favour of research on embryos. Will the right hon. and learned Gentleman be in the same Lobby?
§ Mr. Rifkind
The hon. Gentleman had better await that debate and then his curiosity will be satisfied.
I shall turn to the other allegation that the Opposition made against the Government's proposal—that its practical consequence will be to reduce choice, rather than to increase it. The hon. Member for Livingston has said:Patients will lose the right to go to the hospital of their choice—[Official Report, 27 November 1989; Vol. 162, c. 446.]I am not familiar with the existence of any such right at the moment. The hon. Member for Peckham (Ms. Harman) should appreciate that. A member of the public may express a preference, but the idea that a patient has a meaningful, enforceable right at the present time is not in accordance with the way that the National Health Service has operated at any time since its inception. The real question is whether individual GPs will be more able or less able to respond to the declared preferences of their patients in the future.
The Bill provides for a system in which there will be an incentive for GPs with practice budgets to respond to the wishes of their patients, because that will materially influence the way in which the practice is financed. The consequence of that will be entirely to the patients' benefit.
I hope that the hon Member for Garscadden will address himself to the objectives that he says his party is committed to—the practical consequence of the measures. The hon. Gentleman should appreciate that we are seeking, through group practice budgets and NHS hospitals, to provide a decentralised system of administration that will enable the individual GP and the individual hospital to be more sensitive to the wishes of the general public.
§ Mr. Rifkind
Many hon. Members wish to take part in the debate and I shall not give way.
Opposition Members are perfectly entitled to express their views on the administrative consequences of the proposals in the Bill, and to give their own view of the Government's achievements. What they may not do is express a view that is based on the belief that the last Labour Government made a splendid contribution to the well-being of the NHS. During the period that they were in office, the proportion of resources devoted to the NHS fell, nurses' pay fell by no less than one fifth and waiting lists increased by a quarter of a million.
In 1978 the then chairman of the British Medical Association said of the Labour Government's record on waiting lists:The sum of human misery represented by those record figures is a scandal without parallel in any technically developed country".That was the last Labour Administration's achievement. When they comment on the Government's proposals, I hope that they will do so with the appropriate humility.
§ Mr. Donald Dewar (Glasgow, Garscadden)
I come to the Dispatch Box confident in the knowledge that I will be the first person in the debate today who has spoken about the Bill.
The Minister gave us a suitably elegant lecture. He has obviously been working hard on the plane from Edinburgh 691 this morning. He started with a stylish anti-climax that I found amusing. We were told, or there was an implication, that there would be an announcement about the rural practice fund, and that he was glad to have the opportunity to make that announcement. However, what we wanted to know about the rural practice fund was to what extent it has been increased, and that was the one fact that the Minister failed to give us.
We know that rural GPs will suffer particularly badly from the shift in the GP's contract towards an emphasis on capitation fees. If those GPs are to be fully compensated, the rural practice fund will have to be increased significantly above the cost of living figure. We will have to wait for an answer to that as well as to many other questions.
I shall make on diversion, and I make no apology to the House for that. I came down to London on the overnight sleeper from Glasgow, and found myself in conversation with two members of the ambulance service from the west of Scotland. [Interruption.] During the conversation they told me of their determination to achieve what they and the majority of the public see as a just settlement.
§ Mr. Jerry Hayes (Harlow)
The hon. Gentleman quite rightly criticised my right hon. and learned Friend for not talking about the Bill, but the ambulance dispute has nothing to do with it.
§ Mr. Deputy Speaker (Mr. Harold Walker)
The hon. Member for Glasgow, Garscadden (Mr. Dewar) must relate what he said to the Bill.
§ Mr. Dewar
I have been on my feet for one minute, and the most notable fact has been that my mention of the ambulance dispute was greeted by gales of laughter from Conservative Members and by a frivolous intervention. 1 think that the ambulance drivers will be interested to read of that reaction in Hansard.
I shall not speak at great length about the ambulance dispute, but I want to point out that the situation is deteriorating in Scotland. This week, staff in the west of Scotland have found themselves on and then off full pay three times. Many of them are getting as little as 25 per cent. of full pay, although they believe that they are honouring the agreed guidelines. The Government's insensitive approach, their machismo and the search for victory are doing an enormous amount of damage to morale and to the fabric of the service.
I repeat my view that if the Government's case is so strong, then there seems to me to be no reason why they should not submit the dispute to the independent judgment of an arbitrator. I hope that Ministers will understand in time that it is in their interests to do so, as well as in the interests of the service.
The Bill implements a White Paper which has been heavily and properly criticised. It is seen by many people as another campaign in the war of attrition that has been fought by the Government against the Health Service in recent years. We have had the regrading dispute, and competitive tendering, which makes workers struggle to save their own jobs at considerable cost to their terms and conditions. The threat of competitive tendering is getting nearer to the core of the Health Service.
692 Radiographers from Scotland are coming to London tomorrow to meet Opposition Members to put their case, and to express their fears and anxieties. Ministers have a duty to consider the effect on morale and to measure the difficulties against the proposals in the Bill.
One minor point that I shall mention in passing is the meaning of paragraph 3 in schedule 5 of the Bill, which has had a number of public outings and has been a cause for concern. The Minister may remember that that paragraph refers to the transfer of officers and servants to other health boards in Scotland, and to the common services agency. I am not clear about the definition of a servant in that context, but I suspect that it means all employees, and I do not know the circumstances in which it is envisaged that the transfers will take place. Perhaps the Minister could give me that information by letter, if that is the most convenient, as I have received a number of representations about the matter, and I want to give accurate information in my replies.
The White Paper and the Bill have hardly a friend in Scotland. I do not wish to overstate my case, but the Bill is almost as unpopular as the Minister responsible for health in Scotland, and that is saying something. Perhaps that is not surprising as the Bill is seen as being built in his image.
There have been individual protests in plenty. One that I have mentioned before but that is worth recording again is the view of the hon. Member for Southend, East (Mr. Taylor). That gentleman has a special responsibility for the Conservative party's campaign tactics in Scotland. On 18 October he told The Guardian that the White Paperhas caused so much unnecessary harm. Unless we are prepared to concede a lot, I think we should scrap it.That is not a bad summing-up of what many people in Scotland feel.
In July this year, at a conference in Inverness, a lady who is well known to many of us in Scotland, Mrs. Winnie Donaldson, a leading Conservative councillor in Edinburgh for many years, chairman of the social work committee of both the old Edinburgh corporation and the Lothian region and a former member of the Lothian health board, said:The White Paper absolutely appals me … It seems to be like something out of another country … when out of the blue comes this document, which seems to be something from another world. How do we get sense into people?That may not be the most technically complex of arguments, but it is a cry from the heart of somebody who, from a Conservative point of view, has given a great deal of service to the Health Service in Scotland.
I and my colleagues are often attacked. The hon. Member for Stirling (Mr. Forsyth) is never tired of telling us that we represent nothing more than a narrow vested interest, that we reflect unworthy and prejudiced views. If the House looks a little more closely, it will find that we are being accused of speaking for doctors, nurses, auxiliaries and ambulance drivers. I make no apology for expressing some of their anxieties, but the proposals affect thousands of people in Scotland.
This morning, I received a letter from the hon. Member for Stirling in his capacity as Minister with responsibility for health at the Scottish Office. He wrote:You recently delivered a number of postcards to St. Andrew's house".Close to 50,000 postcards to be precise, each one completed and signed by a member of the public who had taken the trouble and was worried enough by what the 693 Government are proposing to fill it in. I gather—I welcome it—that each of those 50,000 is to receive a postcard from the Scottish health Minister. That is good news for the Post Office, although it might not have wished for it in view of the impending Christmas rush, but it will be a shock to many good, honest Scottish citizens who expect no such honour. Last year, by way of Christmas cheer, they got advertisements in almost every Scottish newspaper telling them of the joys of the poll tax. This year they will get a personalised postcard from the hon. Member for Stirling extolling the virtues of a business-oriented approach to the Health Service. It will be well calculated to take the bang out of anyone's cracker.
In any event, we can take one thing from the Minister's responses—we have drawn blood. He is obviously conscious of his weakness with public opinion and realises that he cannot just shrug off this substantial evidence of disquiet. He was kind enough to send me a copy of his pamphlet, complete with a second-class postage stamp carefully drawn in. I appreciate the artwork. It is clear that someone in a high grade in St. Andrew's house has a second talent. The Minister's little pamphlet illustrates the peculiarity of the debate.
That brings me to what the Secretary of State said. Many of the arguments are indeed common to both sides of the House. We both pay lip service to the concept, history and traditions of the Health Service. The question is not who uses that kind of rhetoric; the question people have to make their minds up about is what is the reality of what is happening and who is committed to preserving the Health Service. The Minister's letter says:We support and will not change the principles that have guided it over the last 40 years … The Labour Party campaign has therefore been built on a misapprehension. I intend to ensure that this is removed.He sounds as though he is talking about an offensive gall stone. I do not think that he is likely to remove deeply-held convictions, based on the private experience of thousands of citizens, that the Government have got it wrong in terms of their fundamental theoretical approach to the Health Service. That is at the heart of the debate.
Of course there is a problem with how efficiently to deliver services and the commitment to escalating costs that new technology brings to health care, but my suspicion is that the Secretary of State, if I interpret his speech aright, is saying, "Look at all the money we have poured in and all the troubles we still have. We have to find another way. That other way will be followed because it is financially prudent. We shall push to one side the genuine byproducts and difficulties which will flow from that."
Much of what the Minister says in his little pamphlet cannot be sustained.
§ Mr. Kenneth Hind (Lancashire, West)
The hon. Gentleman speaks of the rhetoric that both sides of the House use in regard to the NHS and says that hon. Members and Governments will be judged by what they do. Will he cast his mind back to 1977–78, when Labour was in power and there was a 3 per cent. cut in real terms in the NHS? Surely that is the type of judgment that the public are entitled to make.
§ Mr. Dewar
I recognise that every memory works in its own way, but most of my constituents remember the past five years more clearly than the events that the hon. Gentleman has trawled up.
We are told in the pamphlet that the Government's proposalsdo not involve patients having to pay for services currently provided free at the point of delivery.I accept that. There is nothing in the Bill that say that they will have to pay, but I am entitled to observe that the claim sounds a little hollow bearing in mind what has happened to prescription, dental and eye test charges. There is overwhelming evidence, which my hon. Friend the Member for Livingston (Mr. Cook) has given, to show that people are doing without. The pamphlet continues—this is an important claim—The proposals do not involve any hospitals opting out of the NHS".I understand the linguistic nicety on which that statement is based. They are not opting out of the Health Service. I am tempted to agree that that is a fair statement because, in Scotland, there is so little support for this crazy notion that I suspect that no hospital will opt out for that very reason. Nevertheless, we are entitled to some explanation. The Secretary of State said almost nothing about a timetable and what he expects. We know that the Minister with responsibility for health is anxious to be a front-runner—to blaze a trail with opting out and to maintain his claim. Perhaps it is all to maintain his place in "her" heart, which has led to his becoming the leader of the Scottish Tory party. In any event, we know from The Scotsman that among the Minister's claims is thecreation of 'shadow' trusts. They would be ready to assume self-governing status and take over the running of hospitals immediately the necessary laws were approved … He is known to be anxious that Scotland should lead the way on implementation of the reforms"—then comes the sad anti-climax—which have, however, met general resistance from the medical profession.I suppose that not everything can be perfect in this world. I listened in vain to the Secretary of State to learn what the plans are. There are few signs of genuine interest. We know that the target will be the 320 acute hospitals in the United Kingdom with 250 beds or more. The hospitals in Scotland that have been mentioned are peculiarly inappropriate. We are told that the Royal Scottish National hospital at Larbert is interested. It has 800 beds for mentally handicapped patients. Its aim under the new approach to care in the community is to work itself out of existence, not to become a brave new cutting edge for the peddling of services to other NHS agencies. We also have a group of three cottage hospitals in Forfar which I am told can muster 115 beds between them. I hope that I am not being unworthy when I say that they are interested because they fear for their survival in the brave new commercial world of the White Paper. That is not a good basis on which to become the favoured guinea pig in the opting out experiment.
§ Mr. Bill Walker (Tayside, North)
That is a frivolous comment. Forfar is the largest town in my constituency and it is the county town of Angus. The people of Forfar will find it offensive that the hon. Gentleman is so dismissive of it. Its hospitals are important to the people of Forfar. The hospitals are considering self-governing status because local general practitioners and others want it.
§ Mr. Dewar
The hon. Gentleman clearly wants to defend what is happening. As the constituency Member, he is entitled to do that, but on self-governing hospitals Scottish working paper No. 3 speaks of the target beingmajor acute hospitals providing a reasonably comprehensive service.Three cottage hospitals in the Forfar area do not spring immediately to mind as the most obvious example of that.
A more dangerous and more plausible example involves Stracathro and Forresterhill. If, for example, Forresterhill were to opt out, the Grampian health board would be left without its main provider of acute services, to use an up-to-date parliamentary expression. Forresterhill is a major complex with which I am familiar from my days as the Member for Aberdeen. If that hospital opted out, it would not create the market and competition which I understand is at the heart of the Government's arguments. If not the monopoly provider, the complex is the main provider of acute services to the Grampian health board. To introduce competition, it would be necessary to look to Dundee and Glasgow. That would not be meaningful competition.
Perhaps the Minister will tell me if I am wrong, but I believe that Mr. Kyle, the chairman of the Grampian health board, is a great enthusiast of opting out for Forresterhill. Scottish Office selection procedures are admirable because in almost every health board area one can count on at least one enthusiast for opting out—the chair of the health board. When we spoke to the consultants in Forresterhill, over 80 per cent. wanted nothing to do with opting out. Perhaps the Minister will tell us what he thinks about Scottish working paper No. 3, issued by his Department not long ago, paragraph 55 of which says that the health boardswill seek the views of those with an interest, particularly other health boards likely to be concerned, staff affected, general practitioners, local health councils and the local community.We know that the staff at Forresterhill are not interested and I defy the Minister to produce evidence that the local community will be interested in opting out. I do not believe that GPs or anyone else will support opting out. What are we to understand by paragraph 55? Was it just a deceitful aside to pad out the paragraph or will the health board have to consult before opting out? What form will consultation take and what will happen in cases such as that of Forresterhill where the overwhelming evidence is that there is no interest?
The reasons why people discuss the crazy scheme for opting out are simple. One is bureaucratic. That may seem an odd argument from the Labour party but we are not interested in bureaucracy if it is expensive and fulfils no useful social or administrative purpose. Separate hospitals will be separately managed and will have separate legal, personnel and purchasing departments.
§ The Parliamentary Under-Secretary of State for Scotland (Mr. Michael Forsyth)
And separate budgets.
§ Mr. Dewar
And possibly separate budgets. It is dishonest of the Secretary of State or at least highly misleading to suggest that a reference to budgets in the useful paper prepared by two of my colleagues can be equated with a trust which will own assets, hire and fire staff, borrow on the markets and buy and sell its services to the highest bidder at the most advantageous price in the market place. That is a completely different concept, and 696 the Secretary of State knows it. It is a mark of the weakness of his argument that he is reduced to drawing such false comparisons.
§ Mr. Rifkind
Perhaps the hon. Gentleman will do the House a service by explaining what the Labour party means when it says that it would issue hospitals with their own budgets? What kind of budgets would be provided? To what extent would the hospitals be committed to keep expenditure within the budget? What would be the effect if they exceed the level set down? Would budgets be a meaningful change or just a form of rhetoric?
§ Mr. Dewar
No doubt the Secretary of State will have time to discuss that on other occasions. We are discussing the Bill. [HON. MEMBERS: "Answer the question."] The Secretary of State may be interested to consider the possibility of a clinical budget for a ward and an extension of the principle of auditing. We are implacably opposed to the provisions for hospitals trusts outlined in the White Paper. They are divisive and will mean a loss of choice for patients and doctors. If, after discussion with a patient, a doctor decides that he wishes to send a patient not to the Western infirmary but to the Victoria infirmary or Southern General hospital, I am confident that he will be able to do so. However, if the patient needs a form of treatment for which the health board has drawn up a contract with a specific hospital, under the new market arrangements, clearly the patient will have to go to that hospital whether it is Ross Hall—[Interruption.] I have taken the trouble to talk to the people involved and they believe that that will be the case. If the Secretary of State is saying that we have misunderstood, that is an appalling comment on the quality of explanation that has been offered. [Laughter.] The Secretary of State had better clear the matter up. If the famous hip operations to which the Parliamentary Under-Secretary of State always refers are contracted out to a certain hospital by the health board, and that is the only outlet for that treatment, where will be the choice? Can the patient refuse to go there and ask to go somewhere else?
§ Mr. Rifkind
Yes. The patient will be no more obliged to go to the hospital of the doctor's choice than he is now. Presumably a doctor will not enter into a contract with a hospital unless he believes that it gives a high quality of service. He may wish to recommend it to the patient, but it will be for the patient to decide whether he wishes to accept that advice. [HON. MEMBERS: "Rubbish."]
§ Mr. Dewar
On occasions I think that debates in the House are useful. The Secretary of State has made an interesting statement which we shall look at carefully. If it is true, it is another example of a feature of the Government's conduct of this case. Every time that we approach the logic of what they say, whether in White Paper or Bill, they hasten to deny the obvious consequences.
The Bill will move the Health Service towards a two-tier service over a period of time.
§ Mr. Dewar
No, I am up against a time problem.
It may not be the principle or immediate aim of the Government to create a two-tier service but it will be an acceptable by-product to the Government. The tax concessions announced in the Budget for those of 697 pensionable age who opt for private health care underlines that point. We shall see the private sector build wings on opted-out hospitals so that they can share facilities. We shall arrive at a point where a better service is available for those whose credit rating or employment conditions allow them to use private medicine than for those who are not in that position.
I now come to my final point because I do not wish to delay the House for too long. Opting out will disrupt and undermine the planning function of the health boards in Scotland. Perhaps the Secretary of State will tell me if I have misunderstood but I assure him that that misunderstanding is widely shared, particularly by members of the Greater Glasgow health board who have examined the matter carefully. The board is considering its acute services and producing an overall planning framework based on six centres for the whole area. I have had my disputes with the health board about cross-boundary flow, demographic factors and reductions in the number of acute beds and the social assumptions that they have made, but I do not dispute the need for an overall framework. I recognise that many difficult decisions have been taken. A row is already raging about the placement of obstetric units in the health board area. Whether it has got it right or wrong, it is entitled to make such decisions and to have an overall view of how it organises its resources.
What will happen to the overall strategy if a centre of acute care opts out and becomes a free-standing hospital? What will happen to the concept of overall planning and to the health board's role if a trust turns round and says, "The health board may think that the reorganisation is in the interests of patients and the community as a whole, but it is not in the interests of our hospital because we shall have to close wards and stop operations which are particularly profitable and bring us business. We shall not do it."? The Under-Secretary shakes his head fiercely, but many people in the Health Service at health board level see these problems as a negation of good management forced on the Health Service in the false name of efficiency. There will be casualties.
§ Mr. Robert Hughes (Aberdeen, North)
Is my hon. Friend aware that a new unit for psycho-geriatrics has been built in Grampian region and that the health board is actively pursuing the possibility of contracting every aspect of care, not just cleaning and catering, but medical care, to a private medical company? During discussions with the board, it could not say what the medical plans were because it had to discuss costs with the private company. Does my hon. Friend agree that that is a complete negation of planning and, indeed, of the ethos of the Health Service?
§ Mr. Dewar
I agree. These discrepancies and distortions will creep in increasingly. One of the tragedies is that there will be many casualties. I draw the attention of Tory Members to the view that:Medical education, currently regarded as a proud obligation, will become merely tolerated under a market-led system.The principal of Glasgow university also said that medical education was being seen as anadd-on, a non-optional extra that NHS managers would have to put up with.698 It would be sad if that were to emerge as the view on medical education. I would not think that Sir William Fraser, a former permanent secretary at the Scottish Office, was a tyro at looking behind the Scottish Office press releases to the reality of what is happening. Yet that is his considered view of the likely impact of the Government's plans on medical education in his university and in the west of Scotland.
I have dealt with the opting-out issue at some length, partly because of interruptions. General practitioner practice budgets are unlikely to be a major feature in Scotland as only 5 per cent. of Scottish practices reach the 11,000 mark. Where they are introduced, administration will be a major problem. It takes time and effort to negotiate a contract and to shop around as envisaged, and that time will be taken from patients. I plead guilty to finding the practical arrangements obscure. If a GP sends his patient for a barium meal and the patient requires further investigation and ultimately major abdominal surgery, that will come out of the practice budget. Presumably, there will be standard charges to even out costs, but at the end of the day there is little evidence that the service will be improved for patients. I genuinely do not believe that there is much point in the exercise or that anyone will benefit from it. It is like the switch to capitation fees. Ministers spend their time explaining that what everyone thinks will happen will not happen and that everything will go on as before. That is a futile argument.
I accept that, despite the indicative drugs budget, GPs will always be able to prescribe. I shall not go in for scare stories. I am prepared to accept that assurance. Perhaps the Under-Secretary of State will listen to my next point. If we move away from local general practice committees monitoring drugs budgets, we are in danger of putting a cash test in the place of medical criteria. If a doctor pumps out valium and is irresponsible at that end of the trade, he may not reach his indicative budget, but he may prescribe in a way which is clinically damaging and, because of the switch in the criteria, that may not be picked up. I cannot welcome that proposal.
Some provisions in the Bill are good. Health councils survive, although in a different form. There is a medical audit. More important, the Bill provides for Griffiths's key recommendation: that local authorities retain the key role in community care. That decision must have stuck in the Under-Secretary's craw. The key is resources. We can have jointly planned projects, but they must be jointly funded. We can have protections and plans that will be as naught if patients leaving hospital and being maintained in the community do not have the support and services that they require. Perhaps the Minister, again in a letter, can tell me a little about the status of grants to the mentally ill under clause 52. Is it new money or top sliced from existing resources? What arrangements will be made for the co-ordination of community care planning, given the provisions for separate submissions of plans by health boards and local authorities? Will the Minister sit down with the voluntary sector and local government and consider the matter?
I shall ignore the Government health warning that was given at the beginning of the debate. Whatever the precedents, I genuinely regret that there is no separate Scottish legislation. It would have made for better scrutiny and a more easily conducted debate. It is sad that good government has been subordinated to expediency.
§ Mr. Dewar
I apologise to the Secretary of State, but I have spoken for too long already. He knows that I normally give way to him, but he made his points about the statistics and precedents earlier.
Whatever the precedents, it would have been better to have a separate Scottish Bill, particularly as we do not have a Select Committee on Scottish Affairs which could have provided useful back-up scrutiny.
I regret even more the Bill's contents. Ministers will continue to claim that the best is being preserved and nothing is being lost. I can only say to the Secretary of State that if he thinks that, he does not understand the implications of his legislation. We in the Labour party are strongly opposed to the measure which in the long term threatens the basic principle of a comprehensive Health Service fully available at the time of need. It is on that that we cannot compromise.
§ Mr. Roger Sims (Chislehurst)
Notwithstanding the stories that we hear from time to time from the Opposition, we have a good Health Service. Parts are very good and of a high standard. That was demonstrated last week at the Hospital of the Year awards which were sponsored by the Sunday Times. My right hon. and learned Friend the Secretary of State for Health attended the award ceremony. Throughout the proceedings emphasis was rightly placed on the quality of care.
I enjoyed the high standards myself in a local National Health Service hospital during the summer when I underwent skilful surgery and received the most competent, sensitive nursing care. However, nobody would claim that all is as well as it could possibly be in the NHS. Each year more doctors and nurses are employed, more patients are treated and more money is spent. Yet each year we hear of longer waiting lists and more closed wards. That must show that more resources alone are simply not the answer. It points to the need to examine the structure of the Health Service, its administration and the way in which resources are distributed and used. It was just such an examination which the Government undertook two years ago.
The key to success in the NHS must be the staff, from the bottom to the top and particularly the professionals. I understand why the Government in undertaking their review confined the involvement of those who work in the service to submitting papers. They were not involved in discussions. It was unfortunate that the Government then chose to publish the outcome of the review in a White Paper rather than a Green Paper and that in speaking to the White Paper Ministers used language that suggested to those in the service that the Government were presenting them with a fait accompli. It was a pity that the White Paper was not accompanied by a response to the Griffiths report. The review covers hospitals and general practice, but, as it does not refer to community care, it is rather like a three-legged stool with two legs. That omission has been remedied, but rather late in the day.
700 One result of the way in which the matter was handled was a somewhat hostile response to the review—much of it negative and some of it unpleasantly personal. The British Medical Association drew no credit to itself for the way in which it conducted its campaign.
If we examine the reactions of some of the professional bodies, we find that they support many of the proposals and that their concern about some of the others relates to what could happen and what might be the result of implementing the proposals. Some of the comments and some of the literature were misleading; some were downright wrong. They caused unnecessary distress to patients, in particular to the most vulnerable patients. Some of the concerns, however, were perfectly genuine. They sprang from uncertainty and from lack of detail. I hope that the professional bodies—the colleges and in particular the BMA—will accept that the Government are committed in principle to their proposals and that they will take part in a constructive dialogue about the details.
The differences are not all that great. For example, the BMA says that there should be pilot schemes for self-governing hospitals and practice budgets. My right hon. and learned Friend the Secretary of State has accepted that both will be introduced gradually, that each scheme will be a trial and that we shall learn as we go along. The difference between the two approaches does not seem to me to be very great. I am sure, therefore, that if both sides adopt a constructive approach, progress can be made.
I know that my right hon. and learned Friend is fully committed to the National Health Service, but some of the things that he has said and the way that he has said them—in the press, on television and at meetings—have given the impression to the doctors and consultants to whom I have spoken that he is not concerned about their views. I am sure that that is not the case and that he will wish to correct that inaccurate image.
I welcome the principle that underlies the Bill: to ensure that increased resources are devoted to providing the highest possible standards of service and care in the most efficient manner—for example, by giving district health authorities and doctors the freedom to purchase operations and treatment, with the money following the patients. In a debate on the Queen's Speech the hon. Member for Livingston (Mr. Cook) referred to Queen Mary's hospital in the Bexley health authority area and said that it had had to close wards. However, he did not go into the details. One of the reasons for the closures is cross-border patients, some of whom come from my own constituency, but who are a charge on Bexley health authority. That will be put right.
It surely makes sense to bring responsibility down to local level, to let doctors have their own budgets, if they so wish, and to let hospitals be self governing. I am glad that Bromley district health authority's application has been approved. The corollary is local involvement in the service—especially for the local authority to be responsible for community care.
I hope that we shall examine again the proposed composition of health authorities and self-governing trusts. I note that Members of Parliament are to be specifically excluded. Many of us remember our erstwhile colleague, David Crouch, was a member of a health authority and a particularly valuable Member of this 701 House for that reason. My hon. Friend the Member for Gillingham (Mr. Couchman) served for a time on a health authority.
There are many examples of successful co-operation between the National Health Service and the private sector. It must be right to try to develop that co-operation. The private health sector is well established in community care. There is certainly scope for greater co-operation between local authorities and the private sector, as proposed in the Bill. However, standards must be set and maintained in all sectors—local, national, independent and voluntary.
It is equally important that community care should be adequately funded. It is admirable that local authorities should be made responsible for this service, but they must be provided with adequate resources. They will be seeking assurances that sufficient cash will be made available to enable them to handle all the cases that come their way. I am sure that the Secretary of State does not underrate the strength of the ring fencing argument; the money at present being paid for social security purposes must be made available in full specifically for community care.
I am particularly concerned about those who are living in residential homes and nursing homes. I am sure that all hon. Members could give examples of constituents whose social security benefit is insufficient to meet the cost of living in such homes. I am referring not to expensive private homes, but to places such as the Cheshire home in my constituency where the minimum cost for each resident is above the maximum social security benefit that some of the residents are able to obtain. I have been in correspondence with the Secretary of State for a long time about the problem. I was assured that it would be addressed in the Government's response to the Griffiths report. I was disappointed to find that it does not seem to have been adequately addressed in the report. I am particularly worried about those residents who, alas, may not be with us by 1991. The Government should take urgent steps to improve their position.
§ Mr. Mark Wolfson (Sevenoaks)
I support my hon. Friend's point as a result of my own experience of a Cheshire home in my constituency. Exactly the same problem has arisen and I, too, will be seeking reassurances from Ministers.
§ Mr. Sims
I am grateful to my hon. Friend. I suspect that all hon. Members could tell similar stories. I hope that Ministers will take the point on board.
Many hon. Members would like to know more about a number of details. For example, what are to be the criteria for the approval of self-governing hospitals? I dissented from my Select Committee colleagues who advocated that there should be a local ballot. I do not think that that would be practicable. However, we should be given more details about the criteria that the Secretary of State will set. How will those who are parties to a contract be held to it if it does not have legal validity? What definitions will govern a core service? Many other details need to be clarified. It could rightly be argued that these are Committee points, but they are very important to those who are working in the National Health Service. They will 702 have to implement the Bill when it becomes an Act of Parliament. They are also very important to those who are involved with community care.
As these issues are so important, I hope that my right hon. and learned Friend will look sympathetically at the motion that I and other Select Committee members have signed. We urge that the Bill should be considered by a Special Standing Committee. I have some experience of this relatively little-used procedure and I commend it to my right hon. and learned Friend. It provides an opportunity for those who work in the National Health Service to put their point of view on how the Bill could best be implemented and the kind of problems that they envisage. The Secretary of State would then be able to consider those matters. The only alternative is that outside bodies have to find a friendly Back Bencher to present the case on their behalf. Even at this late stage, I hope that Ministers will be prepared to adopt that procedure. I do not believe that it would cause the proceedings to be unnecessarily delayed. In the long run, it may save time.
We all want to make this good Bill better. Politicians, professionals and patients are united, and, as my right hon. and learned Friend the Secretary of State said when he moved Second Reading on Thursday, we all want to make a good National Health Service even better.
§ Mr. Peter L. Pike (Burnley)
I oppose the Bill because I believe that it will be tremendously damaging to the Health Service in Britain. We all have to recognise the way in which the Government work. They often have to go part of the way in the direction they seek and then take it further in subsequent legislation. On Thursday, my right hon. Friend the Member for Blaenau Gwent (Mr. Foot) set out the reasons why the Government, who do not like the Health Service and do not want it to work, dare not go any further than the proposals in the Bill. They recognise that the Health Service has massive public support, and, therefore, they have to tread more cautiously.
The Opposition believe that the two main priorities are that people are entitled to educational opportunities and to health care based on need and regardless of ability to pay. That is why we must not allow the Bill to make progress. It does not tackle the problems facing the Health Service which are based on resources and finances.
I have copies of letters from a general practitioner to the hon. and learned Member for Putney (Mr. Mellor), now Minister of State, Home Department, and to the Under-Secretary of State for Health. After the correspondence had continued for some time the doctor's final letter concluded:Alternatively, of course, you could propose to your Government colleagues that all pretence at improving the NHS should be dropped, and it should instead be admitted to the voting public that the only way to assure ourselves of high quality treatment and freedom of choice under the proposed new arrangements will be to obtain private medical insurance.The Bill underlines the fear that we are moving towards a two-tier Health Service; a Health Service providing for basic needs, but a better level of service for those who have the ability to pay. That would be regrettable.
We have discussed the practice budgets and the indicative drug budgets. Whatever the Minister says about those figures, we all know that, although budgets might not be rigidly cash limited, they influence decisions. I have no doubt at all that when doctors are prescribing drugs, 703 although they accept that they may be permitted to prescribe a more costly drug, they will be influenced by that budget limit. The Minister should recognise that the Opposition know that to be true. We have only to look at what is happening in the Department of Social Security to community care grants. My local office recently wrote to me saying that it could no longer make certain community care grants for the remainder of the year because it had to retain enough of the budget to meet demands for the remainder of the year.
Although Ministers say that doctors will be able to prescribe, general practitioners, the public and Opposition Members fear that the new system will affect their decisions. When I met local GPs and the BMA in my constituency they made two points about budgets.
§ Mr. Nicholas Bennett (Pembroke)
Presumably in 1985 the hon. Gentleman opposed the limited list on drug prescribing about which the BMA also protested. Does he now accept that that was right and that £75 million has now been allocated to pay for other things in the Health Service?
§ Mr. Pike
I do not want to be sidetracked by the hon. Gentleman. In any event, many additions have been made to the original limited list which is constantly under review. I shall not be sidetracked on that point as it was not a finite decision at the time.
The general practitioners made two points about the provision of services to their patients. They do not believe that the decisions that they take concerning the medical treatment of their patients should be influenced by politicians, in the House or anywhere else, or by accountants. They fear that their judgment will be affected if the Bill is enacted in its present form.
The Under-Secretary of State wrote to me on 24 July stating:It is not our intention that budget pressure would ever affect a clinical decision.".In a subsequent letter he wrote:If a doctor spends significantly over his budget, he will be subject to peer review from another doctor who will consider whether there are sound clinical reasons for the level of spending. A doctor will only be subject to a financial penalty if he cannot give a clinical explanation for expensive prescribing practices.The Minister failed to recognise my point that in any event GPs' prescriptions will be influenced by the indicative drugs budget.
§ Mr. Pike
In his opening speech on Thursday, the Secretary of State referred to a practice with a list of 7,000 patients which was spending £800,000 a year on drugs. He said that was 185 per cent. above the average for its family practitioner committee area. He said that that practice dealt with the average number of elderly people, but he did not take into account other factors that may have affected that expenditure. Housing and working conditions also affect people's health and the problems for which they have to visit the GP and could therefore affect the prescriptions. We have to be careful how we judge these matters as we could reach hasty and wrong decisions when determining whether a doctor is overprescribing and that could be extremely dangerous.
I am particularly worried by the Government practice that they always anticipate that their legislation will be 704 enacted. Burnley, Pendle and Rossendale health authority meets this Wednesday. This year it has an additional allocation from the North-West regional health authority of £149,500 to spend on preparation for the implementation of the Bill—before it has received parliamentary approval. The health authority received that extra money when it had to close a maternity ward—it has the highest perinatal death figures—and another hospital was closed in October to save money. Yet suddenly extra money is made available to health authorities. Lancashire has operated a quota system for ambulances since 1986 and we need money to deal with those problems.
The Government do not like to talk in terms of hospitals opting out, but we know that if hospitals move in that direction the Health Service will be absolute nonsense. We should aim for a system in which hospitals provide the maximum possible services locally, although we will always have regional centres of excellence for certain specialised services and needs.
Other hon. Members wish to speak, so I shall conclude by saying a few words about community care, which was hardly mentioned in the Minister's speech. I welcome the Government's decision to make county councils responsible for assessing and supervising the provision of community care, but I should have been much happier if they had made local authorities the major providers of services. Care for our elderly, mentally handicapped and sick people should be provided publicly. The massive growth in private homes and in the profit being made from old people is obscene—[Interruption.] Conservative Members obviously agree with that, but I believe that the care of our elderly, mentally handicapped and disabled people is a public responsibility. In my area, the Government are trying rapidly to run down and close Brockhall and Calderstones.
The Government say that they accept that community care, which we all support and believe to be right, is not a cheap option, but however many times they say that, they still hope that it will be a cheap option. Community care will work only if we ensure that sufficient cash resources are made available and that there are sufficient adequately trained staff to provide services for our elderly, mentally handicapped and sick people.
The Bill fails to tackle the problems facing community care and the Health Service. I hope that it is defeated and that the Government will tackle the problem by providing sufficient resources to deal with both issues.
§ Mr. Michael Latham (Rutland and Melton)
I shall not follow the terms of the speech of the hon. Member for Burnley (Mr. Pike) because I do not agree with what he said.
I apologise to the House for not being present to hear the speech of the Minister, but I was at the Public Accounts Committee. I am grateful to hon. Members in that regard.
The Bill and the proposals in it were not in our manifesto, so when they were first produced I thought it necessary to think carefully about them. Having done so and, as other hon. Members have done in their constituencies, having listened to GPs in my constituency, it is right to give my hon. Friends on the Front Bench and the Secretary of State the benefit of the doubt; I shall support the Bill tonight.
705 However, there is still some doubt, and I hope that in discussions inside and outside the House, and while the Bill is passing through the House, Ministers will listen to members of the profession and continue to discuss it with them. In answer to the hon. Member for Burnley, my hon. Friend the Member for Pembroke (Mr. Bennett) mentioned the limited list, which was an example of how Ministers acted properly. They discussed the proposal with the profession and allowed changes to the limited list, which was much more acceptable and is the way to proceed. I hope that the pilot schemes and the proposals for introducing hospital trusts carefully and deliberately will be followed by the Government.
I should like briefly to mention rural services, which are particularly important to me, as my hon. Friends on the Front Bench will know. Tomorrow, Leicestershire district health authority will visit the House to meet Leicestershire Members of Parliament. I have been dissatisfied with its policy of closing rural maternity units, which I regard as unacceptable, particularly as its chairman gave assurances that closures would not be allowed. He said that the Oakham maternity unit in my constituency would not be closed, but it closed last September. That was extremely regrettable because it deprived my constituents of a service that they regarded as extremely important.
The hon. Member for Burnley referred to the interaction of community care and the Bill. I take it as axiomatic—I assume that Ministers will confirm this—that there will be no question of closing down old geriatric hospitals until community care supportive welfare is in place. We simply cannot allow that to happen—[Interruption.] Hon. Members shout, but in the paper that we shall be discussing tomorrow, regarding the Catmose Vale hospital in my constituency, Leicestershire health authority says thatClosure … will follow the opening of the new buildingsof the Rutland Memorial hospital in 1990–91. I believe that that is the proper way to proceed. New buildings should be provided at one hospital, and then the buildings at the old one can be closed. I expect community support to be in place before decisions are taken, which is essential for elderly people.
I hope that Ministers have not closed their minds—originally it seemed that their minds were closed—to smaller hospitals being hospital trusts. The original intention undoubtedly was that district general hospitals should opt for the status of hospital trusts within the Health Service. I am concerned that smaller hospitals, particularly cottage hospitals in rural areas, may feel so threatened and isolated that they will want to set up their own trusts. I am sure that they would receive much local support for so doing, and I hope that that will not be ruled out by Ministers.
I should like some assurances about the rights of GPs under the new arrangements to be able to send their patients where they want. I was a little concerned by some replies that my hon. Friend the Minister for Health gave. I asked:to what extent … general practitioners who are not budget holders will be permitted to choose the hospital to which they send their patients for (a) non-emergency treatment on an in-patient basis and (b) maternity care, including the delivery of the baby".My hon. Friend replied: 706For all services, including non-emergency and maternity services, GPs should usually be able to choose the hospital that they consider most appropriate, taking account of their patients' needs and wishes. GPs who are not fund-holders will normally refer patients to hospitals with which the district health authority has placed contracts. In placing those contracts, the DHA will be expected to secure the referral patterns which local GPs wish to see put in place, unless there are compelling reasons for not doing so."—[Official Report, 28 November 1989; Vol. 162, c. 222.]I hope that that will be the proposal, because many excellent GP practices in my constituency will not be large enough to be budget holders. I should like them to have the right to send patients to local hospitals in Melton Mowbray and Oakham or across the border. I welcome this aspect of the Bill—to hospitals in Lincolnshire, Northamptonshire, the constituency of the Under-Secretary of State for Health, my hon. Friend the Member for Kettering (Mr. Freeman), or to Nottinghamshire if they believe that that is suitable for their patients. I hope that they will not be prevented from doing so but will be encouraged to do so because they are not large enough to be budget holders.
With those reservations—I shall watch carefully how the Bill proceeds in that regard—I wish my hon. Friends well and will support the Bill tonight.
§ Mr. Deputy Speaker (Mr. Harold Walker)
Order. I remind the House that earlier Mr. Speaker announced that he will impose the 10-minute limit on speeches between 6 o'clock and 8 o'clock.
§ Mr. Andrew Welsh (Angus, East)
I had hoped to address my remarks to Ministers at the Scottish Office, but none is present; indeed, I am the only Scottish Member present in the Chamber. Although they are not present, I hope that they will read Hansard tomorrow, because the Bill illustrates how inadequate the House is to deal with Scottish legislation. These are devolved matters that are very important to Scotland, yet the House is not capable of dealing with them properly. Fundamental changes affecting major Scottish institutions are being tagged on as afterthoughts to legislation for England and Wales. If ever there were perfect subjects for scrutiny by the Select Committee on Scotland, these are they. The House is in breach of its Standing Orders by not having a Scottish Select Committee.
As with Scottish education, the Bill, affecting the National Health Service in Scotland and our community care system, is being pushed through with minimum Scottish input and little or no time properly to debate its Scottish aspects. I should like to place on record my disgust and protest at this cavalier treatment of Scotland. No Scottish Government would ever allow it, and it is to the shame of this place that such circumstances should occur.
The Government are out of step with the majority of people in their treatment of the National Health Service. There is massive mistrust of the motives for the end product of the Governmnent's changes, and I certainly share those feelings. The National Health Service is not safe with the Government, and I fear that the concept of community care will suffer at their hands. Basically, we are being offered a managerial, cost accountancy solution which is inadequate to meet the health problems of the 707 decade that will take us into the 21st century. How do we cope with our increasingly aging population, which is estimated to be 1.1 million by the year 2001? How do we continue to shift resources towards health promotion and the prevention of illness? How do we ensure the supply of professional trained staff, both ancillary staff and those directly connected to health care?
I look for answers but the Bill does not supply them. Nowhere in the proposal do I see consideration of quality of care in medicine and health provision. There is plenty of emphasis on finance and some on technology, but where are the quality assurances? There are dangers of fragmentation of national health services and the creation of a divided, warring, competitive system driven by the profit motive and cost-cutting, rather than a national, comprehensive health care system that is available when and as needed by each individual. That is what we all have a right to expect and what we should be working towards. I do not want a system that pits doctors against patient or hospital against hospital.
The Government heard the united opposition of health care professionals and the general public, yet they have responded only reluctantly and in small measure to the range of thoughtful and considered responses to their NHS proposals. I am worried about the quality of care in the National Health Service and the community care system. The Scottish section of the White Paper dealing with community care is devoid of targets to be pursued. There are 10 references to discussion papers and guidance papers yet to be published, as well as matters which "require further consultation". This leaves a vagueness and tenuousness which all but obviates discussion on the Scottish aspects of the Bill. How can there be meaningful discussion or analysis when many fundamental matters are to be left to the diktat of the Minister?
This Scottish vagueness is in direct contrast to the Welsh section of the White Paper which details the existing situation and sets out targets and objectives for community care in Wales. Why are we not given similar provision by the Scottish Office? Will such information be produced and, if so, when? Scottish legislation is in enough of a shambles without adding these extra handicaps.
Despite the generally accepted underdevelopment, which even the Government have acknowledged, of community care in Scotland, the White Paper on which the Bill is based is weak and lacks a positive sense of direction. Since much is left to further consultation and guidance, how can there be effective debate on these issues without some flesh being placed on these bones? What is the Government's timetable for the 10 matters that require consultation in Scotland? Given their placing in the Bill, how can a full debate in Standing Committee be assured to deal with the Scottish clauses, some of which are very different from those applying to England and Wales? Given all that, are Scottish Office Ministers prepared to have joint meetings with repesentatives of the professional and voluntary organisations to discuss the details in the White Paper and the Bill, in view of the limited parliamentary time available for discussion? I should like them to take that on board. It is a matter of urgency for Scotland.
More generally, what will be the relationship between local authorities, the Government and private provision as part of an overall strategy for community care? In contrast to the Welsh and English position, there appears to have been little positive thought about an overall co-ordinated 708 approach or even specific goals or targets on housing. Scottish Homes does not even rate a mention in the White Paper—perhaps that is a statement of the Government's opinion of its usefulness regarding the provision of housing in Scotland. Why is there no reference to homelessness or to people with mental illness? The approach of the Scottish Office seems to be less adequate than the English one. I should like assurances that something will be done during the Bill's passage to remedy these defects.
In particular, why will not the Government provide proper income to carers? The bulk of caring in the community is met by informal carers, saving the Exchequer billions of pounds because of their work. The Government have failed to recognise that caring for a sick and sometimes terminally ill relative is a full-time job that puts tremendous strain on the carers. When carers cease their caring activities, they are not eligible for benefits in their own right. They have difficulty re-entering the labour market. The proposed review of disability benefits offers the Government the opportunity to provide support through the benefit system, for example, by providing training schemes for young carers. Those people should also he eligible for unemployment benefit.
Changes in the pattern of community care are likely to affect women disproportionately. There is a danger that many women will be trapped into providing care for relatives and become a support safety net. That problem must be urgently addressed. What action will the Government take to protect carers in the front line?
From statements made by Ministers earlier in the debate it could be thought that the NHS has few or no problems and that the Bill provides complete security for the NHS, its patients and work force. Like the majority of people, I have no confidence in the Government or in their approach to the NHS. The Bill is a trojan horse placed before the NHS. It is inadequate to meet the needs of proper health care. I hope that it will be strongly and unitedly opposed.
§ 6.5 pm
§ Mr. Michael Morris (Northampton, South)
Once again, it gives me no pleasure to voice deep concerns about proposed changes to the National Health Service. Once again, I declare a series of interests in that two of my immediate family are doctors and another is a physiotherapist. For all my working life before becoming a Member, I was associated with the pharmaceutical industry, and I advise two companies—Upjohn, and Reckitt and Colman. As my hon. Friend the Minister knows, I have served on the Public Accounts Committee for some 10 years and have asked a fair number of questions on the NHS.
I am the first to admit that changes in the NHS are necessary. A number of items in the Bill are right and should be supported, but—it is a big but—we all need to recognise that this is probably the most dramatic change that the NHS has faced since Aneurin Bevan set it up, based primarily on work done by a Conservative Member, Mr. Brown. Both sides can therefore take pride in the creation of the NHS.
The big difference between then and now is that the NHS had a long period of gestation. There was time to reflect and a groundswell of opinion in favour of the changes. If I felt that the preparation for the Bill had been 709 as thorough as the preparation for the NHS, I could readily support it. I am afraid that I do not. I have studied the Bill in considerable depth and, unfortunately, I feel that there is a degree of shallowness and unreality and a feeling of policy being made on the hoof. It is not good enough that the White Paper referred to GP budgets of £700,000, when it transpired following academic work that the figure was nearer £1.4 million. Now in column 513 of Hansard for Thursday last week we are told that the matter is to be negotiated. This is far too reminiscent of what happened over the limited list, where we started with 31 products on the list, but then the number increased to 156, and it started with a claimed saving of £125 million, but ended with a claimed saving of £75 million, as yet unsubstantiated.
The last thing that any Member should do is undertake ill-thought-out change. One need only look across the Atlantic to see what happens when one pushes through a Bill that is ill thought out in terms of health care. Two weeks ago in the United States, what was called the Catastrophic Health Act had to be repealed. It had been introduced to help the elderly, at their request, but it was found to have unrealistic time dimensions and budgets.
There are some real problems, which we must face. We cannot get away from the fact that the first problem is money. We need to recognise that we spend about 6.5 per cent. of gross national product on health, that the United States spends about 12 per cent. and that the rest of Europe spends about 8.5 per cent. Those figures are indicative of the problem. Those of us from the Oxford region who attended a presentation the week before last had it made clear to us that if in the past five years—and Oxford is allegedly the most efficient region in the country—we had had increases to meet the cost of inflation, we should have had an extra £35.3 million, which would have gone a long way in helping us to deal with problems such as the closure of wards.
If one plans to change the service radically, one must work with the people and with the grain. It is sad that last Thursday, my right hon. and learned Friend the Secretary of State said that waiting lists were a "badge of status" for consultants. They are not in Northampton or elsewhere.
One also has to think clearly about what overseas experience teaches us. Recently, I had the opportunity to go to the United States and to try to relate the proposals for hospital trusts with what has been done there. The American experience suggests that in a market-based system, hospitals and other providers react quickly to changed financial incentives and that contract specification is crucial. The Bill does not seem to anticipate that problem. The American evidence also suggests that providers will change methods of service delivery to maximise income and will engage in favourable selection of patients if there is freedom to do so. What are the safeguards to prevent that?
Quality of care in the United States is, to a great extent, dependent on elaborate arrangements for the external monitoring of quality. The Americans have peer review organisations and I do not know what we have to equal that. From the United States, one learns quickly that administrative costs spiral and we learn from previous announcements that administration costs may spiral here. 710 In the past 10 years, one of the areas that the Public Accounts Committee has challenged has been trying to bring down administrative costs.
The medical audit raises another problem. We all accept that it is a vital area, but I find that the Government have set aside only £1.25 million in the coming financial year, which is less than £100,000 a region. Every experience, not only in the United States, but on the continent, tells us that it is an expensive area. Yet we have not provided major financial resources. A paper by the Medical Audit Advisory Group suggests that teams of general practitioners will go round GP practices. Where are all the GPs who can be spared for the medical audit?
The hon. Member for Burnley (Mr. Pike) referred to the major problem of drug budgets. This is a real fudge issue. We already have the pharmaceutical pricing regulation scheme, prescribing analyses and costs—PACT—formularies, over-the-counter medicines, generic products and the limited list, yet on top of all that my right hon. and learned Friend the Secretary of State wants indicative drug budgets. Only 25 per cent. of GP practices are computerised, so the proposal will not work in the time scale that has been set.
It is also incumbent on the House to understand that, although drugs represent 10 per cent. of NHS cost and are highly visible, many modern medicines are preventive medicines and will stop people having to go to hospital. We also need to understand that the number of elderly people will increase. One can work out that there will be an extra 4 million scripts for people who are 60 to 65 now and another 4 million for those over 75. On top of that, there will be screening and public health programmes, so the number of scripts is bound to increase and the drugs bill will also increase. We need urgently clarification of one central point. How is it that there is a Treasury fixed budget in overall terms for drugs, yet there is to be no restriction on GPs through indicative budgets?
The pharmaceutical industry is important to this country. Such a strong, research-based industry, which makes an £850 million surplus for this country, should not be ignored or forgotten and we must recognise the importance of the new medicines that it has introduced.
I believe in the ethos of the NHS, in good management and in strategic objectives to meet proven needs, but we should cost what has been achieved, experiment, test the market and assess the results before making decisions. We should involve the whole team and work with them. We should look at the implications of the decisions on others who are friendly to the industry. We should learn from the experience of others and we should set realistic time dimensions and realistic targets. Sadly, the Bill tries to do too much in wholly unproven areas, with too few resources. Sadly, I shall not support it.
§ Mr. Joseph Ashton (Bassetlaw)
I shall confine my remarks to local issues, because of the 10-minute rule, and I hope that the House will bear with me. Bassetlaw health authority is one of the three smallest in the country. After great pressure from myself and others under the Labour Government, it was agreed to establish Bassetlaw health authority, although the population is just over 100,000 and the population in the average health authority is about 370,000.
711 When the Bill was announced, there were immediate cheers from my local Tory-controlled health authority, which offered to opt out not just the local hospital, but the entire authority. That decision was greeted with acclaim by the Minister and the Social Democrats. The health authority sent out a letter asking staff to give it full support and stating:The public opposition to our expression of interest has come so far, to the best of my knowledge, solely, from Minister Joe Ashton MP"—I assume that that meant Mr. Joe Ashton—who represents part of our Health District … and a relatively small number of Labour Party activists; and this opposition has been couched in party-political, ideological terms.The authority gave press releases and said that it hoped that most staff would strongly support the scheme from its introduction.
The authority spent a lot of money putting out the Update newspaper using money that should have been spent on health. The authority has been £1 million short of its budget for the past 12 months. The authority said that it would engage Price Waterhouse to investigate the method of setting up a trust and that staff at all levels should be prepared to support it. The authority aroused a great hoo-ha. It placed advertisements in local newspapers and spent a great deal of cash pushing the political idea of the whole health authority opting out.
The authority also said, which I welcomed, that there would be a public referendum after consulation next year. When that was announced, the Parliamentary Under-Secretary of State for Health began to have second thoughts. He visited the area, as did the Secretary of State. The one thing they did not want at any price was any form of public referendum. Public consultation was entirely against their policies.
While congratulations were levelled at the health authority, it suddenly had cold feet about the referendum. In June, the trumpets and fanfares were sounded. What happened last Friday? The local newspaper announced:NHS trust abandoned. Bassetlaw Health Authority has abandoned its plan to set up an NHS trust. The opt-out plan, which met with strong opposition in the area, is, announced the Authority yesterday, no longer an option being pursued".When these opt-outs are analysed and costed they may not turn out to be such a good thing after all.
The health authority maintains that it is going ahead with opting-out the hospital, but again with no mention of a referendum. The whole area has campaigned for many years, as have I, for a brand-new hospital. This is a mining area and we finally got the hospital, which the Government delayed for many years despite six visits by Ministers to the area, because, by an act of God, a miner was carried in on a stretcher, having broken his leg. Stinking, black and bleeding he was brought in from one of the many accidents in the pit and he had to be treated in a corridor in a collection of tin huts—that was what finally convinced Ministers that the need for our hospital should go to the top of the list, and we managed to get one built.
Now we discover that all our pressure does not matter. The people at the top will decide whether the hospital will opt out, not the people who use it, who campaigned for it and who paid their stamps every week for it. The people who will decide are those at the top who wanted to keep their good administrative jobs by opting out the small health authority.
712 The staff have been consulted, meaning that they were told of this at a mass meeting and asked whether they had any questions. Naturally, they did not want to jeopardise their jobs or to be awkward and shout their disagreement like Oliver Twist. They all want promotion, so they say nothing, enabling the people who held the meeting to claim that the staff agreed without complaint.
If there were a secret ballot it would be different. If a trade union wants a political fund it must hold a secret ballot of its members. If a council estate is to be sold off to, and run by, a private landlord the Government insist on a ballot, but hospital patients and visitors and people living in the area are not balloted on whether their hospital should opt out. The Secretary of State will not entertain that at any price.
Last week the National Union of Public Employees conducted an opinion poll in the east midlands in which 400 people canvassed 7,000 respondents. In that reliable survey 94 per cent. of those questioned said that there should be a ballot. They did not say that the hospital should not opt out, but they were in favour of a ballot. Many were Conservatives who had voted Conservative all their lives and who might even support much of this Bill, but they want a referendum before the hospital decides to opt out.
There has been much propaganda about how self-sufficient hospitals will be, but that will depend where they are. If a hospital is new and owns a lot of land, having bought an extra couple of fields paid for by the NHS, it will be able to survive the first few years by selling off surplus land, holding extra flag days and selling off ancillary services. Undertakers will set up in the foyer, flowers and food will be sold under franchise and people will be turned away and told that they should have gone private. Insurance may even be sold under franchise, and in that way the hospital will make a profit.
The Minister has assured staff that they have nothing to fear. They have everything to fear. They are assured that they will be guaranteed Whitley council wages and the same sort of pensions and holidays as they receive now, but that is nonsense. Once hospitals no longer have to pay regular wages they can pay the market rate. There is still 9 per cent. male unemployment in my area, despite all the part-time jobs in supermarkets that have been created. Hospitals will pay a damn sight less than they have to pay under the NHS.
I cite Mr. James Butler who held a top-level job as a commissioning officer in Bassetlaw hospital. He was made redundant in March last year and Bassetlaw health authority refused to give him an early pension even though it was guaranteed by the Whitley council and the Minister had said that he was entitled to it. God help him if he had not been in the union, which took the health authority to court. The authority took legal advice and then backed down because it realised that Mr. Butler, NUPE and the Minister were right—after having spent several thousand pounds on legal advice.
This shows that once a hospital has opted out under these provisions it will pay any wages and pensions that it likes, it will privatise what it likes, it will adjust holidays and it will destroy the long tradition of fair conditions. And staff will have no comeback. Hospitals that have opted out will be run as they used to be—on flag days. If they are hospitals in Bournemouth, where there is plenty of local cash and millionaire do-gooders abound, they will make money as they did in the 1930s. If they are in places 713 such as Barnsley and Bassetlaw, people will put 20p in the box—the hospitals will not be left big legacies in wills—and the hospitals will have to scratch around, send people where it is cheaper and turn them away, sometimes advising them to go private.
All these matters must be explained at length and in a democratic way to the people of the country, who must be given the chance to vote in a full referendum after extensive local discussions. I hope that the Minister will insert in the Bill a clause providing for referendums.
§ Mr. Jerry Hayes (Harlow)
I listened carefully to what the hon. Member for Bassetlaw (Mr. Ashton) had to say. I suspect that hon. Members on both sides were none the wiser having heard his speech because if the hon. Gentleman puts his hand on his heart he must admit that he has not read the White Paper or the working documents or the Bill; if he had, he would not have said what he did.
We are not talking about hospitals opting out of the Health Service; we are talking about self-governing National Health hospitals—[Interruption.] That is in the Bill. Why has the hon. Gentleman not read it?
Thank heavens, the electorate are rather forgiving. They can forgive us for messing around with their jobs and taxes and perhaps even for messing around with their rates, but they will not forgive us if we misinform them about their health and about what will happen to the health of their loved ones, the frail and the vulnerable. The BMA and the Opposition have done for the truth of the White Paper and the Bill what King Herod did for babysitting.
On 7 December the hon. Member for Livingston (Mr. Cook), the shadow Secretary of State for Health, made a speech which I should like to go through, analysing precisely what he said. I asked him whether he was going to commit his party to voting against medical audit, against money travelling with the patient and against resource management. All those points were medically led—they did not drip out of a back room of 10 Downing street or Richmond house. They were advanced by the medical profession and supported by it.
The hon. Member for Livingston replied:I am sorry to disappoint the hon. Gentleman. There is nothing in the Bill about a medical audit. If the hon. Gentleman is thinking of voting for the Bill because he supports the idea of a medical audit, I would … welcome his joining me in the Division Lobby".Of course the Bill does not mention medical audit; it does not mention resource management either—but these things are all in the White Paper. They are all in the working documents. So much has been written about it that I suspect that whole Amazonian rain forests have been destroyed.
§ Mr. Hayes
I expect nothing less from the hon. Gentleman.
The shadow health spokesman then referred to money travelling with patients. He said:Of course we do not oppose the idea of money following the patient. The question is whether the Bill does anything to provide for money following the patient.In other words, this is all about resources. If it was all about resources, the Government would have fudged it 714 long ago because we are spending 45 per cent. more now than in 1979. The difficulty is that we have a ridiculous state of affairs where there is no financial incentive for health authorities to reduce their waiting lists. In fact they are penalised. There is also no financial incentive for hospitals to treat more patients. At this time of the year, money runs out and beds and wards are closed.
§ Mr. Hayes
It is absolutely scandalous. Opposition Members do not accept that that scandal is finally being laid to rest. Money is travelling with the patient and there will be a financial incentive to reduce waiting lists and to keep beds open.
The Opposition claim that the amount of money involved is not mentioned in the Bill or in the White Paper. Of course, that is not mentioned there. It is a matter for the Autumn Statement. However, I can give the Opposition a clue. Believe it or not, a lot of people distrust politicians. They put us on the same level as journalists, estate agents and burglars. I want to remind the House of what Mr. John James, a senior civil servant, said to the National Association of Health Authorities. He made it clear that because of the system of money travelling with the patient, more money would have to flow into the Health Service. If hospitals and health authorities know precisely what their unit costs are and how much operations and treatment cost—which they do not know at the moment—they will be able to put in bids to the Treasury which would lead to more money coming into the Health Service.
The Bill is all about resources and the patient.
§ Mr. Hayes
I want to draw the attention of the House to other points made by the shadow health spokesman on 7 December. He said:The Bill does not extend choice to patients.He was making the same point as the hon. Member for Bassetlaw about self-governing trust hospitals. He wanted to know why we do not have a ballot and ask the patients, doctors, nurses and cleaners. How can we do that? We do not even do that under the present system when there is a proposal to close a hospital. In those circumstances, we consult the people in a proper and statutory fashion through the community health council involved. I believe that a ballot would divide communities and divert valuable resources and attention from patient care. [Interruption.] The hon. Member for Cardiff, South and Penarth (Mr. Michael) will say that I am shooting myself in the foot. How ridiculous. If we do not have a ballot or a referendum when a hospital closes, why should we not use the existing procedure which has worked perfectly for many years to express people's views?
§ Mr. Hayes
No, I want to make progress. The hon. Gentleman will have plenty of opportunities to hold himself spellbound in a few moments.
The shadow health spokesman also said:Under this Bill, the GP will not have the opportunity to send his patients to hospitals at which the district health authority does not have a contract."—[Official Report, 7 December 1989; Vol. 163, c. 518–20.]715 That is nonsense. It has been made absolutely clear that a special fund will be available for those referrals. Has the shadow health spokesman not read the Bill or the White Paper? Has he not seen the guidance from the Department of Health stating that referrals will be much the same as they are now? Of course he has not. Regrettably that is the mass deception by the Opposition, the BMA and others.
At last the BMA, the presidents of the royal colleges and the other caring professions accept 80 per cent. of the Government's proposals. Some Opposition Members say that the Health Service is just a wonderful quaint museum piece. They believe that we just have to pat it on the shoulder, patronise it and throw it a few more pounds and everything will be all right. Several thousand of my constituents have been waiting 24 months for elective surgery and they waited 12 months before that to see a consultant.
§ Mrs. Rosie Barnes (Greenwich)
The Bill has much to commend it, but much more to condemn and criticise. I want to discuss the provision for hospital services in some detail and, if time permits, I will refer briefly to general practitioners and community care.
The Secretary of State for Health must be congratulated on promoting a number of important initiatives within the hospital services—for example, the introduction of capital charging, the development of the resource management initiative and the empowering of the Audit Commission to scrutinise the NHS.
Those three moves should together encourage better financial management of the Health Service. Other welcome aspects include the differentiation between purchasers and providers of service which should clarify the responsibilities in planning and operations, the introduction of clinical audit which will form a better framework from which to assess the effectiveness of the service, the streamlining of district and regional health authorities and the full participation of executive directors which will enhance proper decision-making.
Why, if I find so much in the proposals to applaud, am I so adamantly opposed to them? First, the effectiveness of district health authorities will be seriously eroded by the operation of fund-holding general practitioner practices. It is ironic that after the Government have put so much effort into the development of the public health function within district health authorities over the past two years, they are about to undermine some of those achievements.
The public health departments have been developing two vital functions—they have become increasingly powerful in promoting good clinical practice and they have been acquiring the necessary expertise to anticipate and thus facilitate the timely provision of the services that people need.
I challenge the appropriateness of general practitioners making the market in hospital care. If it is to be made, let the patient do it and let the DHAs play a more pivotal role. 716 The error will be compounded by the limited authority that a DHA will be able to exercise over a National Health Service trust hospital.
A trust hospital may become a model of good practice. If it does, will the local DHA be able to afford comprehensive access to its services? Conversely, a trust might become a bastion of backward-looking practice Would a DHA then want access to its services?
It is far more likely that NHS trust hospitals will become more interested in the wider market at the expense of the local population. It is vital that a comprehensive definition of care services is incorporated in the Bill to safeguard the interests of local residents.
My third and very important point is that the Minister has failed satisfactorily to integrate the primary service provided by general practitioners and hospitals at local level. I urge him to consider that fundamental problem. District health trusts, as a sensible, comprehensive alternative to self-governing hospitals, would enable district health authorities to ensure that proper services were provided within their areas, and to plan strategically for all the local population. They would also facilitate smoother transition from one part of the service to another, and thus deal with a considerable flaw in the current proposals.
Fourthly, and critically, the Minister has failed to demonstrate any grasp of the dynamic relationship between quality, cost and timeliness. He talks glibly of raising the standards of all to the standard of the best, but fails to acknowledge that authorities have already been deciding on differing priorities for the best local use of scarce resources. We must ask the Minister to include absolute commitment to quality in the Bill, as well as clinical audit. Quality figures large in the White Paper but appears to be absent from the Bill, which is an unsatisfactory state of affairs. "Quality" must include adequate provision, accessibility and reasonable waiting times. While I am on the subject of quality, let me also ask the Government to make an unequivocal commitment to the work on "total quality" being carried out by the Kings Fund in its hospital accreditation programme.
The Minister is to be congratulated in part on the proposals for GPs, who will certainly be more accountable for the services that they provide. I doubt, however, whether the new contract arrangements imposed on them will resource them adequately for their new responsibilities. I have already spoken at length in the House on my misgivings about fund-holding GPs' practices in conjunction with NHS trust hospitals, and the unwelcome complication that financial considerations will introduce to the relationship between GPs and their patients.
Let me devote the remainder of my speech to the community care aspect of the Bill, which I think is long overdue and has tended to be ignored. Again, I must give credit where it is due: the Government must be congratulated on facilitating better differentiation between residential care, community or social care and the medical components of the service, while balancing that with a commitment to the joint working of all three. What is entirely unsatisfactory, however, is the lack of definition in the allocation of responsibilities.
We have two key anxieties. First, we fear that the Government will progressively make more demands on local authorities to fund local services directly—and, as we all know, the areas in greatest need are often those least able to afford such services. Secondly, the Government are 717 demonstrating an unnecessary bias against the direct provision of residential accommodation by local authorities. We support a mixed market; if the Government truly supported that, they would have the courage of their convictions and allow local authority provision to flourish where it is working.
Finally, let me make some general points covering all aspects of the Bill. First, I am concerned about the speed of change. The problems involved in this development are highly complex, not least in the way in which they are interrelated, but the targets are over-ambitious in their timing and owe more to party-politial considerations than to professionalism and concern for patients' well-being.
Secondly, I am worried about the lack of genuine choice. There has been some slight modification to the way in which patients may choose their GPs, but the rest follows automatically and they will have very little say. As the hon. Member for Livingston (Mr. Cook) said earlier in the debate, the patient follows the money rather the money following the patient; the patient travels with the money but the money does not travel with the patient, as Conservative Members claimed earlier this evening.
I am also very concerned about the lack of patients' rights. There are no tangible commitments or improvements, particularly as regards waiting time. I refer hon. Members to the amendment that I tabled, along with others, to the Health and Medicines Bill, proposing that statutory times should be laid down for treatment to be delivered, and for patients to exercise their right to go elsewhere if their own health authority could not deliver that treatment. If that provision were in the Bill the money would truly follow the patients, and they would have more control over their share of the Health Service's money.
Resourcing is a major problem. The Government's achievements in that respect—as we hear week after week from the Dispatch Box—cannot be ignored or denied, but in return they must acknowledge that genuine need continues to outstrip their commitment to provide, especially in view of the aging population and the increasingly technological service that is now available across the board. In particular, the Minister must acknowledge that the great majority of the development moneys that he gave the NHS recently will be absorbed by inflation and the financing of existing workloads.
I agree that the NHS requires organisational development to promote changes in its management and clinical practices, but I am concerned that the Government have responded by foisting on the service their uniform precription for the public sector: it is inadequate, it is dangerous and, in its present form, it must be rejected.
§ Mr. Michael Irvine (Ispwich)
Scaremongering and distortion have been the characteristics of the campaign against the Government's plans for reforming the National Health Service. I am afraid that both have been very much in evidence in many Labour speeches in this debate.
Another feature of the opposition to the proposals for reform, and to the Bill, has been the almost unremittingly negative character of the criticisms that have been made. It seems that the only answer to the problems of the National Health Service from Labour Members and 718 others who campaign against the Government's proposals is a call for more resources. They are on dangerous ground there, because the record shows that, far from being a poor provider of resources, the Government have been a very good provider. My hon. Friend the Member for Harlow (Mr. Hayes) produced the acid figure: a real-terms spending increase of 45 per cent. since the Government came to power in 1979. Such a figure really stands up to examination; it shows the merit of the Government's health policy, and their ability to provide the necessary resources.
It is not just a matter of resources, however. The key question is how we apply those resources. The great weakness in the present structure of the NHS is that it simply does not give sufficient account to cost. It does not reward efficiency; all too often indeed it stifles and suffocates good management. Several Conservative Members have given examples of how, time and again—especially at this time of year—hospital beds are left empty and operating facilities left unused.
Why does that happen? Sometimes, but not always, it is due to bad management. Sometimes, however, it is the hospitals that have been particularly efficient, have maintained a good patient throughput and carried out more than their fair share of operations that run short of resources. The proposals for self-governing hospitals are directed towards remedying that fundamental flaw in the system. The managers of self-governing hospitals will be free to manage. They will be free to attract to the National Health Service those staff for whom there is a particular need. They will be free to provide incentives to overcome shortages. They will be able to make their hospitals more efficient, to make the administration more flexible and to make their hospitals more responsive to patients' wishes and better able to provide a better quality of patient care.
That new freedom for management will have an additional effect. It will make it more likely that higher-calibre managers will be attracted into the National Health Service—
§ Mr. McCartney
Will the hon. Gentleman explain the new freedom for managers? I refer to the Atherleigh hospital near my constituency, which cares for the elderly confused and those with senile dementia. Because of the shortfall in his budget, the district general manager gave 24 hours' notice to the community health council that he was closing the hospital and moving out as many patients as possible to the private sector. That was done without consultation with patients' representatives, their families or the community health council. Is that the type of management decision that will be taken because of unit costs and the need for local decision-making at Health Service district management level?
§ Mr Irvine
I shall not follow the hon. Gentleman down that rather dangerous road into a precise problem affecting his constituency. However, perhaps the problem that he has identified shows that at the moment the National Health Service is not working as effectively as it should.
There is one element of the criticisms that have been made about self-governing hospitals of which the Government should take careful note. An effective point was put to me by hospital doctors and consultants in my constituency when I met them. It is that there is some risk that self-governing hospitals may be tempted to skimp on medical training and education. I have in mind the 719 education and training not only of doctors and consultants, but of radiographers, technicians, nurses and others. There is also a risk that self-governing hospitals might be tempted to skimp on research and development. There is just an element of risk that some self-governing hospitals might not provide the resources that they should in those directions. We need to guard against that risk. Therefore, I was glad to hear my right hon. and learned Friend the Secretary of State for Health say on Thursday that he will indeed be on guard against that risk, that there are powers in the Bill to enable him to intervene if he feels that that is the case in any particular self-governing hospital and that he will stand ready to use those powers.
Basically, I have no doubt that self-governing hospitals are an excellent idea. We should remember that they are optional. No hospital will be forced to become self governing against its will. Why then is there such hostility to the idea? I suspect that much of the opposition to self-governing hospitals is based on the fear that they will be successful and show up those hospitals that are badly administered and not up to standard. Self-governing hospitals will set a standard by which others are judged. That point is at the heart of much of the fear about self-governing hospitals and of the hysterical campaign that has been mounted against them.
If there has been scaremongering and distortion about self-governing hospitals, there has also been quite a bit of the same about indicative drug budgets. For the vast majority of responsible and able doctors who prescribe sensibly and effectively and who have a proper regard for costs, indicative drug budgets hold no fears. The budgets are directed against the minority of doctors who prescribe wastefully. They are directed against those who prescribe Valium as if it were bubble gum and who do not have a proper regard for costs. If good doctors who prescribe carefully overrun their budgets, they will be able to justify that overrun by referring to special aspects of their practice affecting their need to prescribe. It will be the small minority of wasteful doctors who have no regard for costs who will be caught out.
I am glad that the principle of the proper allocation of resources will characterise the new framework for community care. The great dangers to effective community care services are duplication, lack of co-ordination, overlap and fragmentation. By providing clear lines of accountability and care packages for individual patients, the Griffiths proposals will do a lot to overcome that risk. They will help to reduce waste and will save resources. Those resources will be needed because there is no doubt that community care will be expensive in the coming years, partly because of demography and the increase in the age of the population but also because the increased efficiency of the National Health Service, which I believe will result from these proposals, will place greater demands on community care. More operations will be carried out and people will be discharged from hospital at an earlier stage of their treatment. That in turn will place greater burdens on community care services.
In my constituency of Ipswich much strain has been placed on the home help service, not because of any reduction in the amount of money being devoted to the home help service, but because people are being discharger from hospital at an earlier stage of their treatment. This means that personal care from the home help service is 720 becoming increasingly in demand. As a result, strains are building up on the home help service. However, by providing a more efficient framework—
§ Mr. Deputy Speaker (Sir Paul Dean)
Order. I am sorry to interrupt the hon. Gentleman, but he has overrun his time. I call Mr. Bradley.
§ Mr. Keith Bradley (Manchester, Withington)
I thank you for calling me to speak in the debate, Mr. Deputy Speaker, because this issue is of immense importance to my constituents. Indeed, no more important area of concern has been expressed in correspondence from consultants, doctors, and the general public than the reform of the National Health Service.
We cannot discuss the Bill without considering resource allocations—on which the Bill is silent. Whether we are talking about hospital services, community services or general practitioner services, the Government's proposals are silent on the need for extra resources. Ministers trot out figures time and again about the extra money that is spent on the Health Service, but they never put that in the context of the extra demands for health care, the growing numbers of elderly people who need health care and the new technologies that increase the cost of health care.
We should consider the Bill in the light of what is found in individual health authorities, such as my own in south Manchester. It has been suffering from a financial crisis for many years and, despite all the cost improvement programmes that it has implemented, it is now £1.5 million short in its budget for this financial year. The health authority has therefore had to freeze vacancies, and 120 posts in the provision of health care have been lost this year.
Despite repeated representations to the Secretary of State for Health for more resources for south Manchester, he has refused to entertain our request. The latest letter that we have received from him shows his thinking on how that financial crisis has arisen. He says:I do not know whether the clinical regrading costs arise from previous errors in the original gradings or over-generous findings on appeal.The Secretary of State says that one reason for the problem is that south Manchester health authority, when it was assessing the grade of staff in the nursing service, was overgenerous, and gave them more money than it should have. That is the sort of Secretary of State we have; that is how he considers the needs of our staff.
What is the health authority now doing to save money because of the financial crisis? It has published a consultation document on rationalisation of the service. That means further cuts in service. The document does not identify how much money it intends to save or give the figures. We can be sure that two things will be lost in south Manchester: the accident and emergency department at Wythenshawe hospital will be closed for major accidents and transferred to Withington—Wythenshawe is next to Manchester airport, but it will not have a major accident service—and Withington hospital maternity unit will be closed, with all mothers transferred to Wythenshawe. What patient choice does that mean?
Let us consider the Second Reading debate to date. When asked about obstetric services, the Secretary of State said:The other day, it was hinted that expectant mothers may lose local obstetric services because of our proposals. That is721nonsense. No right hon. or hon. Member would suggest any of that rubbish."—[Official Report, 7 November 1989; Vol. 163, c. 503.]South Manchester is having to close maternity services to save money. Can we believe the Secretary of State's statements about the Bill?
I have the unhappy task of trying to defend one of the hospitals that is on the Government's long shortlist for opting out—Christie hospital in south Manchester.
The Secretary of State justified opting out, saying that it will free nurses and doctors who have been frustrated by the constraints of bureaucracy for years, and will allow them to use their abilities and to work as they wish. When I asked doctors, consultants and nurses why they had expressed an interest in opting out, they identified one reason—lack of cash. They are heartily sick of a Health Service in which they cannot provide care to the number of patients they want because they are short of resources. That is the only reason why they have expressed an interest in opting out. They do not want to go down that road, but they want to get more money out of the Government. They are appalled that the regional health authority is bringing in extra staff to develop plans for opting out when there is a freeze on nurses' jobs in the hospital. There is a freeze on nursing staff, but more accountants can come into the Health Service. That shows the strength of the Government's commitment.
A meeting of 185 local doctors in Manchester and of the local medical committee passed a resolution that was in absolute opposition to the Government's plans for GP services. GPs are fearful, regardless of the assurances given by the Secretary of State, about what cash-limited budgets will mean for the service delivered. As my hon. Friend the Member for Burnley (Mr. Pike) said, what is happening to the social fund is a good example.
Last weekend a constituent came to me because she had been refused a community care grant. She was told that there was no money left in the budget. After further investigation, I found out that the Department of Social Security is having to reassess priorities within the budget, because the cash is running out rapidly. If my constituent had gone to the DSS earlier in the year, she would have got a grant, but at this stage, because of the change in priorities, she will not. GPs fear that the same thing will happen with their practice budgets. They may be able to prescribe a particular treatment for one patient at the beginning of the year, but when money is getting short they may have to prescribe another treatment for a similar patient later in the year.
General practitioners are worried that they will not have the capital that they need to develop their clinics and practices to meet the demands of the extra treatment that they will have to undertake.
In my area of Chorlton, the local health centre is already bursting at the seams. There is no room for a typewriter let alone a computer to undertake the administration that will be imposed by the Bill.
General practitioners are anxious because they already face restrictions on where they can send patients. Last week they received a letter from the regional health authority which said that, because of financial and manpower resources constraints, neurosurgery would be 722 limited to which hospital a particular doctor in a particular area could send his patients. We already have restrictions on patient choice, and the Bill will make that worse.
Finally, GPs are concerned that waiting lists will be transferred from the hospital to the GP's practice. GPs will have to determine where to send patients, but the amount allowed for under the contract with a particular hospital for a range of services may have run out. The waiting list will be at the GP's door, not at the hospital's door.
Our opposition to the Bill is summed up best by a letter that I received from a constituent. He clearly reflects the Labour party's view when he says:I am an ordinary citizen, with a wife, three young children, and elderly parents. We all have cause to be thankful that our GPs have given us the best treatment they could provide to meet our needs, rather than the best treatment they could offer within the limits of their local budgets. And they have referred us to hospitals near our homes which provided services the population needed, rather than those which managers decided they could market efficiently. I would like it to stay that way, and if that means I must pay more in tax, I will pay more in tax. I have never before written to make my feelings known to a Member of Parliament. That I do so now is a measure of my profound opposition to the Government's proposals.That letter is one of thousands that I have received. The people of Manchester and the other people of Britain will totally oppose the Bill.
§ 7.7 pm
§ Miss Ann Widdecombe (Maidstone)
I am grateful for the opportunity to speak in this debate because I am grateful for the Bill. It will herald a new era for the National Health Service and will turn it into the thriving, expanding concern that is should be.
My constituents will benefit substantially from the proposals for self-governing hospitals. They will also benefit substantially from the greater flexibility in referral patterns, and the greater knowledge that will be available to doctors about where waiting lists are shortest.
It is a matter of considerable regret to me that my constituents, in particular the elderly, the sick and the vulnerable, should have been frightened and misled by the utterly irresponsible campaign waged by the British Medical Association.
An example of the way that my constituents have been frightened is that sick and elderly people have been literally shaking with fear when they come to my surgery. They told me that they would not be able to get medicine because their doctors would no longer be allowed to prescribe it when it became too expensive.
The Secretary of State said, from the outset, that indicative budgets would not be cash limited. On the basis of those assurances, which he gave time and time again, I was able to circulate a leaflet to all my constituents, telling them that there was no truth in the BMA's claims.
Several months later, when the BMA realised that it could not sustain its lies any longer, it said that the Secretary of State had done a U-turn, and had now said that indicative budgets would not be cash limited. That leaves us with three possible options. First, that the BMA simply did not understand what the Secretary of State was saying right at the beginning, and genuinely did not realise that drug budgets would not be cash limited. If that is the case, it is too stupid to represent a highly-educated profession. Secondly, it is possible that the BMA understood perfectly but chose to ignore it, and pushed it to one side. In that case, it is too irresponsible to represent a highly-respected profession. The third option is that the 723 BMA understood, did not ignore it, but thought that it would be effective if it could frighten people, so deliberately deceived the elderly, sick and vulnerable into believing that drug budgets would be cash limited. If it did that, it is too thoroughly dishonest to represent any profession which acted more like trade union bully boys than a group of respectable professionals.
I am not surprised that two of the most respected local consultants in my constituency have resigned from the BMA and I am not surprised when local doctors tell me that they believe the BMA's campaign has been wholly unjustified. I think that, as the public realise that the BMA has misled them about indicative drug budgets, about the effects of opting out and about the effects of independent budget holding, the professional relationship between doctor and patient will be damaged far more than by anything that the Government are proposing.
If the BMA wants to hold the confidence of the public, it should start to tell the truth pretty soon. I am delighted to have the Opposition Front Bench's confirmation that drug budgets will not be cash limited.
Meanwhile, my constituents can be assured that they will benefit from the fact that, if Maidstone hospital chooses to become self-governing—I do not know whether it will—it will be able to fix pay and conditions there. One of the biggest problems that we have in the south-east is recruitment. Flexibility on pay and conditions will make it much simpler to cope with that problem.
If there is one thing that I regret about the White Paper it is that it did not seize the opportunity to hold all consultant contracts at district rather than regional health authority level. It does not allow even self-governing hospitals to take on existing contracts rather than just new ones. For a self-governing hospital to be truly effective, it must have complete flexibility over who it employs, and consultants are obviously a key to the services that a hospital provides.
We in Maidstone are efficient. Every year we have an enormously ambitious budget, and every year we comfortably exceed our activity levels. In future, with money following the patient, that will not lead to our being confronted with budget problems at the end of the year. We shall no longer be penalised for being efficient. I believe that the people of Maidstone will benefit greatly from the Bill.
When I first came to the House, many constituents came to me complaining that they had been on waiting lists for too long and asking me whether they could go anywhere else to get operations done more quickly. Although I willingly took it on, it did not seem my role as a Member of Parliament to shop around the country on behalf of my constituents, so it is much to be welcomed that the technology which is to be made available will enable doctors to get speedy and efficient information on where there are shorter waiting lists. They will be able to give their patients a better service, and patients will not have to ask their Member of Parliament to do the shopping around for them. That will be an enormous plus.
For all those reasons, I believe that the Bill is one of the best things that has happened for Britain, especially for my constituents. What I regret most is the party politicisation of a major asset such as the NHS. Opposition Members should join us to make these proposals work so that we can guarantee the future of the service.
§ Mrs. Alice Mahon (Halifax)
It is party political when the district health authority confronts massive cuts every year. This year, my local authority faces yet another £500,000 cut. How can the hon. Lady think that that is not a political issue? People on waiting lists in my constituency think that it is political, and blame the hon. Lady's party.
§ Miss Widdecombe
The hon. Lady should be honest enough to tell her constituents that my party is not to blame, and that the problem is a thoroughly overburdened system that will be much relieved by these reforms. Precisely because we have such problems, we should pull together to make the reforms work. Subject to refinements of detail, which I think necessary, particularly in regard to referral patterns, these reforms provide a basis for the future. They should not have become the object of party politics. They should be the object of a good, thorough, thriving, expanding, researching, developing and serving British health service for a century to come.
§ Dr. Kim Howells (Pontypridd)
The National Health Service is not above criticism. It is not an untouchable monument. Indeed, it is no more unassailable than the former Chancellor of the Exchequer was.
The NHS has been scarred by many shortcomings in many of its facets, whether lengthy waiting lists, miserable waiting rooms or a minority of consultants and registrars who seem to belong to a James Robertson Justice' impersonators' club treating patients with all the sensitivity and delicacy of a vet treating sheep for wind.
Likewise, the managers of the NHS, like any management of a large high-spending organisation, need constant monitoring. I do not argue with any of that. Whatever its faults, however, the NHS was recognised as being infinitely preferable to the private service and panel systems which it replaced in the late 1940s. Indeed, it became during subsequent decades the most public image of governments and societies which viewed the health of the nation as a matter not to be determined by the vagaries of personal wealth or the market.
During the past 40 years, the British people have come to regard the NHS almost as a birthright—the right of access to the best health care that can be provided, regardless of personal or corporate wealth. Most of us have moaned and groaned about the Health Service, but most of us are also inordinately proud and fond of it.
That is why, it seems to me, the British people have reacted with such vehemence and distaste to key aspects of the Government's proposals. They regard the Health Service—general practitioners, practices, local hospitals and the long-term care facilities for the chronically sick and infirm—as a keystone in the structure of their communities. They do not want that keystone to be loosened. They do not want their elderly and very young to be hawked around in search of health care as their young are now being made to hawk themselves around in search of jobs in a metropolis such as this. They do not believe that health is a marketable product, but the Government do.
The proof is in the Bill, or rather it is evident in what is not in the Bill. It is evident in the lack of explanation of what is to happen to those vital elements of NHS provision which relate to care of the chronically ill, the elderly and the mentally ill and to those areas of the NHS which cannot be milked for a fast buck.
725 The Bill smells of the same oily rag which the Government have used to clear the decks for the privatisation of other public services. The people know that smell, and it angers them. They want to know why the Bill does not concern itself with resolving the many problems that beset the NHS. The Bill will solve none of those problems. It has been drafted by a Government who are deaf to the huge sigh of protest and concern that has greeted it. The Bill is an abrogation of responsibility. It is drafted by a Government who are drunk on bootleg privatisation. I rejoice in the knowledge that that deafness and this ideological drunkenness will drag the Government to a well-deserved resting place at some miserable footnote on a page of history that most of us would have much preferred never to have read.
§ Dr. Charles Goodson-Wickes (Wimbledon)
I have hitherto been reluctant to speak on the Government's proposals for the reform of the National Health Service. There are times when one is almost too close to an issue, caught between one's profession and one's political colleagues. Since becoming a medical student some 25 years ago, I have had more than a passing experience of the great matters involved, and I am grateful for the opportunity to comment on some of them today.
St. Bartholomew's, where I trained, is arguably the oldest London teaching hospital as it was founded in 1123. St. Bartholomew's hospital has continuously adapted and developed for the past 866 years. It strikes me as peculiar in the extreme to assume that, after a mere 41 years, the National Health Service is incapable of modification and improvement. Indeed, any suggestion of change is interpreted in some quarters as an attack on the whole concept of the NHS.
It was with distinct unease that I watched the posturing and skirmishes of the past few months. I imply a degree of blame on the Government, the Opposition and the British Medical Association respectively. I am utterly convinced that my right hon. and learned Friend the Secretary of State was right to extend to the NHS the challenge presented to so many of the institutions and vested interests in our society. We have tackled the City, trade unions, the teaching profession and the legal system. We have made them justify their practices or abandon them—all this in the interests of the consumer. Why should the medical profession be immune?
As a practising physician and a non-practising barrister I suppose that I have cause to feel singled out for persecution. I make no complaint about that, but it was as a member of a trade union—the BMA—that I felt most uncomfortable. It was with astonishment and sadness that I saw the discredited techniques of old-style trade unionism adopted by a professional body. I cannot believe that ultimately it was in the interest of anyone to frighten vulnerable people in surgeries across the country with alarmist and mischievous literature. From sheer misinformation to merely putting the worst possible construction on virtually all the proposals in "Working for Patients", the BMA let itself down. However, I have had a series of civilised and constructive meetings with the chairman of the BMA council and his senior colleagues. We all agreed that it was time that peace broke out.
726 In extensive consultations with general practitioners and hospital doctors in my constituency anxieties have been aired and misunderstandings ironed out. I welcome the Government's flexible reaction to various practical objections which proved valid. Nothing is more unsettling than uncertainty. The sooner that we move on the better.
The latest BMA literature uses the recurring theme of "risk of failure", a phrase which is hardly indicative of enlightened and optimistic thinking for the future. If the Government had baulked at the formidable range of problems presented to them during the past decade because of the risk of failure, their achievements would have been minimal.
I have worked as a hospital doctor in various parts of the country. Despite believing that NHS treatment is the best in the world from a professional point of view, I recoil with horror at memories of queues of out-patients where tens of people were given identical appointment times. They waited phlegmatically and passively in outdated and uncomfortable hospital buildings that were either too hot or too cold. I recall the impersonal, condescending and sometimes almost patronising attitude of administrators, doctors, clerks and technicians. I remember the wastage of materials and time. I remember the blunderbuss ordering of expensive, poorly directed investigations into problems and the haphazard methods by which patients were called forward for admission. In out-patient departments people traipsed from the examination cubicle to further waits outside the X-ray department or blood laboratory and so on. It would be a rash person who, including travel by public transport, assumed that the whole process would take less than half a day. What happened next? They were told to come back in a week's time. They were extremely lucky to see the same doctor. Results were often delayed or mislaid or fell foul of technical problems and tests would have to be repeated.
§ Dr. Goodson-Wickes
No, I shall not give way because of the time limit.
I make no apology for putting over that litany. I do not say that that position was universal, but in every constituency one could still walk into an out-patient department and see a picture similar to the one that I have painted. The medical treatment may have been excellent, but did the patient come away feeling that he had been served by the National Health Service?
In the first day of this debate, my right hon. and learned Friend the Secretary of State said:Patients also tolerate variations in the times for which they must wait for treatment, and … facilities".—[Official Report, 7 December 1989; Vol. 163, c. 500.]He will agree with me that in the 1990s the time for tolerating inadequate services is over. His enlightened proposals should increase the pace of change for the better. Administrators and doctors should no longer communicate badly with each other, and with nurses, physiotherapists and technicians and all the people who make the management of a hospital possible. Good management and good morale follow each other inseparably.
So much for personal accountability. What about financial accountability? A whole generation of doctors, patients and politicians have grown up knowing nothing other than the welfare state and the NHS. It may be free 727 at the point of delivery and financed mainly out of general taxation, but who knows the cost of anything? Only relatively recently have the best GPs become conscious of the cost of drugs, dressings and so on. How many know the cost of operations in the local hospital? More importantly perhaps, do the hospitals themselves know the cost of the operations carried out in them? Do they ever question the bed-stay times in different hospitals for identical operations, or, indeed, the waiting lists in different hospitals where the same surgeon operates? It is hardly surprisng that doctors have been labelled bad managers when they lack the data on which to make decisions and thus the opportunity to debunk that fallacy.
We know the argument that medicine cannot be equated with a production line. However, the NHS cannot be regarded as immune from normal financial pressures. There is nothing paradoxical about a service run on prudent and businesslike lines. For far too long, this Government as well as their predecessors have chucked money at problems instead of solving them—a palliative if ever there was one. If each family had been asked to write a cheque for £35 each week of the year, specifically for the NHS, I suspect that minds would have been concentrated earlier.
I commend wholeheartedly the combination of GP practice budgets, now called practice funds, and self-governing hospitals, now called NHS hospital trusts. I believe that each will play a part in increasing choice, efficiency and accountability linked to a developing internal market. I also hope that the new term "self-governing hospitals" will lay to rest the label "opting out" which is used with great effect but a lack of honesty by the Opposition. The Opposition's representation of self-governing hospitals has resulted in many people needing to be convinced that, far from opting out, NHS hospitals will opt in to a new standard of excellence in a service held in such great affection by the British people.
I entirely endorse my right hon. Friend the Prime Minister's statement that the NHS should be so good that no one will want to go to the private sector. I say that as a practising physician in the private sector— [Interruption.]—no member of whose family has ever been treated other than in the NHS. My wife, my two sons and I have all been in-patients in the NHS during the past 10 years and have much admired the treatment that we were given.
I welcome the biggest ever increase in the health budget announced in the Autumn Statement. Extra resources will go towards provision of new consultant posts, proper audits for managers, improved information technology and medical audits. Now at last Britain's biggest enterprise will have the opportunity to move away from charity, paternalism and rationing as we prepare for the next century in a time of great demographic and technological change.
The ultimate test for the efficacy of the Government's proposals will be whether the changes are perceived to be for the better by the only person who matters—the patient. I am confident that owing to my right hon. and learned Friend's persistence—
§ Mr. Deputy Speaker
Order. I am sorry to interrupt the hon. Gentleman, but he has overrun his time.
§ Mr. Tom Pendry (Stalybridge and Hyde)
I do not wish to follow the arguments of the hon. Member for Wimbledon (Dr. Goodson-Wickes) or those deployed by the hon. Member for Harlow (Mr. Hayes), whose contribution was a sharp reminder to us all that the pantomime season is upon us.
My hon. Friends and I could talk at great length about the deep resentment of our constituents—doctors, nurses, ancillary workers, patients and would-be patients—about the monstrous proposals in the Bill, but, because of the restriction on time, I shall confine my remarks to part III which relates to community care.
Many hon. Members said that the Secretary of State for Scotland did not mention the Bill when he introduced the debate. If hon. Members look at Hansard tomorrow, they will see that the words "community care" did not pass his lips. At least I can agree on one aspect of the Government's approach. Despite the shilly-shallying following the Griffiths report, they took notice of the advice of those consulted and agreed to let local authorities take charge of community care. That is where my appreciation ends. It is unfortunate and arouses much suspicion that the Government do not seem prepared to give the community care part of the Bill much debating time. That has been amply demonstrated.
Since the Bill was produced only five working days after the White Paper was published, there has been no time for consultation. If hon. Gentlemen wish confirmation of that, they should look at their postbags today. They will find that many organisations have submitted views on the White Paper and the Bill, but they are too late for inclusion in this debate.
Community care is of particular concern. As the House is aware, there are already some 6 million disabled people with about the same number of unpaid carers. By the year 2001, the number of people aged 65 and over will have reached 9 million, 1.15 million of whom will be over 85. The Bill in no way addresses itself to the magnitude of that problem.
The Government may well have appointed local authorities to play a leading role in community care, but as usual they are unwilling to provide the resources that are essential for the system to function properly. The Bill is insubstantial. It needs to spell out clearly what is expected of local authorities which are undergoing ever-increasing demand on their ever-decreasing resources. The rhetoric of the White Paper has not been translated by the Bill into definitive proposals for action.
To arrange, organise and devise the necessary services is a mammoth task which has huge resource implications. Again, the legislation lacks detail. How much cash will be available is open to speculation, as we know from arguments already made. By channelling money through the revenue support grant, there is every likelihood that some of it will be diverted into other urgent projects, and we cannot blame local authorities for doing so.
In order to force local authorities to put their elderly people's homes up for sale, or, as the Government put it, to give themevery incentive to make use of the independent sector",the funding policy of the legislation deliberately discriminates in favour of private residential care at the expense of public provision. Clearly, that enables the Government to deny that they are introducing compulsory 729 privatisation of care, while effectively doing so for all but the severest of cases. As the House knows, the tendering is to be policed by the Secretary of State for Health who will "issue direction" and "give guidance", whatever that means, to authorities that do not seem to be doing their utmost to stimulate privatisation.
Will the Minister for Health spell out what powers she intends to take to ensure that local authorities comply with community care plans? How is it possible for local authorities to balance this form of compulsory tendering to the private sector with the requirement to retain facilities where needed? Obviously, the Government have in mind commercially unattractive areas of the market with what they term "challenging patterns of behaviour", which the private sector will not touch with a barge pole.
Private sector homes will probably concentrate their efforts on the 40 per cent. of the elderly who do not need financial assistance from the state. Others will be cared for in the community—or so the Government envisage. The White Paper called on local authorities to support unpaid carers, yet the Bill does not provide the means for them to do so. By encouraging private sector service provision, the Government believe that that vulnerable sector of society will benefit from the increase in choice, but, as with so many of the Government's ideas, that so-called choice exists only for those who can afford it.
How can the provision of home helps be both good business for the private sector and yet affordable to the average pensioner, without there being a lowering of carers' working conditions and wages? Why should the elderly and disabled be subjected to the risk of corner cutting and slipshod standards, which will almost certainly arise from accepting the lowest bids for private sector services?
he legislation seeks to encourage the voluntary sector to play an even greater role in care provision, while failing yet again to provide the resources needed to fund such a change. I have discussed the Bill's proposals with many national and voluntary organisations, of which Crossroads is the largest. It provides direct services to the disabled and to informal carers and families in their homes.
Crossroads can give voluntary help to 12,000 families, but it already has 7,000 on its waiting list. It has told me that it fears that funding will be insufficient to fulfil all the unmet needs that already exist in our constituencies and that voluntary funding is not a realistic option. It raises as many funds as possible, but it cannot possibly be expected to meet all the cost by voluntary donation. Many depend on joint finance and are worried that local authorities will not pick up the bill, should joint finance come to an end, as the legislation implies.
Crossroads has monitored a marked tendency among local authorities to focus dwindling resources on the highly dependent. If the legislation is implemented, even greater numbers of such people will be dependent on community care and local authorities will be forced to prioritise even further. Naturally, they will focus on the most dependent. That will leave carers, already a low priority group, even further out on a limb, increasingly burdened and possibly receiving poor standards of help.
My local borough of Tameside has informed me that it may well prove difficult to develop the voluntary sector as 730 the Government want. Despite good contacts with Age Concern and other organisations, a common voice is lacking and there is little tradition of these groups working together.
The Bill is a direct attack on the quality of life of many women in society, as women make up the vast majority of paid and unpaid carers. The provision on contracting out community care poses a threat to many jobs, especially among members of my sponsoring union NUPE. Those who manage to keep their jobs are likely to see pay and conditions deteriorate under the private sector. The legislation will lead to yet more women taking on the role of unpaid carer while receiving no extra financial help, at a time when the poll tax will add yet another heavy burden to their daily lives.
This commercialisation of community care has been described as a "charter for despair". How true that description is. It is hardly surprising, knowing the Government's record, that the old, the disabled and the mentally handicapped now have cause to feel as though they have a shelf life rather than that they deserve a life which can be both longer and of greater quality.
§ Mr. Kenneth Hind (Lancashire, West)
As my right hon. Friends have recognised, the National Health Service is not a sacred cow that is incapable of reform. The 1987 Conservative manifesto suggested reforms. Now we face the reality of the considerations to change and improve it. The emphasis is on patient care. The Bill is about improving the standards of care for patients. If we look at the Bill from that point of view, we are looking at the driving force behind it.
The new system is patient-led. It is based on demand and the needs of the patient. The money will follow the patient. We have tackled the problems connected with waiting lists and the closure of wards. Nobody has considered in the past where the demand really lies. With money following the patient, it will be made available where that demand exists. The demand is for hip replacements and cataract operations. They are among many of the items towards which Ministers have directed their waiting list initiative.
There was a real need to tackle the problems in the National Health Service. Two years ago there were articles in the press and letters from our constituents suggesting that the NHS needed to be reformed. We have now devised a solution. It may not be acceptable to the Opposition, for the simple reason that we have not followed the old formula of throwing money at the problem and hoping that money will solve it. Money has to be adequately and efficiently spent if we are to provide maximum care for the patient.
The Opposition can tell us nothing about care. In the 1970s when the Labour Government were in office there was a cut of one third in the hospital capital building programme. That is why so many people have had to wait for a very long time for new hospitals. Waiting lists increased by 250,000 and nurses' pay decreased by a fifth. There was a 3 per cent. cut in real terms in the National Health Service budget for 1977–78. The Opposition cannot, I repeat, tell us anything and they have offered no solutions in the debate. The public will judge them on their record. When the Bill is considered in Committee, the 731 Opposition will have to table amendments, which presumably will be based on the Opposition's ideas. We shall then be able to judge them.
Various criticisms have been levelled at the Bill, including GP budgets. They do not exist; there is simply a guide for GPs as to the money available to them. Information about the treatments that a general practitioner has prescribed over the past three years can be fed into a computer. That will include the background and the age profile of the GP's panel. It can be allied to the panel's prescription patterns. It enables one to find out what the general practitioner is likely to spend on his patients in the forthcoming year. That is a sensible approach. We need to know what will be spent on patient care. The system is based on technology.
If my constituents believe that the Government are imposing a cash limit on the budget for GP treatment, or the drugs that are prescribed, ignoring the fact that a doctor may have heart bypass patients, or AIDS patients, or people suffering from influenza, they must think that we are well and truly off our trolleys. The system has been devised to give guidance on how much money is spent, and that is all.
The funding of the National Health Service has not changed. It is paid for by taxation and it is free at the point of delivery. All that has changed is the organisation of the funding, and the public should have no fears.
On drugs and practice budgets, who will decide whether prescribing practice is adequate for modern treatments? That will not be decided by officials or Members of Parliament. Doctors will examine the practice of their fellow doctors. They will decide whether, in certain circumstances, it is reasonable to prescribe a certain drug, or whether there is an adequate generic substitute. Judgments will be made by one doctor about other doctors. Clinical decisions will not be made by those who are not qualified to make them. Doctors will make them.
It has been suggested that because the money will follow the patient, he will be sent to the hospital that can provide the cheapest treatment and that he may have to travel a very long way for it. Today, 80 per cent. of patients are treated in their local hospitals. That pattern will, I am sure, continue. The hospital in my area is small and relies for certain essential services on hospitals in Liverpool, Manchester and Wigan. It will continue to rely on them for those services. If, however, there is a waiting list in a certain area, the patient will be able to say to his GP, "I need care urgently: can you look, using the new technology, for a bed somewhere else so that I can get help quickly?" No patient will be obliged to go to the hospital with which the GP has an arrangement. He will be able to choose his GP, the hospital and the consultant. My right hon. and learned Friend the Secretary of State for Scotland said that there will be a fund for those cases.
The role of the district health authority will be crucial. People have asked how the provision of health care for particular groups will be protected under the new system. It will be protected because of the obligation on the district health authority to provide a full range of health care for the people in its area. In the vast majority of cases, people will follow the pattern of the past and go to their local hospital. For my constituents, for example, I expect some treatments to be available in Wigan, Manchester and Liverpool, but it will be for the DHA to ensure proper provision for their health care is made.
732 Hospitals, it is claimed, will be able to opt out. That is nonsense. They will be NHS hospitals, controlled by the NHS and funded by central Government. The Government have provided a 45 per cent. increase in real terms in health care. It has tripled since 1979—
§ Mr. Doug Hoyle (Warrington, North)
As the joint president of the Manufacturing, Science and Finance Union I do not intend to refer to matters that have already been discussed. I intend to refer to the forgotten people, the 40,000 members, apart from junior hospital doctors, whom MSF represents. Most of them are speech therapists, clinical psychologists, medical laboratory scientific officers and hospital pharmacists.
I know that the House has a great deal of goodwill towards speech therapists. An early-day motion signed by 96 hon. Members recognises that speech therapists in the Health Service are being treated most unfairly. Despite being highly skilled professionals, they are badly paid because it is almost entirely a female profession. Speech therapists are badly paid compared with other professions in the Health Service. We in MSF consider that they should be comparable with other professions such as clinical psychologists and hospital pharmacists. We are waiting for a review tribunal to look into the matter. Meanwhile, speech therapists have been offered an increase of only 6.5 per cent. and that is causing a great deal of concern. I received a letter from a speech therapist who has been qualified for 33 years, yet her salary is only £10,947. Will the Minister who replies to the debate say what the Bill offers speech therapists as a profession?
Clinical psychologists are also highly qualified but they are leaving the Health Service in droves because the pay in the Health Service does not compare with that in the private sector. In the private sector they are used in top management and would not receive below £30,000 but at the top grade in the Health Service they receive just over £28,000. The Department of Health commissioned management consultants MAS for advice on clinical psychologists. There are rumours that the advice was that the conditions and salaries of clinical psychologists should he compared with those of consultants. Can the Minister confirm whether that is true?
Hospital pharmacists are also on the front line. The Bill is the thin end of the wedge for privatisation. It has started in Greater Glasgow health board which is the largest regional health service in Britain. It was caught out because it placed a notice in the official journal of the European Community asking for private companies to tender for pharmacy and laboratory work. Studies are still being undertaken but there is no doubt whatsoever about its intentions.
There are two major objections to the privatisation of hospital pharmacies. First, a private company would be looking to maximise profit. Hospital pharmacies will simply offer drugs over the counter, but at present they do far more than that. They give clinical advice to doctors and nurses about the correct drugs to use and that service will be lost. Secondly, an even more serious consequence is that many companies that retail drugs also manufacture them. There is a danger of double standards as those companies which obtain tenders will be pushing their own drugs in the 733 hospital pharmacy and there could be a conflict of interests. Far from reducing costs, that tendency might increase costs.
Medical laboratory scientific officers are also in the forefront of privatisation because in certain areas laboratories will be privatised. Before we privatise the laboratory service we should consider what happens in north America where the service is privatised. In north America the staff are poorly trained and the laboratory equipment is old because of the need to maximise profits. Some doctors look at the samples themselves and the errors in diagnosis are as high as 27 per cent.
Inaccurate tests have led to fatal consequences and many women have died of cervical cancer because they received a negative smear test and the error was discovered far too late. Financial compensation is not much good when lives are lost. The reverse also occurs when people receive a positive result instead of a negative one and again lives are lost. The staff maximise the number of tests. They even take work home. Because they are poorly paid they work long hours for overtime and they are not properly qualified. Laboratory staff are spending seconds on difficult tests which should take quite some time. That is because poorly qualified laboratory staff are working with outdated equipment and private laboratories are reluctant to install new equipment. That is what could result from the privatisation of the National Health Service. Instead of being a professional service, it will be concerned more about profit than about patients' needs. We should be very wary of the lessons to be drawn from north America.
The Secretary of State will become the Arthur Daley of the Health Service and we all know who "'er indoors " is. The Government would flog off anything and this is only the beginning. The public should be warned because, although there will be a little privatisation before the general election, if the Government are returned to office, there will be wholesale privatisation of the National Health Service. I conclude by applying the words of Lady Macbeth to the Secretary of State:Stand not upon the order of your goingBut go at once."—and take the Prime Minister with you.
§ Mr. Nicholas Bennett (Pembroke)
The speech by the hon. Member for Warrington, North (Mr. Hoyle) bore very little relation to the National Health Service and Community Care Bill. He sounded like a trade union spokesman making a bid for the next wage round. There is nothing in the Bill about privatisation and his speech was yet another example of the scare tactics that the Opposition have used in the past year. It is despicable that they should do that; they have managed to scare many ordinary people into believing that the Government would produce a totally different Bill.
I support the Bill because it is important to examine what should be improved in the National Health Service after 41 years of existence and praise its qualities. I and my family have always used the National Health Service and I believe that it is the best health service in the world. But that does not mean that I do not recognise that it has many grave faults which could be corrected. I believe that the Bill will do that.
734 It is interesting that after two days of debate the Opposition have not yet addressed themselves to the many problems that have come to light. General practitioners' referral rates differ greatly. Some GPs refer 25 times as many patients to hospitals as do others and some GPs prescribe twice as many drugs as do others. Operating costs can vary by 100 per cent. between different hospitals in the same district for the same operation. Operations per session can vary greatly between different hospitals, and accident and emergency departments continually complain that most of the vast numbers of people they see are there for entirely the wrong reasons. They clog up casualty departments. Statistics show the difference in the use of the National Health Service from district to district and hospital to hospital. We are entitled to ask why there are such marked divergences in spending and use.
We must ensure that the expenditure on our Health Service—£28 billion at the last count—is spent properly. That is what I wish to discuss. It is not new for the Health Service to have problems with its budgets and spending. I recently read John Campbell's biography of Aneurin Bevan. On page 177, he says that in 1949there was inadequate financial disciplineof the National Health Service. A year after the National Health Service came into operation, Aneurin Bevan, speaking at a meeting in London on 15 November 1949, warned:Now that we have got the National Health Service based on free prescriptions …I shudder to think of the cascade of medicine that is pouring down British throats at the present time. I wish that I could believe that sufficiency was equal to the credulity with which it is being swallowed.These problems with Health Service spending and ensuring that resources are properly used have not disappeared.
It is interesting to read the works of academics who support the National Health Service and want it to be improved. Alan Maynard, writing in the Health Service Journal on 10 September 1987, said:At present the majority of healthcare treatments cannot be demonstrated to be good value for money because their costs are uncertain and their outcomes largely unmeasured. Unless GPs and consultants can demonstrate the superiority of the costs and benefits of their activities, the economic case for financing these activities is absent.Consequently the argument that the NHS is underfinanced is seriously flawed. It may be—and only an evaluation of practices will demonstrate it—that the NHS is overfinanced and the existing improvements in health status, or benefits, could be achieved by a budget less than that currently available to the NHS.He further said that it is important, if we are to spend more on the Health Service, to ensure that resources are spent properly, that we know the outcomes of operations and that we know that resources have been targeted on the right sectors and operations.
It was interesting to read shortly after that an article in the British Medical Journal entitled "Mr Q the surgeon", "Conversations with Consultants" by Tony Smith. The consultant said that his hospital formed an economy committee to consider the use of intravenous needles and other disposable materials by the National Health Service. It discovered that it could save £80,000 or £90,000 a year by changing the brand of needles, catheters, bags and other disposable items. Suddenly, there was a National Union of Public Employees strike, and overnight the hospital lost over £250,000 because it was not allowed to 735 use its pay beds. He asked what was the purpose of saving that money if the union can lose £250,000 in the next week simply by strike action? He says:If you asked me what can we do aboutresources in the National Health Service,I would answer that we must stop the terrific wastage in the NHS. The reason for the wastage is that there is virtually no incentive to save in an enormous organisation like this. In your home you are paying the electricity bill and you turn off the lights as you walk out of the room, but in a hospital you don't. Even though many of us may turn out the lights as we walk out of the department in the evening when we come hack in the morning every single light is back on. The cleaners have been in in the night and left them all on.The consultant argued that the National Health Service would happily save money if it was told that for every pound that it saved by being careful with disposables, being more efficient, watching electricity, turning the lights off in the evening and the other things that people in the Health Service could do, it could be given back the 10p or 15p in the pound that it saved towards its research funds.
What surprises me about Labour Members is that whenever we talk about budgets or finance, they say, "We do not want to hear about that; we do not want to hear about accountancy." But we all know that they are very careful with their own money. They somehow assume that there is an unending supply of public money that does not need to be monitored. I only wish that, like the rest of us, Labour Members would treat public money in the same way as they treat their private resources.
§ Ms. Diane Abbott (Hackney, North and Stoke Newington)
Is the hon. Member aware that we have one of the most cost-effective health services in the world? It is four times more cost-effective than that in the United States, and we spend less per head on the Health Service than any other industrialised nation. Will the hon. Gentleman withdraw the slur that the National Health Service wastes money?
§ Mr. Bennett
The hon. Lady's assertion is incorrect. Italy spends less than us. She should consider the figures for the amount of gross domestic product spent on health services in different countries. It is interesting that although Britain spends less of its GDP on health than other countries in Europe, it is largely because many of those countries have a far larger private sector. Much depends on the size of a country's GDP, and Britain has seen the largest increase in GDP over the past two years of any country in the European Community. We should bear in mind the fact that health spending has increased under this Government because we have had the resources to make increases and because we have increased prosperity so much since 1979.
It is interesting to note the Labour party's policies, or the lack of them. I have read the debate of the first day, and I was present for the speech of the hon. Member for Livingston (Mr. Cook) and on the Welsh Grand Committee when the hon. Member for Alyn and Deeside (Mr. Jones) led for the Labour party in a debate on the National Health Service. What are its policies? We have not heard how it would improve the National Health Service.
§ Mr. Bennett
The hon. Member for Warrington, North says, "You are the Government." We are, but the Labour party tries to claim that it is the Government-in-waiting. If 736 so, it has a duty to tell the public how it would spend the Health Service budget of £28 billion and ensure that the service was improved.
§ Mr. Bennett
The hon. Gentleman knows that every Queen's Speech says "Other measures will be laid before you", of which this is one.
The Labour party believes that we should do nothing to the Health Service and leave it as it is. Let us consider its policies. When the Labour Government were in power between 1974 and 1979, they did not increase spending on the Health Service, as this Government have done, but cut it by 3 per cent. in real terms in 1977–78. They cut the hospital building programme by 30 per cent. in 1976, and hospital closures were 50 per cent. higher under the Labour Government than under this Government. Nurses' pay went down in real terms by 21 per cent. and GP's pay was cut by 16 per cent. The trouble is that the Labour party's policy is predicated not on what the people want but on what NUPE and the Confederation of Health Service Employees want. They want a Health Service run by NUPE and COHSE for the benefit of NUPE and COHSE, not for the benefit of the people of this country.
I shall conclude by asking three questions, to which I hope my hon. Friend the Minister will reply. The first concerns the definition of "resident" in the Bill. I represent a health authority that, in the summer, covers three times as many people as it does in the winter because of holidaymakers visiting our beautiful county. Can we be assured that we shall be given the resources to deal with those holidaymakers and that they will be defined as being "resident" during that time?
Secondly, what will happen when someone has been referred to another health district for an operation but it is not done properly and remedial work becomes necessary? Can we be assured that the health district which did the operation will pay for the remedial work and not the health district that sent the patient to the operating district? That is important because it would be unfortunate if the health district that sent the patient had to pick up the bill for unsuccessful operations.
Thirdly, the family practitioner service authorities should have GP representatives who are elected locally by GPs in their areas. I hope that the Government will consider that carefully when we debate the clauses dealing with FPSAs, because it is an important worry of some GPs and it is worth considering further.
I draw attention to my health authority, because it is important to talk from the experience of what happens in our districts. I have been immensely impressed by the fact that since Pembrokeshire health authority came into operation in 1982 it has managed to spend resources properly and carefully. It has managed to increase outpatient attendances by 34 per cent., radiology attendances by 24 per cent., occupational therapy attendances by 90 per cent. and operations by 153 per cent. It has managed to save £340,000 by tendering out some services within the hospital, and that money has been reallocated to other services carried out by the health 737 authority. The authority has been able to employ 80 more staff this year and the unit of work costs in the DHA are the lowest for all the Welsh authorities.
It is therefore no surprise to me or my constituents that this year Withybush hospital in the Pembrokeshire health authority region has won an award from The Sunday Times for being the best district hospital in the United Kingdom. That is what can be done if resources are spent properly. The Bill is about making sure that that happens, and I commend it to the House.
§ Mr. Ian McCartney (Makerfield)
As a member of the Select Committee on Social Services, which for 12 months has been carrying out a review of the Government's proposals and the deliberate underfunding of the Health Service, it was my original intention to discuss the amendments which have been tabled in the name of my hon. Friend the Member for Birkenhead (Mr. Field). If my hon. Friend is not in his place, I intend to move those amendments formally at 10 o'clock.
I should like to discuss the implications of the review for my constituency. Because of the proposals and the Government's preparation for the reorganisation of the Health Service, my constituents in the Wigan metropolitan borough find themselves in an incredible position. The health authority has proposed the closure of five hospitals which cover not only my constituency but those of my hon. Friends the Members for Wigan (Mr. Scott) and for Leigh (Mr. Cunliffe) and the hon. Member for Lancashire, West (Mr. Hind). This summer, I wrote to the Under-Secretary of State about the way in which the matter was approached by senior officers and the chair of the health authority and in general about the cavalier attitude towards the proposals, in that no proper consultation was taking place with the community health council, Members of Parliament or the local authority.
At a meeting held in private, on the ground that it was not an issue that involved the public interest, the Wigan health authority decided to employ Amec consultants, an American company which owns Fairclough Construction and Fairclough Homes. The company was offered the use of public money to come forward with proposals to reorganise the health service in Wigan, in view of the Government's proposals in the White Paper and the need for the local authority to take account of the market-based economy which would thereafter operate both within the health authority and in terms of its relationship with other health authorities in the north-west.
The contract was awarded without public scrutiny. People were not able to make submissions and there was no proper check on funding for the contract. Amec proposed that the health authority close all five hospitals —Billinge, a maternity and general hospital in my constituency, which has a large section for the mentally ill, Atherleigh, a hospital for the frail elderly and those with senile dementia, the Wigan Royal Albert Edward infirmary, an accident and emergency unit and general hospital, Leigh hospital, an accident and emergency unit and a general hospital with a new section for the mentally ill, and Astley general hospital.
The proposal was to close the hospitals and to sell the land, without tender, to Fairclough Homes and 738 Fairclough Construction. Subsequently, the health authority decided to close all five hospitals and to approach the regional health authority to fund a new single-site hospital, which was to be built by Fairclough Construction without going to public tender. I wrote to the Minister asking him to intervene, taking account not only of any public impropriety but of the view of my constituents, the local authority and the community health council, which opposed the way in which the matter had been handled. The Minister not only rejected my appeal but wrote a letter supporting the idea.
Four weeks ago, the situation changed for the worse. The health authority—because of Amec's recommendations—withdrew a request for funding for the reorganisation of Leigh hospital and its redevelopment phase. Two weeks ago, the North Western regional health authority advised the Wigan health authority that the Government had not made available a single penny of capital resources for construction of a new hospital. My health authority is going ahead with the programme of closure of five hospitals, with no plan for alternatives. That is happening because of the Minister's encouragement.
This action is unhealthy and is a gross dereliction of duty by the health authority and the Under-Secretary of State, who could have intervened this summer but refused to do so because of his ideology on the review of the NHS. The hon. Member for Lancashire, West, who has left the Chamber, shares a constituency boundary with me. He should tell his constituents—in Up Holland—what will happen to the maternity unit at Billinge hospital, which covers the south-east of his constituency. He should tell them what is happening in terms of patients following money at the Wigan Royal Albert Edward infirmary. There will be no hospital to follow. What will prevent the health authority from implementing hospital closures? The Secretary of State has refused to provide the regional health authority with funding for construction of a single unit to replace the five hospitals.
The Minister refused to intervene this summer when I wrote to him about Atherleigh hospital. With 24 hours' notice, the health authority was decanting patients into the private sector without consultation with the community health council, the social services department, patients their relatives, or their representatives—a huge proportion of the residents of Atherleigh—on the ground that the authority's financial position was so serious. A confidential report, which was leaked to the four Members of Parliament affected, showed that provision has already been made for the hospital to close and for the private sector to receive from Wigan health authority over 124 additional places for the frail elderly.
A private sector nursing home in my constituency recently submitted a planning application to extend its premises, on the ground that the local health authority would provide additional patients because of the closure programme. To do that, the nursing home sought an amendment to a previous planning application to get rid of the physiotherapy unit, recreation area and the hydro-pool facility. Those facilities are important to the environment of people living in public or private sector homes and needing long-term care. Because of my health authority's decision, the home was prepared to get rid of those facilities to provide additional beds, at a cost to the taxpayer.
The Minister owes us not just a scanty explanation. He failed to answer my points on the three occasions that I 739 raised them. He cannot do that now. He will have to sit down with the four Members of Parliament concerned and tell us and our constituents what we are to do about the crisis.
The health authority is embarking on a programme of closure of our facilities, but with no alternative facilities with which to replace them. The Minister cannot simply hide behind the claim that it is a matter for the district general manager and the health authority. He positively encouraged the authority to go down that road. Nor can he hide behind the fact that the health authority needs to take account of changing circumstances.
What would his position be if he were Under-Secretary of State for the Environment and a Labour or Conservative local authority sold off, without tender, large-scale public assets or became involved with a private sector developer in the wholesale disposal of public assets at a knock-down price? He would be the first person to bring in the district auditor to examine the way in which that local authority was operating, yet he, as a result of his inability or unwillingness to act in the matter over the summer months, has been a party to the asset stripping of resources in my constituency.
He owes it to me and to my constituents to meet us at the earliest opportunity to resolve the issue.
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)
Before the hon. Gentleman sits down, I must point out that, as he probably knows, I shall not be replying to the debate. My hon. Friend the Minister for Health will be replying. However, I and my officials will read the record of what he has said because he has made a number of allegations about me personally. As I shall not have the opportunity to reply in this debate, I shall write to him and send copies to the hon. Members who are affected.
§ Mr. McCartney
I thank the Under-Secretary for those comments. Perhaps he will also agree to meet us to discuss the activities of my health authority.
Again as a result of the cut in resources, nurses leaving the training school in the hospital in my constituency this month have been informed that there is no placement for them in the health authority. That has happened at a time when the Government are, supposedly, spending £4 million on advertisements to encourage people to join the nursing service. At the end of this month, my local trainee nurses will be receiving in one hand a certificate saying that they are trained nurses and in the other hand a redundancy notice.
What will the Secretary of State do about that? Is he prepared for public money to be wasted in that way? Is he prepared to see nurses going through a full training scheme and at the end of it being told that neither the health authority in Wigan nor nearby health authorities are able to give them a position as a result of cuts in their budget for this and next financial year? Those trained nurses will have to sign on the dole in January 1990. The reality of the Government's policy of public expenditure cuts is reductions in services, a reduction in the overall money spent on nurse training and the asset stripping of the resources of local district health authorities.
§ Mrs. Mahon
Will my hon. Friend take on board what is happening to enrolled nurses? A scandal is being allowed to happen. The 150,000 enrolled nurses are the backbone of our nursing profession. Fifty thousand of them have 740 applied for conversion courses, but there are only 1,000 places. It will be well into the next century before even one quarter of those nurses are retrained under the Government's own training programme.
§ Mr. McCartney
My hon. Friend is right. The Select Committee on Social Services, in an earlier report this year, pointed out to the Government their failure in trying to provide resources for training in other aspects of the Health Service. The Government are already damaging the Health Service at local level. The Bill will do nothing other than further damage it and that is the all-party view of the Select Committee, which has examined the matter in great detail not over just a few months, but over a lengthy period. The Committee's report on the way in which the Government have handled the issue has the support of both Conservative and Labour Members.
§ Mr. Mark Wolfson (Sevenoaks)
I welcome the clear confirmation that was given, once again, by the Secretary of State in the debate last Thursday that the fundamental principle on which the Health Service reforms are based is that free medical treatment should be provided regardless of means and financed largely by general taxation. I also welcome the undoubted fact that the resources that are being made available to the Health Service by this Government have been increased steadily and that the past two public spending rounds have themselves raised the available cash by more than 20 per cent. I am also aware of the essential need to make the best use of every penny of those resources. That requires a public Health Service that is efficient and where waste is minimised. Many of those who now work in the Service, dedicated and effective as they are, are not at all satisfied that the National Health Service today uses its resources as carefully or effectively as it should. They too want reform and they too look for improvement, even though they may disagree with some —or in some cases all—of the proposals.
It is of key importance that the decision-making process in the Health Service and the objectives of each unit and department in it be clarified and improved, and that the opportunity for local leadership and more localised decision-making be increased. The Bill aims to do this and addresses the issues that can enable that to happen.
During my 10 years as a Member of Parliament, my experience is that complaints against the quality of care that is given by the Health Service are very few and that, in the main, they refer to the length of the waiting list for consultation and for treatment in specific areas of difficulty. These are the orthopaedic and ear, nose and throat specialisations. There is also a continuing problem of providing adequate care for the elderly and infirm, and for those most vulnerable groups in our society—the mentally ill and handicapped. I accept that the provisions are designed to deal with those issues, but however good the intentions, they will not be realised unless the available resources are increased continually, as well as the organisation being improved to deliver the service as efficiently as possible.
I am concerned, as other colleagues have already said that they are, about resources. The overall funding of the Health Service makes no provision for pay alone. A centrally-assessed allowance is included which is meant to cover pay and general price increases, and it is left to individual authorities to use that sum to suit best their own 741 circumstances. The point at issue is the overall adequacy of that allowance. For some years now, the level of inflation that has been experienced by the health authorities outside their control has exceeded the national provision. I know that extra resources have been given, especially for pay review body awards, but they have not covered the true additional costs.
We are all aware that the Health Service is highly labour intensive and that any underfunding on pay is critical. It is a fact that there is a considerable difference between the index increases that the central allowance takes into account and the actual inflation in wage costs that the health authorities have had to pay. The result is that despite the necessary additional finance, which is welcome, health authorities have had to supplement their provision for inflation from their existing resources. I agree that that pressure has led to increased efficiency, a better use of resources and a more streamlined and cost-effective system, but there is a limit to the savings that can be achieved in that way. The squeeze has, in many cases, made the pips squeak, but when the pips themselves are dry the service will suffer and the level of care will decline.
I accept that the demands on the Health Service are continuing to increase. That is for good reason. The benefits of medical advances keep people alive and well for longer and the expectation of a full life into old age is vastly greater than it was even 20 years ago. But that means that to fulfil its proper role the service must be adequately staffed on a cost-effective basis.
In my health authority area the use of agency staff has been growing rapidly. Low rates of pay and a high level of local employment are making recruitment more and more difficult. Agency staff are required and must be used in all disciplines. The premiums paid to agencies represent a loss of purchasing power to the health authority, and the presence of such agency staff, often on higher pay rates and sometimes with less commitment to the unit in question, creates problems with staff morale.
I highlight the problem of resources not as criticism of the Bill, which I support in principle and which I believe will provide the opportunity to deal with the issue of local wage rates more effectively, but because it is necessary continually to remind Ministers of local pressures and the problems on the ground.
I now turn to community care, for which the proposals in the Bill are positive. They tackle the problem that has bedevilled community care for years—the split responsibility between local authority and health service—thus providing a better base for dealing with what is bound to be a mounting social and financial responsibility in the years ahead.
I have important reservations, however, which I want to air. The first is that central funds for local authorities to cover community care should be ringfenced. I am not confident that without this local authorities will continue to direct those funds to the main purpose for which they are intended.
Secondly, I want to emphasise that removal of patients from mental hospitals must be strictly limited from now on to equate exactly with the provision of alternative facilities in the community. Those new facilities require buildings and adequate staff; until now, the arrangements have too 742 often been the wrong way around—closing existing facilities before new ones are ready. I welcome the fact that recent ministerial statements have dealt with this important issue but we now expect to see the policy followed in practice. As I am sure the Minister of State knows, many professionals in the field exactly predicted the problems that have arisen when the wholesale closure was first mooted.
Finally, I ask my right hon. and learned Friend to do his level best during the passage of this important Bill through both Houses to listen and respond to the continuing anxieties of many who work in the Health Service and in the service of community care. Some of those concerns are not necessarily politically motivated. They are genuinely based on professional knowledge and a wish to see the Health Service improve. I accept that the BMA's propaganda got it badly wrong.
I shall support the Bill tonight, but with some reservations and with the firm expectation that a well-intentioned Bill can be improved during its passage through the House, provided that the Secretary of State is prepared to show flexibility and to respect views that may differ from his own. That is what well-respected doctors, highly qualified and thoughtful paramedics and sensible staff at all levels of the service in my constituency want, and I support their view.
§ Mrs. Alice Mahon (Halifax)
This Bill and the White Paper on community care do not face the real health demands of a growing elderly population who are becoming more frail by the day and more dependent on all of us. The Bill does not deal with the problem of caring for the mentally ill or handicapped, or the problem of those who are languishing in prison and on remand and who would not be so doing had there been proper care in the community.
The Bill does not address the problem of the large number of homeless people who have suffered from mental illness in the past—[Interruption.] If the Secretary of State would pay attention for a moment he might agree that it would be a good exercise to carry out a survey of the number of such prisoners on remand or of people who have ended up in cardboard boxes on the Embankment. He would then have to admit that his policies on community care have been a total failure; and to judge from the White Paper, they will get even worse.
The Bill and the White Paper do not deal with how to shift our policies towards preventing bad health and they offer no strategy for real care in the community. Most of all, the Government proposals will do nothing to improve the low morale that is endemic among NHS staff.
I have mentioned, in an intervention in the speech of my hon. Friend the Member for Makerfield (Mr. McCartney), what is happening to enrolled nurses. It is scandalous that neither document contains a word about retraining of and proper training for nurses.
I cannot remember morale among nursing staff and everyone working in the NHS being so low. The Secretary of State said that I was not qualified to vote on the Bill; that highlights his attitude to the rest of us. At least I gave many years of my life to working in the NHS and I have a greater understanding of its problems and of the staff who work for it than he has.
743 The logical conclusion of the Government's proposals on opting out of district health authority control and setting up hospital trusts is privatisation, and no amount of denial by the Secretary of State, other Ministers or Conservative Members will convince the public otherwise. If these proposals go through, the hospitals in my area will be called "Halifax General plc" or "Halifax Royal Infirmary plc". Unless public pressure can make the Government change their mind, that will be the logical outcome. Once hospitals are set up as businesses, with information systems that show the cost of every treatment in the smallest detail and with the freedom to borrow in the City and to hire and fire at will, that will be the direction in which we shall move.
The Secretary of State treats the rest of us with contempt if he does not realise that we have rumbled him and his plans. What he says about doctors scaremongering is rubbish. I hope that they carry on with what they are doing. The only people who appear not to be listening to them are the Secretary of State and those who support him.
I asked the Secretary of State some months ago to give me a guarantee that the accident and emergency services in my district health authority area would remain there. He did not give that guarantee, and I warn all Government hon. Members that they could lose their accident and emergency services if managers decide that they can purchase them adequately from elsewhere. I am not willing to hand over that reponsibility without a damn good fight. The manager in my area came from British Steel, where he did a good job closing it down for the Government before being made redundant. Will a Minister give us a guarantee tonight that he or she has had a change of heart about this proposal?
There has been much talk about privatisation and the saving of money. There was a small example of privatisation in my local authority area when the Secretary of State was a Minister at the Department of Health and Social Security in 1983—he was not then top dog. There were proposals to build a new laundry in Calderdale before the 1983 general election. The proposals had been worked up and costed and we were going to go ahead, but we were told that a decision could not be made for some months because of other priorities. After the election the Secretary of State said that the laundry had to be put out to tender and that we could not build a new one. We put it out to tender and won by a margin of just over £12,000. The Secretary of State said, "That's not good enough. Try again." With the help of the trade unions which are much maligned by the Conservative party, we worked up another scheme and won the tender by a margin of £250,000. The Minister said that we still had to privatise. So we did. Since then, the laundry service in my district health authority has gone from bad to worse. Elderly patients have had no underwear and patients were sleeping on paper sheets. There has been a series of disasters because the Minister said that privatisation had to go ahead regardless of the fact that it would have been cheaper not to privatise by a margin of £250,000.
§ Mr. McCartney
The privatisation of laundry services highlights most effectively what goes wrong when a market philosophy is imposed on a health authority. The laundry services in my district health authority have been 744 privatised. The district general hospital had to cancel operations because the privatised service could not provide clean linen when the hospital required it.
§ Mrs. Mahon
Many hon. Members have experienced similar difficulties in their constituencies.
Privatisation in the NHS is bad for the patients. The Government introduced managers into the NHS from the business sector and they propose to introduce more of them under the Bill. The community health councils are not to be strengthened and the local authority representatives are to be kicked off DHAs because Government-appointed managers do not want any opposition. In many instances managers do not have the interests of patients at heart, as the Minister would like us to believe. In my district health authority a couple of years ago a manager referred to elderly patients as "bed blockers". I cannot think of a more dehumanising statement than that.
The management have done their job for the Government. They have privatised the care of the elderly almost wholesale. What is left of that care is to be finished off under the White Paper. What choice does the White Papter offer to the elderly and their relatives? If all that the elderly have on offer is a private home, where is their choice to enter the public sector? There is no choice, as the Government are well aware.
The Government have based the White Paper and the Bill on the model that they saw in America. Under that disgraceful model, 40 million people in the richest country in the world have no access to any kind of free health care. The future for Britain can be seen in the provision of health care in America.
The Government do not want to improve access to decent free health care in this country. Their cynical and provocative attitude to the NHS staff over the past 10 years proves that. Indeed, nothing proves it more than the way in which the Secretary of State is upping the dispute with the ambulance service. We know what he is up to and we do not trust him.
It has been said that the Secretary of State is ambitious. In the past, I understand that his name has been put forward as a possible leader of the Conservative party. That has nothing to do with me and if I pursue that I might be ruled out of order. However, the writing is on the wall for the right hon. and learned Gentleman and his career. Just about every section of opinion is against his proposals in the Bill and in the community care White Paper. He cannot fly in the face of that tide of human hostility and hope to get anywhere in politics. He is finished and I for one think that that serves him right.
§ Mr. David Nicholson (Taunton)
I welcome the provisions in the Bill for community care, and I also welcome the presence of my hon. Friend the Minister for Health in the Chamber. I believe that this will be the first debate in which I have spoken to which she will reply, although I did speak in the debate on community care in October. I also support the points made about community care by my hon. Friend the Member for Sevenoaks (Mr. Wolfson).
In The Times today there is a headlineHospitals account for over 80 per cent. of mental health care".745 The article states that a report published by the Office of Health Economics today points out that spending is concentrated in hospitals rather than in community provision. I welcome the fact that, since we debated community care in the House, my health authority in Somerset has produced a consultative document about the provision of services for health and community care and the measures it is taking to update those services.
The report states that the current pattern of services does not provide the ideal network for ensuring that the population of Somerset, which the district health authority serves, has an equality of access to a modern health service. It states that through the introduction of efficiency savings and income-generation programmes additional funding has been provided. A good example of that are the major funding strategies supporting the successful care in the community policies for the mentally handicapped and mentally ill.
The report states that large institutions, to which I referred in our earlier debate, such as Mendip and Tone Vale were an enormous drain on resources requiring huge expenditure every year on such items as fuel and maintenance. Many of the buildings in that care group have serious building defects and are uneconomic to repair and modernise. They are also too large and functionally unsuitable for modern mental health care practice. The sooner the authority's strategy of replacing those institutions with small community units can be implemented, the more it will be possible to avoid expenditure on repairs and fuel in those old buildings. I strongly commend that proposal by Somerset health authority and I hope that it will be able to serve the Bill's principles with regard to community care.
I want to make three basic points about the main issues facing the National Health Service and its future. I want first to refer to resources to which my hon. Friend the Member for Harlow (Mr Hayes) and others have referred. I draw the attention of the House to the contrast between two sets of figures showing total NHS spending per head for England over the past 10 years. Over the four-year period1982–83 to 1985–86, inclusive total NHS spending per head rose by £52. Between 1986–87 and 1989–90 it rose by £104, the rise being from £340 to £444 per head. I have not translated those figures into real terms, but I believe that they show a marked increase in resources in the Health Service over the past four years.
Hon. Members asked earlier why the proposals in the Bill did not feature in the 1987 Conservative party manifesto. All of us encountered strong pressure in our constituencies with regard to NHS resources at the time of the 1987 general election. Since then the resources have been provided and we have produced proposals to ensure tht those resources are used properly. Within the context of resources, I support the point made by my hon. Friend the Member for Sevenoaks with regard to the pay of certain NHS staff. I am not referring to the doctors, nurses or even the ambulancemen. I am referring to the semi-forgotten sections of staff who are badly paid. I hope that as a result of the thrust of the reforms in the Bill we shall see a certain negation of the trade unionism in the NHS. That trade unionism has meant low productivity and also low pay for so many people working in the NHS. I hope that the Bill will remedy that.
§ Mr. Nicholson
I am afraid I will not give way, because, as the hon. Lady knows, several other hon. Members wish to speak.
Earlier this year we saw a concentrated argument about GP services. The Government have made clear their commitment to GP services and made clear pledges against the deceitful propaganda put out by the British Medical Association. Last Thursday my right hon. and learned Friend the Secretary of State cited, as an example of the misuse of drugs under the present system, the fact that 1 million tablets had been found in the space of two weeks in Avon and Somerset. For me, that example was pretty close to home.
In recent weeks the controversy has switched to the issue of self-governing hospitals. Certain hon. Members have suggested a referendum, but it is impossible to hold a referendum on such a hypothetical matter when everyone is being bombarded with propaganda to the effect that the service will get worse. I would have no objection, however, to a local poll to assess the performance of self-governing hospitals—two years, say, after they had become self-governing—and I hope that my right hon. and learned Friend will consider that suggestion. After all, if the measures in the Bill do not lead to an improved service, they are not worth enacting.
My final point is political. The Bill's opponents—the Opposition, the British Medical Association and, at times, my hon. Friend the Member for Macclesfield (Mr. Winterton)—claim that the Bill will lead to lower standards of health care, and at the beginning of the debate the hon. Member for Glasgow, Garscadden (Mr. Dewar) claimed, like others, that a two-tier system would result. Let me emphasise that I have no intention of allowing my constituents, my neighbours or indeed my family to be dragooned into using private facilities instead of the National Health Service that we have all used hitherto. They are committed to the service, as am I, and I believe that my right hon. and learned Friend also uses and is committed to it. I entirely reject the accusation that the Government's proposals are a Trojan horse to promote the extension of compulsory private facilities.
My hon. Friend the Member for Cheadle (Mr. Day) spoke about health in the debate on the Queen's Speech. He and I were the only Conservative Members from the 1987 intake to vote against the abolition of free eye tests, a subject on which the hon. Member for Livingston (Mr. Cook) has spoken forcefully, as he did in this debate. Many of us listened to the hon. Gentleman with rather more than respect on the earlier occasion; I am sorry that he did not find a rather more worthy cause to which to devote his talents today and on Thursday. Nevertheless, I think that lessons have been learnt from our experience in the Lobbies when we voted on eye-test charges, and that is one reason why I believe that the underlying principles of the NHS will be safe under the Bill.
I do not believe for a moment that our opponents are right. They are on a high-risk road, because they do not simply claim that the Bill would make no difference. That might be credible, for we have all witnessed the introduction of legislation accompanied by a flourish of trumpets—the Health Service legislation of some 10 years ago is an example—only to find its implementation and 747 practice somewhat disappointing. Our opponents, however, have chosen to claim that the Bill will restrict and neglect the NHS, while my hon. Friends and I believe that it will enhance and expand it.
As we draw near the end of this two-day debate we must ask, "What if our critics were right and virtually every Conservative Member was wrong?" In that event there would, I think, be three consequences. Two are fairly obvious, being political and personal, but the third would be much greater local political interference in the NHS. No hon. Member worth his salt would tolerate a worse or more inconvenient service for his constituents: we all want and intend to enhance the present service.
As for the other two consequences, they would affect my party and my right hon. and hon. Friends who are in charge of the Bill. I do not believe for a moment that either my party or my right hon. and hon. Friends are bent on political suicide. For that reason, I strongly support the Bill and believe that, before the next general election, it will bring forth the fruits for which we aim. I therefore hope that the House will give it a powerful Second Reading vote.
§ Mr. Eric Martlew (Carlisle)
In the debate on the Gracious Speech, I spent some time comparing the amount that we devote to our Health Service with that devoted by Europe and America to its counterparts. The fact is that we devote a far smaller proportion of our gross national product to our Health Service, which means that our Health Service is very efficient. I wish that Conservative Members would accept that.
I also spoke about reorganisation, pointing out that over the past 15 years the Health Service had been reorganised three times, each time by a Conservative Government. The Conservatives seem to accept that those reorganisations failed; what frightens me is that, if the Bill becomes law, it will succeed—succeed, that is, in privatising the NHS. For that is what the Bill is about: it is a privatisation enabling Bill.
If we do not defeat the Bill, or defeat the Conservatives in the next election, within 10 years the spivs of the City, Wall Street and the Tokyo stock exchange will be picking over the bones of the National Health Service, and we shall see our local hospitals quoted on the Footsie index. The Secretary of State is encouraging such an outcome by attacking those who provide the care and deceiving the general public.
Was it not the Secretary of State who accused the doctors of reaching for their wallets? Was it not he who gave the impression that GPs earned £65,000, when in reality they earn half that? Was it not he who gave the impression that they were working 24 or 38 hours a week, when the flu epidemic is forcing doctors in my constituency to work 50, 60, 100 or 138 hours a week to care for the sick? That is happening in every constituency, but the Secretary of State tries to tell us that doctors do not work hard. Was it not he who attacked the ambulance personnel? He said at the Dispatch Box that they had not been responding to emergencies; in fact, they have not only responded but done so without being paid for it.
The Government told the nurses that their regrading and pay claim would be fully funded. I met a delegation from the Royal College of Midwives in my constituency. They were very perturbed that the core of the Bill made no 748 mention of maternity services, and were also very concerned about regrading. They know that they are worth more than East Cumbria health authority is prepared to regrade them to, but the fact is that the health authority cannot afford to regrade those midwives.
I accept that a considerable sum of money went towards nurses' pay last year, but how the Government and Ministers can put that amount of money into a service and make such a hash of it that people are more demoralised after the pay increases than they were before is almost beyond me. The reality is that the Government are so inept that they squandered the resources. As a result, the nursing service is more demoralised now than in any of the 14 years in which I have been associated with the NHS. The National Health Service is the largest employer in western Europe. It needs great skills and great leadership in man-management at its head, yet we have a Secretary of State who goes around acting like a boorish bully.
I turn now to community care. The principles of care in the community are excellent, but during the past 10 years those principles have been degraded by the Government's efforts. To the Government, care in the community has meant saving money and closing wards. As we leave the Chamber tonight and go home to our nice comfortable flats, we shall be able to see the results of that care in the community—on park benches, sleeping in shop doorways in Victoria street, and in cardboard boxes under Waterloo bridge. That is what community care has meant under this Government.
I have received a letter from voluntary organisations in my constituency which are deeply concerned about the White Paper. In essence, they have said that they cannot be the substitutes for statutory services. The Government cannot get away with voluntary organisations doing that work on the cheap. Those volunteers volunteered to help society, or a specific part of it. They do not want anything to do with taking over statutory responsibilities.
§ Mr. McCartney
I have had experience of the way in which the Government are attacking the voluntary sector in my constituency. An elderly lady in her 80s has been looked after at home for several years by her daughter who is now in her late 60s. That saves the National Health Service and the community care budget between £300 and £400 per week. However, the daughter was notified only last week that the number of incontinence pads would be cut from 300 to 120. The daughter, herself a pensioner, will have to make up the difference because the health authority does not have the resources to maintain the supply of pads so that that elderly pensioner can look after her elderly mother at home. That is the Government at work.
§ Mr. Martlew
I accept what my hon. Friend says because there are similar cases in my own constituency.
The voluntary organisations are also concerned because there is no talk in either the White Paper or the Bill of extra funding for community care. Community care is not a cheap option. It needs extra resources and we are fearful that the Government will not provide them.
The question tonight is not whether the community cares, because the community that I represent certainly cares. The community cares for the sick, for the elderly and 749 for the dispossessed. The question is whether the Government care, and the answer is that they do not give a damn.
§ 9.1 pm
§ Mr. Peter Thurnham (Bolton, North-East)
I welcome the Bill and congratulate the Government on their necessary reforms. I am sorry to hear the view expressed by Opposition Members. The hon. Member for Makerfield (Mr. McCartney) talked about ideology, but he is blinkered by his own ideology and is turning his back on private sector funding initiatives that will give better patient care. He reminds me of the old guard in eastern Europe, which the people of eastern Europe are busy throwing out so that they can have the benefits of a mixed economy.
§ Mr. McCartney
Is the hon. Gentleman saying that I should not defend my constituents who are currently in beds in a National Health Service facility and who are suffering from senile dementia? My constituents, aged between 75 and 95, are being kicked out into the private sector without their relatives or the community health council having a say in whether the alternative facilities being provided are up to the standard required for their care.
§ Mr. Thurnham
The hon. Gentleman's constituents will benefit from the Bill.
I should like to speak principally about those aspects of the Bill relating to care in the community but, first, with regard to the National Health Service reforms, I was thankful of the opportunity to take a delegation to see my hon. Friend the Under-Secretary of State.
Care in the community is a challenging and radical part of the Bill. Perhaps my hon. Friend the new Minister of State will find the opportunity to visit Bolton to see the scheme that was introduced there at an early stage to pilot some of the ideas that are now expressed in the Bill. The pilot scheme has been described as successful, and that success relates to the commitment of the officers and staff of the health authority and the local authority. As a result of the pilot scheme, nearly 100 people have been settled in neighbourhood network homes.
However, although the scheme has been described as successful, there are problems, principally with funding. I have written to my right hon. and learned Friend the Secretary of State about those funding problems and now appeal to him to consider the funding deficit that has arisen in Bolton. As a result of the commitment given to the pilot scheme, there is a deficit of over £400,000 in the current year and a projected deficit of £200,000 for next year. The local authority has written to me, stating that it entered the pilot scheme in good faith. The local authority believes that it would be a betrayal of the initial good will if nothing could be done to help overcome the deficit that has arisen. The danger of leaving matters as they are is that we may end up with a two-tier service in Bolton. There is a good network scheme for some 100 people who have found places in neighbourhood network homes, but hundreds more people in Bolton desperately need a better service.
Two priority areas were identified in the recent Audit Commission report, "Developing Community Care for 750 Adults with a Mental Handicap." One priority is the 19 or 20-year-old with challenging behaviour and profound handicaps, the other priority is older people with frail parents who can no longer look after them. In the normal course of events they might have looked for a home in one of the old institutions, but now they are unable to go there because the number of places has been run down. They cannot have a place on the neighbourhood network scheme because of the lack of funding for the provision of additional places.
Will my right hon. and learned Friend the Secretary of State consider funding and ask the Audit Commission to examine Bolton's scheme to see what lessons can be learnt? The shortfall in funding arises from the need to have a ratio of one member of staff to three residents rather than one to four, which means that costs run nearer to £400 than £300. Those lessons can be learnt elsewhere in Britain. The more they are studied now, the easier it will be to introduce new proposals.
I commend the success of the Bolton Handicap Action Group to my right hon. and learned Friend. I helped to set up that group after the last election, when I was besieged by people who had problems caring for handicapped children and adults at home.
The action group has been extremely successful in lobbying local services and exposing scandals—for example, the fact that it takes a bus more than two hours to do a journey to a day centre and a further two hours to come back again. That scandal is just the tip of the iceberg of inadequate services.
The recent social services inspectorate report on inspection of day services for people with a mental handicap says:Units frequently had little contact with families. Few families and no clients were involved in overall planning of services.That is the most welcome part of the Bill.
I hope that parents' groups and carers' groups will be incorporated into family services.
Will the Secretary of State consider funding a pilot scheme allowing the Bolton Handicap Action Group to set up a charitable company to quote for the services that are so inadequately provided by the local authority at the moment? I mentioned the bus services, and there is also a problem with day centres that are grossly overcrowded and not sufficiently well-staffed to provide the service that people attending them want. It would be helpful if my right hon. and learned Friend would consider funding that pilot scheme so that the Bolton Handicap Action Group can provide those services itself.
I notice that the Bill will enable local authoritiesto provide community care services by making arrangements with any organisation capable of providing them.I think that a word stronger than "enable" is needed. Many local authorities will need a strong push to use a novel form of service that will provide better care to the mentally handicapped and to other patients.
The Audit Commission's report says that the fundamental change will be thatin future the care manager must be the principal budget holder … This will come as a shock to many social workers and councillors.I am sure that we need a stronger Bill to ensure that reforms and changes are properly introduced.
Many groups need to benefit from the changes outlined in the Bill which we shall consider closely in Committee. There are more than 125,000 mentally handicapped adults, 751 of whom about one half are at home and one half are in residential care. Those at home need the greatest help possible for carers, and a great deal more help than is available at the moment.
The survey of the Office of Population Censuses and Surveys identified more than 5,000 handicapped children in institutional care. That is 5,000 too many. I appeal to my hon. Friend the Minister to do all that she can to help find families to care for those children, who should not be in institutions.
§ Ms. Diane Abbott (Hackney, North and Stoke Newington)
Conservative Members have said that they do not believe that Ministers are bent on political suicide. We beg to differ. An enormous amount of cant has been spoken about Conservatives' care for the Health Service. Conservative Members and Ministers say how they want to preserve a free Health Service and that it is safe in their hands, but that is cant. The professional organisations know it, the public know it and the Opposition Members know it.
To illustrate my point, 1 shall take the House back to November 1987, shortly after the last general election. Quite by chance, I happen to have the confidential minutes of the Carlton club political committee. The document is stamped "Confidential. Restricted circulation. Strictly private and confidential." I shall tell the House all it needs to know about the document in the few minutes available to me.
The minutes are of a top secret seminar at which the future of the Health Service was discussed. Who was there? Nurses? Doctors? Patients? People from voluntary groups with a record of concern and care for the Health Service? No. Bankers. Plenty of bankers. At least 50 per cent. of the people there were from private health care companies. There were people from the Institute of Directors, people from Central Office, a man from the No. 10 policy unit and, above all, Ministers. What proposals did they come up with? First, opting out. Surprise, surprise. Secondly, proposals to extend the principle of charging and to create a costed service. Does that sound familiar to Opposition Members? Thirdly, a joint venture between the private sector and the NHS was proposed. Fourthly, there were proposals for tax relief on private insurance. All of those will be familiar to the House and the country.
The seminar also came up with proposals which were too bizarre even for the Prime Minister. One was to rename the Health Service so that the public would know that the whole thing had changed. That seems to have been jettisoned. It came up with a proposal with which the Secretary of State seems now to be involved, to smash "old fashioned" Health Service unions such as the National Union of Public Employees and the Confederation of Health Service Employees to force the creation of a single union with professional sections for the Health Service. That appears to be the Secretary of State's aim with the ambulancemen.
The seminar also came up with proposals to privatise intensive care, pathology and the ambulance service. These are proposals which business men, people who run private hospitals and Ministers discussed in November 1987. It is no surprise to us that the Bill has emerged in this form. 752 Behind it lies no concern for the Health Service. There is no real interest in what professional organisations and workers have to say. Behind it lies pure, naked ideology.
When Ministers tell us that the underlying principle of the Health Service is that free medical treatment should be provided regardless of need, how can they expect people to believe them?
Way back in November 1987 Lord Skelmersdale, a Government Minister, said at the secret Carlton club seminar:the NHS has never been a full, comprehensive and entirely publicly funded system:Among other things he said that there may be aneed to allocate resources which could involve establishing priorities so that elective procedures were either paid for by the patient or only took place when more urgent needs had been satisfiedThe origin of the Bill is ideology and secret seminars. A major Bill has been introduced without proper consultation with nurses, doctors, patients or the public. The Government refuse to do pilot studies, but way back in 1987 they were consulting at the Carlton club. The Bill comes out of the Carlton club and ultimately will benefit only the members of such clubs.
We know the reality of the Government's position on the Health Service. We remember what they said about charging for eye tests. We remember the Secretary of State telling the House that charging would have no effect on the level of eye tests and that at most the charge would be £10. We know that the average is higher and that the number of people having eye tests has plummeted. That means that the elderly, the poor and the sort of people that I and my hon. Friends represent are not having eye tests. We know the Secretary of State's purpose because of what he told us about eye tests and because of his sustained campaign to starve the ambulancemen back to work as a preparatory project for privatisation of that service, among others.
We can see the reality of the Government's promises about the Health Service when we look around us at local areas. In my constituency in east London, St. Bartholomew's hospital, the oldest teaching hospital in London, is half empty because of Government cuts. The Government will not fund the nurses to keep the wards open. I receive letters every day from people who have spent years in pain waiting for surgery that the Government will not fund.
We know the Government's purpose for the Health Service. The Bill is the first step towards privatisation. The public know it, Health Service workers know it, professional organisations know it and the public know it. As someone whose mother worked for more than 30 years in the Health Service until her retirement a few years ago, one of the many millions of ordinary people who have worked to build the Health Service, I shall be proud to go through the Lobbies this evening and vote against the Bill.
§ Ms. Harriet Harman (Peckham)
This debate has been conducted against a background of overwhelming opposition to the Bill. The only response from the Government and from Conservative Members is that people oppose the Bill because they do not understand it. People do not want the Bill precisely because they do understand it. They understand that the family doctor service will be cash limited and that, for the first time, people will receive the treatment and care that their GP can afford rather than the treatment and care that they 753 need. They understand that, for the first time, they will lose the ability to choose which hospital they go to for treatment and that, instead, that choice will be made by managers. Patients will simply have to go where the managers have placed the contract. People understand that when placing contracts managers will look at the cost rather than the quality. A patient will be sent where the care is cheapest rather than where it is best.
People understand that the Bill will enable the Secretary of State to allow their local hospital to opt out from the local National Health Service and that patients will have no way of stopping him. They understand, too, that the Government plan to cheat on community care spending and blame councils for the lack of local services. They understand that the Government are rigging the system so that people will have to go into private commercial care homes rather than have the choice of a council home or a NHS nursing home.
I shall deal first with community care. The Secretary of State for Health said virtually nothing and the Secretary of State for Scotland said absolutely nothing about it. It is lamentable that the community care provisions have been tagged on to the Bill as nothing more than an afterthought. Undoubtedly the Government hoped that community care would be an uncontroversial appendix to the Bill.
The publication of the White Paper and the clauses on community care in the Bill have met with widespread apprehension. In particular, there is anxiety that the Government will not make available the resources necessary to make good-quality care in the community a reality. Again and again the worry about resources surfaces from organisations such as Age Concern, MIND, Mencap and numerous others which represent those who will use the services in the community. Even the National Association of Health Authorities and the Institute of Health Services Management have expressed anxieties about resources.
Why should the Government command any respect in this area? The Secretary of State for Health is fond of quoting the increase in services for people with mental illness, such as day and hostel places. But he never mentions that the increase in provision is far outweighed and cannot nearly match the numbers leaving mental hospitals. He quotes the increase in local authority social services spending as if somehow he can take credit for it, when councils' increases in social services spending have taken place despite the Government, not because of them, as hard-pressed Labour councils have tried to improve and increase the services they make available in the community despite Government spending cuts.
The Conservative commitment to care in the community can be seen in action in Conservative-controlled local authorities where the provision of home helps and meals on wheels for the elderly, the vulnerable and the dependent takes second place because the priority is to keep rates down. Social services are already underfunded and my hon. Friend the Member for Wakefield (Mr. Hinchliffe) gave us a case in point. He told the House of a young disabled male constituent who lives with his parents. The social services authority could not provide enough domiciliary or respite care to enable that family to carry on caring for the young man, so he had to go into residential care. As no National Health Service 754 nursing care or council residential care was available, he had to go into a private home. That family now faces the prospect of having to sell their house to pay the private nursing home fees.
Councils are already underfunded and their services are overstretched, yet downward pressure on spending, which is the intention of the poll tax, will reduce that already inadequate base still further. Councils throughout the country have been calculating what they will have to do if they are to levy a poll tax of £278, which is what the Government have said will be the average. A council in London calculated that if it had to rely on a poll tax of £278, it would mean a 30 per cent. cut across its social services. It would have to cut all its home help and all its meals on wheels services. A council in the north-west of England calculated that even to bring its poll tax down to £400 would mean that it would have to withdraw its home help services from 2,000 of the people who depend on it or find another way of cutting social services by £13 million.
It is against that background that the Government make local councils responsible for care in the community. That is why there is deep suspicion that there is to be no earmarked funding for community care. The Government and their Back Benchers criticise us for asking for earmarked funding and say that that shows that we do not trust councils. It is not that we do not trust local councils. It is because we and local councils do not trust the Government that we demand earmarked funding for community care.
As my hon. Friend the Member for Halifax (Mrs. Mahon) said, there is already little choice for someone who needs residential or nursing care in the community. As cottage hospitals and geriatric wards have been closed, those who might previously have been able to use their services have been forced into private nursing care. As my hon. Friend the Member for Makerfield (Mr. McCartney) said, virtually no NHS nursing care is left. As council spending is squeezed, fewer places are available for the elderly and the disabled. Despite the growing demand, there are fewer places in council residential care, with the result that people have been moved into private residential care homes. A major privatisation programme has been achieved by means of a combination of Department of the Environment spending cuts on local councils and social security handouts by means of payments to private homes.
The Bill takes privatisation one step further. It is nonsense to say that it will provide a level playing field for private and council care. People will retain the right to income support and housing benefit only if they go into private care. To go into council care results in people losing their right to those benefits. Councils are unable to monitor the standard of care in private homes.
I have read all the decisions of the Registered Homes Tribunal. They tell an appalling tale of abuse, neglect and ill-treatment. Vulnerable and dependent people are tied to chairs, drugged and abused. People with strings of convictions have set up private old people's homes because they see the chance of making a quick profit.
I shall refer to two out of many cases. The first is Mrs. Scorer who ran a residential home in Cambridgeshire. According to the findings of the Registered Homes Tribunal,There was mental cruelty … residents were … abused and insulted by being called names to their faces and humiliated by being shamed in front of other residents. They were physically abused in that some … were roughly755handled, pushed and pulled unnecessarily, frog-marched, slapped; … some had their clothes yanked off … Mrs. Scorer shouted at residents; insulted and humiliated them by calling them names (`fat old pig', 'stupid', 'dirty', 'smelly' and `filthy')".
§ Ms. Harman
The other case concerns Mrs. Canning who ran an old people's home called Warwick Hall. Witnesses to the Registered Homes Tribunal spoke of her using obscene and filthy language and that,She said to one resident, 'I do hate you, your family hate you, that's why you're here.' A former employee said of Mrs. Canning … she loathed children and said mongols should be gassed.' Another former employee told of Mrs. Canning's attitude to a resident who had chronic diarrhoea.`If they mess the bed, don't change it, let them lie in it.' A relative said: 'New residents wanted to go home and stood by the door. She shouted at them loud and aggressive. It was awful and sad.'For all their lip service to quality—
§ Ms Harman
—Ministers never talk about these cases. [Interruption.] Perhaps they do not even read the reports of such tribunals. Conservative Members do not care, because these homes are private. [Interruption.] The Government's commitment to the market takes priority over their commitment to the vulnerable and the dependent.
§ Mr. Deputy Speaker
Order. The hon. Lady has made it quite plain that she does not intend to give way.
§ Ms. Harman
The Bill will do nothing to ensure that councils have the resources to provide the care that people need to stay in their own homes. It will do nothing to ensure that councils have the resources to monitor private care homes, or to provide resources so that people can choose whether to go into a council home. It will do nothing about giving carers a voice or about giving disabled people the chance to have the services that they need. Having established the supremacy of the private market in residential care homes, the Government now seek to bring market forces into health care.
§ Mr. Deputy Speaker
Order. I have heard nothing out of order in the hon. Lady's speech and bogus points of order only delay the progress of the debate.
§ Ms. Harman
I have put on record on numerous occasions my condemnation of what happened in the Nye Bevan lodge. I should like to hear whether Conservative Members, and in particular Ministers, will condemn or at least show some concern about these cases.
§ The Secretary of State for Health (Mr. Kenneth Clarke)
Would the hon. Lady not concede that the Government introduced legislation giving local authorities and health authorities powers to inspect private nursing homes to expose just those cases? A moment ago the hon. Lady was making the absurd case that somehow such cases are typical of private nursing home care provision when hon. Members on both sides of the House are extremely anxious to stamp out all such behaviour whether it be in the private or the public sector. We are interested in the quality of care, not in whether it is run by the council or by a private owner.
§ Ms. Harman
The Secretary of State appears not to be interested in facing up to the inability to monitor what happens in private homes. The Registered Nursing Homes Association, the organisation which represents the owners of private nursing homes, has said that the Government's expansion of private nursing homes through the social security system has led to such an enormous increase in the number of those homes that a cowboy element has entered the market. The Bill, inasmuch as it will fuel further the private sector and stamp out council homes, will make it more difficult to monitor the quality of care in the private sector.
Having established the supremacy of the private market in residential care homes, the Government now seek to bring market forces into health care, and GP services are to be cash limited. Drug budgets will be cash limited as will GPs' practice budgets. That will have three disastrous consequences. First, some patients will not get the treatment they need because their GPs will be running out of money. Secondly, people with long-term chronic illnesses will be unattractive patients and will have less chance of getting the GP they want. Thirdly, it will poison the doctor-patient relationship. If GPs advise patients that they do not need drugs or tests, patients will not know whether that advice is based on their medical condition or on the GP's financial condition.
§ Miss Widdecombe
Did the hon. Lady hear the clear statement from the hon. Member for Glasgow, Garscadden (Mr. Dewar) accepting that the drugs budget will not be cash limited?
§ Ms. Harman
The hon. Lady misunderstands what my hon. Friend said. What he said clearly showed that he understands that there will be a chilling effect on GPs' prescriptions. Although the Government deny that there will be cash limits, if there are not to be cash limits, why are family practitioner committees drawing up plans to dock GPs' pay if they overspend their indicative drugs budget? If there are not to be cash limits on GPs' practice budgets, why did the White Paper consider it necessary to set up a system of watchdogs in accident and emergency departments of hospitals to find out whether all the patients are emergencies or whether some of them have been sent there by their GPs who cannot afford to get them into hospital under a normal contract because they had run out of money and had advised them to go to accident and emergency?
The Government clearly believe that the family doctor service is costing too much. That is why in the Bill for the first time they have taken the power to restrict the number of doctors going into general practice. The Secretary of 757 State and the Secretary of State for Scotland talked about the money following the patient, but the Bill makes the patient follow the money.
Either the Secretary of State for Scotland has not read the Bill and the White Paper or, if he has, he does not understand how things work at present. Let me give the example of maternity services. A pregnant woman has a choice of hospital in which she can have her baby delivered. She may choose to have her baby at the hospital closest to home, but she may decide that a hospital in a neighbouring district provides the care that she would choose for her delivery. Every year, thousands of women make exactly that choice, but under the Bill it will be taken away and she will have to go where managers have placed the contract. The Secretary of State shakes his head, but what is the point of a contract system if no one has to follow the contract?
GPs, who at present advise their patients which hospital to go to, will find that they are locked in the straitjacket of the National Health Service contract and that they will no longer have the choice of where to refer their patients. That choice will have been made by managers and a patient who has a hernia will have to go where the block booking is for hernia—[Interruption.] I am basing my speech on the White Paper and the Bill, unlike the Secretary of State, who feels that he can make any claim whatever.
The only way that GPs will retain their rights of where to refer a patient will be if they opt out of the frying pan and into the fire by opting for a cash-limited practice budget. Otherwise, managers will make all the decisions.
What will a manager consider when placing a contract? The first thing will be cost. They are not recruited to know about quality, but they certainly will know about cost. To win contracts, hospitals will compete to cut costs. As they do so, they will cut corners, and that will cost lives. The lessons from America are clear—the fiercer the competition, the higher the mortality rate. Patients will be sent where care is cheapest rather than where it is best, and they will be required to travel anywhere managers see fit to place a contract.
The core services that were mentioned in the White Paper, which were supposed to guarantee patients access to local services and to some crucial services, have not found their way into the Bill; they have stopped dead in the White Paper. People will no longer have automatic access to their local hospital if the Secretary of State opts-out their hospital. My hon. Friend the Member for Bassetlaw (Mr. Ashton) rightly said that the people who use the hospital, those who work in it and even its doctors will have no say in whether it opts out.
Knowing how controversial the plans will be, the Secretary of State is going about them with secrecy and stealth, an example of which is the advertisement for shadow finance manager to make the application for the London hospital to opt out without telling the district health authority, its patients or even the general manager what will happen.
The Government have sought to disguise the aim of the Bill. The only response that they have made to criticism is to change its language. They know that to have a cash-limited budget for GPs is unpopular, so it is now called not a budget-holding practice but a fund-holding practice. Clearly, they got out their "Roget's Thesaurus" 758 and thought that "a fund" sounded as though it had more money than "a budget". They know that local representatives are to be knocked off district health authorities, so we no longer mention the word "accountability"—that is a non-word—but use instead the word "leadership", which is a code for the Secretary of State deciding everything and local people having no say. The Government realised that people did not like the idea of people buying and selling health care, so we are told that the "purchaser" is to be called "the acquirer". The Secretary of State has just about trained himself to stop describing "opted-out" hospitals as such and now calls them "NHS trusts". We know that, whatever they are called—whether NHS trusts or anything else—they will be opted out of the local health authority.
The Government imply that anyone who is against the Bill is against change in the NHS. That is a travesty. If we had a Government who could listen, they would know that the Health Service and patients' organisations are abuzz with ideas for changing and improving service deliveries. The real reason that people do not want the Bill—
§ Mr. Michael Colvin (Romsey and Waterside)
On a point of order, Mr. Speaker. I have no objection to the hon. Member for Peckham (Ms. Harman) reading her speech, but I object to her reading it to the Serjeant at Arms rather than to the Chair.
§ Ms. Harman
The real reason why people do not want the Bill is that they do not want to see their Health Service broken into a thousand fragments ready for privatisation. That is why we shall vote against the Bill.
§ The Minister for Health (Mrs. Virginia Bottomley)
The Government's overriding aim is to achieve the best for the individual patient, the individual carer and the dependant who requires social care. Our policy depends on caring for the patients, not scaring the patients. What we have heard from the Labour party is alarmist, frightening misinformation, calculated to misinform and to stir up people's strongest fears.
We have had a lengthy debate about extremely important proposals. We speak at a time when the Government are spending more than ever before on the Health Service. The Conservative party has delivered improved health care. Where we have a competition in terms of the rhetoric of compassion, it may be that the Labour party could outbid us. If it comes to a competition in terms of delivery of health care, there is no doubt that the frail, the vulnerable and the sick have every reason to have confidence and to put their trust in the Conservative party. Every week of the year, 25,000 more patients are treated because of our investment in and commitment to the NHS. These proposals are intended to develop and build on our NHS.
The management changes, which are fundamental in terms of producing health care of the highest quality in an age of rapidly increasing science and technology, are intended to benefit the individual users of our health and social care services. All our plans put the individual at the heart of things. My hon. Friend the Member for Newbury (Sir. M. McNair-Wilson) called last Thursday for a 759 patients' charter. As my right hon. and learned Friend the Secretary of State said after First Reading, the Bill is just that.
I pay tribute to all the hon. Members who so fulsomely participated in the debate. There has been a robust exposition of Government proposals and a rebuttal of many of the more ludicrous Labour suggestions by my hon. Friends the Members for Harlow (Mr. Hayes), for Ipswich (Mr. Irvine), for Maidstone (Miss Widdecombe), for Wimbledon (Dr. Goodson-Wickes)—who speaks with special knowledge, having worked as a medical practitioner for many years—for Lancashire, West (Mr. Hind) and for Pembroke (Mr. Bennett). As they make clear, under the Labour Government, the National Health Service was run by the International Monetary Fund. We would rather leave our health care in the hands of the NHS.
Only today we are announcing an increase of about 25 per cent. in NHS consultants in the past 10 years. There are 60 per cent. more female consultants. The number of hospital medical staff has increased by over 17 per cent. in the same period and, again, many more women are working in the Health Service.
A major mechanism for improvement will be the new funding systems. Hospitals will be funded more directly for the patients whom they treat. Where they offer high quality service, they will find that additional patients and additional resources will flow towards them. The present system can all too often work against patients who are caught by a geographical boundary or by the so-called "efficiency trap". We are putting in place a system that will work for patients, not against them, and a system that will favour rather then frustrate the most efficient medical practitioners.
My hon. Friends the Members for Harlow and for Ipswich talked about the perverse incentives of the present funding arrangements. We want to have a virtuous effect, not a vicious effect. Managing that system will be the central task of the strengthened district health authorities. They will look at all suppliers of services in their areas to find the best mix of NHS contracts to provide comprehensive services for their residents. It will be an open process—far more so than it is now. Each health authority will undertake extensive discussions with local general practitioners to ensure that the pattern of contracts properly reflects local referral patterns. The community health councils will have their voice heard. It is a recipe for patients and their representatives to have a far greater input in the decisions about their care.
Much mention has been made about National Health Service trusts. Once again, this is not an attempt for hospitals to opt out of the NHS and it is not the first step to privatisation. The alarmist and irresponsible scare stories put about by the hon. Members for Glasgow, Garscadden (Mr. Dewar), for Bassetlaw (Mr. Ashton), for Halifax (Mrs. Mahon) and for Hackney, North and Stoke Newington (Ms. Abbott) have no part in our proposals for the Health Service. The fact is that the opportunities offered by the National Health Service trusts are not simply freedom from the shackles of unnecessary central control, but a new freedom to use resources more flexibly to raise standards of care.
We mean standards in the widest sense. Shorter waiting time for admission is central, as are satisfactory systems of medical audit, better out-patient appointment systems and the personal treatment of all visitors and patients received 760 from each member of staff. There is every incentive for quality to run through every aspect of National Health Service work. Both patients and staff will have reason to be proud of what their local National Health Service has been able to achieve. The importance of quality has been registered by several hon. Members and we fully and warmly endorse that.
My hon. Friend the Member for Chislehurst (Mr. Sims) asked about the definition of "core services". It will be for each district health authority to decide the precise pattern of services to meet its needs. We cannot and should not prescribe for that from the centre, but the Bill gives the Secretary of State powers of direction over the NHS trusts' ability to enter into contracts, which can be used to safeguard local access to services in the unlikely event of difficulties arising.
My hon. Friend the Member for Chislehurst raised a further point about NHS contracts being enforced if they are to have legal status. NHS contracts will contain provision for the resolution of any disputes that may arise. The Secretary of State will be able to investigate any disagreements and to enforce a solution. That is a more appropriate response than the sight of two NHS bodies fighting each other through the courts. These are management rather than legal documents.
My hon. Friend the Member for Rutland and Melton (Mr. Latham) asked about the size of the NHS trusts. We shall not be prescriptive about the type or size of unit that can apply for self-governing status. The reason why the Bill refers to NHS trusts, rather than NHS hospital trusts as we called them in the White Paper, is that the concept is proving attractive to all kinds of candidate, not just to the major acute hospitals. Many other hon. Members raised points about the trusts, but I shall not be able to do justice to all of them. The key point is to release NHS units from some of the shackles of bureaucratic control and interference and to allow centres of excellence with a corporate ethos to develop and flourish.
Several hon. Members talked about the importance of dialogue with the medical profession. My hon. Friends the Members for Chislehurst, for Rutland and Melton, for Northampton, South (Mr. Morris) and for Sevenoaks (Mr. Wolfson) all spoke about the importance of discussion. I want to make it clear that all of us at the Department of Health have met about 100 different groups from the medical profession since last January. We are working closely on resource management and on many medically-led initiatives such as medical audit, and we shall continue to do so. Further, we are funding a range of pilot schemes so that we can learn lessons for implementing the Bill when it completes its passage through Parliament. I cite, for example, the enhanced role of the district health authority, the development of contracts, management budgets, and information to assist with the determination of cross-boundary flows.
I turn now to the substantial part of the remarks made by the hon. Member for Peckham (Ms. Harman)—
§ Mrs. Bottomley
I appreciate that, but I want to talk about some proposals of great importance—those on community care. It is deplorable to exploit people's fears about divisiveness and scandals in the public or the private 761 sectors. We want high quality community care for people; we want choice and proper standards and we shall ensure that we achieve precisely that in this Bill.
In the Bill we set out the framework for care in the community for the next decade. The proposals will secure the delivery of successful community care services, ensuring the best use of resources to achieve diversity and flexibility of provision. That is welcome for local authorities, which have long argued that responsibility for social care should rest with them. I wondered, as she spoke, whether the hon. Member for Peckham wanted to deprive local authorities of this important responsibility, which is intended to build on the substantial work that they already undertake planning for the overall social care needs of their populations. I know that local authorities are keen to rise to the challenge, and there have already been many examples of innovative and pioneering work providing community care.
§ Mr. Nigel Spearing (Newham, South)
I am grateful to the hon. Lady for giving way and for rightly emphasising the importance of local councils in social services. If the Government are determined to retain councils' part in this area, why are they excluding them from the district health authorities in which co-operation and knowledge of what is going on in the community are almost as important?
§ Mrs. Bottomley
It is clear from our proposals on district health management that the NHS—a £28 billion organisation—requires clear and decisive management. There will certainly be scope for consulting local people about their needs. I am not sure whether the hon. Gentleman wants to deprive local authorities of their important new responsibility of providing care in the community.
Many local authorities are already developing excellent projects. I hope to take up the invitation of my hon. Friend the Member for Bolton, North-East (Mr. Thurnham), whose scheme is one of 28 pilot projects set up some time ago by the Department to develop new forms of care in the community. There are similar projects and developments in Kent, Newcastle and Bolton to ensure that people can live dignified and independent lives at home.
Community care has too long been the victim of confusion over where responsibility lies for the public support of people in residential care and nursing homes. Not enough priority has always been given by local authorities to the development of high quality care, and we intend to set that right so that local authorities fulfil their responsibilities and high standards and choice are available.
Some hon. Members have suggested that the proposals have come forward too swiftly. That lies ill with the former allegation that there has been a certain amount of delay. After Sir Roy Griffiths' report on community care, a great deal of detailed consultation on his recommendations was entered into. My right hon. and learned Friend made a statement last July, since when there have been further detailed discussions about the proposals. There was a full day's debate in the House to which many hon. Members contributed; then, last month, we brought forward our White Paper.
It is right that the responsibility for providing all forms of community care should be entrusted to local 762 authorities, but equally it is essential that we ensure that local authorities fulfil those important responsibilities. Community care extends from good neighbourliness to 24-hour-a-day residential home care provision. Having heard Opposition Members, it would seem that their course of action would be to nationalise good neighbourliness. Government recognise that the majority of care is frequently provided by family, friends and neighbours. Most carers take on those responsibilities willingly. However, many need help to manage before they become overwhelmed with what can become a considerable burden.
§ Mr. Tom Clarke (Monklands, West)
The Minister referred to consultation. I presume that that was a reference to the week between the White Paper being published and the week the Bill was published. Does that consultation mean that the Government accept the view of the Association of County Councils and the Association of Metropolitan Authorities that allocations for community care should be ring-fenced?
§ Mrs. Bottomley
The key point is that my right hon. and learned Friend the Secretary of State made our intentions clear last July. At that time there were a great many allegations that it was high time that the proposals on care in the community were forthcoming. I shall refer to the particular point about resources shortly.
This is the first time that the needs of carers have been properly recognised. The Bill is a very important mark in terms of our legislation for the dependent and the frail. The White Paper states that the key components of community care should be thatservices should respond flexibly and sensitively to the needs of individuals and their carersand toensure that service providers make practical support for carers a high priority.That is an important step forward from the time when the Labour party was in office. At that time I was involved in an organisation concerned with carers which received no assistance under that Labour Government. The carers' national association, with which I was involved, now receives £77,000. We give about £350,000 annually to various organisations supporting carers. We recognise the pivotal role that carers play and that the views of carers, their ability to provide care and their needs for support should all be fully acknowledged.
It is important that there should be adequate resources for the provision of care in the community. We have made it clear that the amount of money presently used to fund those in private residential homes will be made available for the development of care in the community services. There have been several entirely unfounded allegations about the level playing field between public and private residential homes.
The present situation inordinately favours the use of private residential homes as the local authority involved does not need to find any money. In future, we will establish a more level and fairer system. We will ensure that those in local authority homes receive the same personal allowances. At the moment they receive less. We will ensure that everyone entering a residential home will have a full assessment to discover whether the money that is currently used for residential care could be more 763 appropriately used to preserve their dignity and privacy and bring forward a package of domiciliary care to meet their needs.
It was deplorable of the hon. Member for Peckham to try to arouse people's greatest fears about the provision of care in private homes. AH the residents of Nye Bevan house would have wanted the structure of care in the community including the inspections and local authority control that we are introducing in our measures.
There is much to be done to translate our community care proposals into a successful and working reality. This is a Bill for people—the people who need care, and the people who provide it—and concern for individuals lies at the heart of our action in the NHS and community care. It is because of their importance that we are right to act quickly and decisively.
We have clear and common aims: we intend to move from policy to implementation. The Bill is a key step along that road, and I heartily commend it to the House.
§ Question put, That the Bill be now read a Second time:—
§ The House divided: Ayes 323, Noes 247.766
|Division No. 12]||[10 pm|
|Adley, Robert||Carrington, Matthew|
|Aitken, Jonathan||Carttiss, Michael|
|Alexander, Richard||Cash, William|
|Alison, Rt Hon Michael||Channon, Rt Hon Paul|
|Allason, Rupert||Chapman, Sydney|
|Amess, David||Chope, Christopher|
|Amos, Alan||Churchill, Mr|
|Arbuthnot, James||Clark, Hon Alan (Plym'th S'n)|
|Arnold, Jacques (Gravesham)||Clark, Dr Michael (Rochford)|
|Arnold, Tom (Hazel Grove)||Clark, Sir W. (Croydon S)|
|Ashby, David||Clarke, Rt Hon K. (Rushcliffe)|
|Aspinwall, Jack||Colvin, Michael|
|Atkinson, David||Conway, Derek|
|Baker, Rt Hon K. (Mole Valley)||Coombs, Anthony (Wyre F'rest)|
|Baker, Nicholas (Dorset N)||Coombs, Simon (Swindon)|
|Baldry, Tony||Cope, Rt Hon John|
|Banks, Robert (Harrogate)||Cormack, Patrick|
|Batiste, Spencer||Couchman, James|
|Beaumont-Dark, Anthony||Cran, James|
|Bellingham, Henry||Critchley, Julian|
|Bendall, Vivian||Currie, Mrs Edwina|
|Bennett, Nicholas (Pembroke)||Davies, Q. (Stamf'd & Spald'g)|
|Benyon, W.||Davis, David (Boothferry)|
|Bevan, David Gilroy||Day, Stephen|
|Blaker, Rt Hon Sir Peter||Devlin, Tim|
|Body, Sir Richard||Dorrell, Stephen|
|Bonsor, Sir Nicholas||Douglas-Hamilton, Lord James|
|Boscawen, Hon Robert||Dover, Den|
|Boswell, Tim||Dunn, Bob|
|Bottomley, Peter||Dykes, Hugh|
|Bottomley, Mrs Virginia||Eggar, Tim|
|Bowden, A (Brighton K'pto'n)||Emery, Sir Peter|
|Bowden, Gerald (Dulwich)||Evans, David (Welwyn Hatf'd)|
|Bowis, John||Evennett, David|
|Boyson, Rt Hon Dr Sir Rhodes||Fairbairn, Sir Nicholas|
|Braine, Rt Hon Sir Bernard||Fallon, Michael|
|Brandon-Bravo, Martin||Farr, Sir John|
|Brazier, Julian||Favell, Tony|
|Bright, Graham||Fenner, Dame Peggy|
|Brown, Michael (Brigg & Cl't's)||Field, Barry (Isle of Wight)|
|Browne, John (Winchester)||Finsberg, Sir Geoffrey|
|Bruce, Ian (Dorset South)||Fishburn, John Dudley|
|Buck, Sir Antony||Fookes, Dame Janet|
|Budgen, Nicholas||Forman, Nigel|
|Burns, Simon||Forsyth, Michael (Stirling)|
|Burt, Alistair||Forth, Eric|
|Butler, Chris||Fowler, Rt Hon Norman|
|Butterfill, John||Fox, Sir Marcus|
|Carlisle, John, (Luton N)||Franks, Cecil|
|Carlisle, Kenneth (Lincoln)||Freeman, Roger|
|French, Douglas||Lord, Michael|
|Gale, Roger||Luce, Rt Hon Richard|
|Gardiner, George||Lyell, Sir Nicholas|
|Garel-Jones, Tristan||Macfarlane, Sir Neil|
|Gill, Christopher||MacGregor, Rt Hon John|
|Glyn, Dr Alan||MacKay, Andrew (E Berkshire)|
|Goodson-Wickes, Dr Charles||McNair-Wilson, Sir Michael|
|Gorman, Mrs Teresa||McNair-Wilson, Sir Patrick|
|Gorst, John||Madel, David|
|Gow, Ian||Major, Rt Hon John|
|Grant, Sir Anthony (CambsSW)||Malins, Humfrey|
|Greenway, Harry (Ealing N)||Mans, Keith|
|Greenway, John (Ryedale)||Maples, John|
|Gregory, Conal||Marland, Paul|
|Griffiths, Peter (Portsmouth N)||Marlow, Tony|
|Grist, Ian||Marshall, John (Hendon S)|
|Ground, Patrick||Marshall, Michael (Arundel)|
|Grylls, Michael||Martin, David (Portsmouth S)|
|Hague, William||Maude, Hon Francis|
|Hamilton, Hon Archie (Epsom)||Maxwell-Hyslop, Robin|
|Hamilton, Neil (Tatton)||Mayhew, Rt Hon Sir Patrick|
|Hampson, Dr Keith||Mellor, David|
|Hanley, Jeremy||Miller, Sir Hal|
|Hannam, John||Mills, Iain|
|Hargreaves, A. (B'ham H'll Gr')||Miscampbell, Norman|
|Harg reaves, Ken (Hyndburn)||Mitchell, Andrew (Gedling)|
|Harris, David||Mitchell, Sir David|
|Haselhurst, Alan||Moate, Roger|
|Hawkins, Christopher||Monro, Sir Hector|
|Hayes, Jerry||Montgomery, Sir Fergus|
|Hayward, Robert||Moore, Rt Hon John|
|Heathcoat-Amory, David||Morrison, Sir Charles|
|Heddle, John||Moss, Malcolm|
|Heseltine, Rt Hon Michael||Moynihan, Hon Colin|
|Hicks, Mrs Maureen (Wolv' NE)||Neale, Gerrard|
|Hicks, Robert (Cornwall SE)||Nelson, Anthony|
|Higgins, Rt Hon Terence L.||Neubert, Michael|
|Hind, Kenneth||Newton, Rt Hon Tony|
|Hogg, Hon Douglas (Gr'th'm)||Nicholls, Patrick|
|Holt, Richard||Nicholson, David (Taunton)|
|Hordern, Sir Peter||Nicholson, Emma (Devon West)|
|Howard, Michael||Norris, Steve|
|Howarth, Alan (Strat'd-on-A)||Onslow, Rt Hon Cranley|
|Howarth, G. (Cannock & B'wd)||Oppenheim, Phillip|
|Howe, Rt Hon Sir Geoffrey||Page, Richard|
|Howell, Rt Hon David (G'dford)||Paice, James|
|Howell, Ralph (North Norfolk)||Parkinson, Rt Hon Cecil|
|Hughes, Robert G. (Harrow W)||Patnick, Irvine|
|Hunt, David (Wirral W)||Patten, Rt Hon Chris (Bath)|
|Hunter, Andrew||Patten, John (Oxford W)|
|Hurd, Rt Hon Douglas||Pattie, Rt Hon Sir Geoffrey|
|Irvine, Michael||Pawsey, James|
|Irving, Charles||Peacock, Mrs Elizabeth|
|Jack, Michael||Porter, Barry (Wirral S)|
|Janman, Tim||Porter, David (Waveney)|
|Johnson Smith, Sir Geoffrey||Portillo, Michael|
|Jones, Gwilym (Cardiff N)||Rathbone, Tim|
|Jones, Robert B (Herts W)||Redwood, John|
|Jopling, Rt Hon Michael||Renton, Rt Hon Tim|
|Kellett-Bowman, Dame Elaine||Rhodes James, Robert|
|Key, Robert||Riddick, Graham|
|King, Roger (B'ham N'thfield)||Ridley, Rt Hon Nicholas|
|King, Rt Hon Tom (Bridgwater)||Ridsdale, Sir Julian|
|Kirkhope, Timothy||Rifkind, Rt Hon Malcolm|
|Knapman, Roger||Roberts, Wyn (Conwy)|
|Knight, Greg (Derby North)||Roe, Mrs Marion|
|Knight, Dame Jill (Edgbaston)||Rossi, Sir Hugh|
|Knowles, Michael||Rost, Peter|
|Knox, David||Rowe, Andrew|
|Lamont, Rt Hon Norman||Rumbold, Mrs Angela|
|Latham, Michael||Ryder, Richard|
|Lawrence, Ivan||Sackville, Hon Tom|
|Lee, John (Pendle)||Sainsbury, Hon Tim|
|Leigh, Edward (Gainsbor'gh)||Scott, Rt Hon Nicholas|
|Lennox-Boyd, Hon Mark||Shaw, David (Dover)|
|Lester, Jim (Broxtowe)||Shaw, Sir Giles (Pudsey)|
|Lightbown, David||Shaw, Sir Michael (Scarb')|
|Lilley, Peter||Shelton, Sir William|
|Lloyd, Sir Ian (Havant)||Shephard, Mrs G. (Norfolk SW)|
|Lloyd, Peter (Fareham)||Shepherd, Colin (Hereford)|
|Shersby, Michael||Trippier, David|
|Sims, Roger||Trotter, Neville|
|Skeet, Sir Trevor||Twinn, Dr Ian|
|Smith, Tim (Beaconsfield)||Vaughan, Sir Gerard|
|Soames, Hon Nicholas||Viggers, Peter|
|Speed, Keith||Waddington, Rt Hon David|
|Spicer, Michael (S Worcs)||Wakeham, Rt Hon John|
|Squire, Robin||Waldegrave, Hon William|
|Stanbrook, Ivor||Walden, George|
|Stanley, Rt Hon Sir John||Walker, Bill (T'side North)|
|Steen, Anthony||Waller, Gary|
|Stern, Michael||Walters, Sir Dennis|
|Stevens, Lewis||Ward, John|
|Stewart, Allan (Eastwood)||Wardle, Charles (Bexhill)|
|Stewart, Andy (Sherwood)||Warren, Kenneth|
|Stewart, Rt Hon Ian (Herts N)||Watts, John|
|Stokes, Sir John||Wells, Bowen|
|Stradling Thomas, Sir John||Wheeler, John|
|Sumberg, David||Whitney, Ray|
|Summerson, Hugo||Widdecombe, Ann|
|Tapsell, Sir Peter||Wiggin, Jerry|
|Taylor, Ian (Esher)||Wilshire, David|
|Taylor, John M (Solihull)||Winterton, Mrs Ann|
|Taylor, Teddy (S'end E)||Wolfson, Mark|
|Tebbit, Rt Hon Norman||Wood, Timothy|
|Temple-Morris, Peter||Woodcock, Dr. Mike|
|Thatcher, Rt Hon Margaret||Yeo, Tim|
|Thompson, D. (Calder Valley)||Young, Sir George (Acton)|
|Thompson, Patrick (Norwich N)||Younger, Rt Hon George|
|Thurnham, Peter||Tellers for the Ayes:|
|Townsend, Cyril D. (B'heath)||Mr. Alastair Goodlad and|
|Tracey, Richard||Mr. Tony Durant.|
|Abbott, Ms Diane||Clay, Bob|
|Adams, Allen (Paisley N)||Clelland, David|
|Allen, Graham||Clwyd, Mrs Ann|
|Alton, David||Cohen, Harry|
|Anderson, Donald||Coleman, Donald|
|Archer, Rt Hon Peter||Cook, Frank (Stockton N)|
|Armstrong, Hilary||Cook, Robin (Livingston)|
|Ashdown, Rt Hon Paddy||Corbett, Robin|
|Ashley, Rt Hon Jack||Corbyn, Jeremy|
|Ashton, Joe||Cousins, Jim|
|Banks, Tony (Newham NW)||Cox, Tom|
|Barnes, Harry (Derbyshire NE)||Crowther, Stan|
|Barnes, Mrs Rosie (Greenwich)||Cryer, Bob|
|Barron, Kevin||Cummings, John|
|Battle, John||Cunlitfe, Lawrence|
|Beckett, Margaret||Cunningham, Dr John|
|Beggs, Roy||Dalyell, Tam|
|Beith, A. J.||Darling, Alistair|
|Bell, Stuart||Davies, Rt Hon Denzil (Llanelli)|
|Benn, Rt Hon Tony||Davies, Ron (Caerphilly)|
|Bennett, A. F. (D'nt'n & R'dish)||Davis, Terry (B'ham Hodge H'i)|
|Bermingham, Gerald||Dewar, Donald|
|Bidwell, Sydney||Dixon, Don|
|Blair, Tony||Dobson, Frank|
|Blunkett, David||Doran, Frank|
|Boateng, Paul||Douglas, Dick|
|Boyes, Roland||Duffy, A. E. P.|
|Bradley, Keith||Dunnachie, Jimmy|
|Bray, Dr Jeremy||Dunwoody, Hon Mrs Gwyneth|
|Brown, Gordon (D'mline E)||Eadie, Alexander|
|Brown, Nicholas (Newcastle E)||Evans, John (St Helens N)|
|Brown, Ron (Edinburgh Leith)||Ewing, Harry (Falkirk E)|
|Bruce, Malcolm (Gordon)||Ewing, Mrs Margaret (Moray)|
|Buchan, Norman||Fatchett, Derek|
|Buckley, George J.||Faulds, Andrew|
|Caborn, Richard||Fearn, Ronald|
|Callaghan, Jim||Field, Frank (Birkenhead)|
|Campbell, Menzies (Fife NE)||Fields, Terry (L'pool B G'n)|
|Campbell, Ron (Blyth Valley)||Fisher, Mark|
|Campbell-Savours, D. N.||Flannery, Martin|
|Canavan, Dennis||Flynn, Paul|
|Carlile, Alex (Mont'g)||Foot, Rt Hon Michael|
|Clark, Dr David (S Shields)||Forsythe, Clifford (Antrim S)|
|Clarke, Tom (Monklands W)||Foster, Derek|
|Fraser, John||Morgan, Rhodri|
|Fyfe, Maria||Morley, Elliot|
|Galloway, George||Morris, Rt Hon A. (W'shawe)|
|Garrett, John (Norwich South)||Morris, Rt Hon J. (Aberavon)|
|George, Bruce||Morris, M (N'hampton S)|
|Gilbert, Rt Hon Dr John||Mowlam, Marjorie|
|Godman, Dr Norman A.||Mullin, Chris|
|Golding, Mrs Llin||Murphy, Paul|
|Gordon, Mildred||Nellist, Dave|
|Gould, Bryan||Oakes, Rt Hon Gordon|
|Graham, Thomas||O'Brien, William|
|Grant, Bernie (Tottenham)||O'Neill, Martin|
|Griffiths, Nigel (Edinburgh S)||Orme, Rt Hon Stanley|
|Griffiths, Win (Bridgend)||Parry, Robert|
|Grocott, Bruce||Patchett, Terry|
|Hardy, Peter||Pendry, Tom|
|Harman, Ms Harriet||Pike, Peter L.|
|Hattersley, Rt Hon Roy||Powell, Ray (Ogmore)|
|Haynes, Frank||Prescott, John|
|Healey, Rt Hon Denis||Quin, Ms Joyce|
|Heffer, Eric S.||Radice, Giles|
|Henderson, Doug||Randall, Stuart|
|Hinchliffe, David||Redmond, Martin|
|Hoey, Ms Kate (Vauxhall)||Rees, Rt Hon Merlyn|
|Hogg, N. (C'nauld & Kilsyth)||Reid, Dr John|
|Home Robertson, John||Roberts, Allan (Bootle)|
|Hood, Jimmy||Robertson, George|
|Howarth, George (Knowsley N)||Robinson, Geoffrey|
|Howell, Rt Hon D. (S'heath)||Rogers, Allan|
|Howells, Geraint||Rooker, Jeff|
|Howells, Dr. Kim (Pontypridd)||Ross, Ernie (Dundee W)|
|Hoyle, Doug||Ross, William (Londonderry E)|
|Hughes, John (Coventry NE)||Rowlands, Ted|
|Hughes, Robert (Aberdeen N)||Ruddock, Joan|
|Hughes, Simon (Southwark)||Salmond, Alex|
|Illsley, Eric||Sedgemore, Brian|
|Ingram, Adam||Sheerman, Barry|
|Janner, Greville||Sheldon, Rt Hon Robert|
|Jones, Barry (Alyn & Deeside)||Shore, Rt Hon Peter|
|Jones, leuan (Ynys Môn)||Short, Clare|
|Jones, Martyn (Clwyd S W)||Sillars, Jim|
|Kaufman, Rt Hon Gerald||Skinner, Dennis|
|Kennedy, Charles||Smith, Andrew (Oxford E)|
|Kinnock, Rt Hon Neil||Smith, C. (Isl'ton & F'bury)|
|Lambie, David||Smith, Sir Cyril (Rochdale)|
|Leadbitter, Ted||Smith, Rt Hon J. (Monk'ds E)|
|Leighton, Ron||Smith, J. P. (Vale of Glam)|
|Lestor, Joan (Eccles)||Smyth, Rev Martin (Belfast S)|
|Lewis, Terry||Snape, Peter|
|Litherland, Robert||Soley, Clive|
|Livingstone, Ken||Spearing, Nigel|
|Livsey, Richard||Steel, Rt Hon David|
|Lloyd, Tony (Stretford)||Steinberg, Gerry|
|Lofthouse, Geoffrey||Stott, Roger|
|Loyden, Eddie||Strang, Gavin|
|McAllion, John||Straw, Jack|
|McAvoy, Thomas||Taylor, Mrs Ann (Dewsbury)|
|McCartney, Ian||Taylor, Matthew (Truro)|
|McCrea, Rev William||Thomas, Dr Dafydd Elis|
|Macdonald, Calum A.||Thompson, Jack (Wansbeck)|
|McKay, Allen (Barnsley West)||Turner, Dennis|
|McLeish, Henry||Vaz, Keith|
|Maclennan, Robert||Walker, A. Cecil (Belfast N)|
|McNamara, Kevin||Wall, Pat|
|Madden, Max||Wallace, James|
|Mahon, Mrs Alice||Walley, Joan|
|Marek, Dr John||Warden, Gareth (Gower)|
|Marshall, Jim (Leicester S)||Wareing, Robert N.|
|Martin, Michael J. (Springburn)||Watson, Mike (Glasgow, C)|
|Martlew, Eric||Welsh, Andrew (Angus E)|
|Maxton, John||Welsh, Michael (Doncaster N)|
|Meacher, Michael||Wigley, Dafydd|
|Meale, Alan||Williams, Rt Hon Alan|
|Michael, Alun||Williams, Alan W. (Carm'then)|
|Michie, Bill (Sheffield Heeley)||Wilson, Brian|
|Mitchell, Austin (G't Grimsby)||Winnick, David|
|Molyneaux, Rt Hon James||Winterton, Nicholas|
|Moonie, Dr Lewis||Wise, Mrs Audrey|
|Worthington, Tony||Tellers for the Noes:|
|Wray, Jimmy||Mr. Ken Eastham and|
|Young, David(Bolton SE)||Mr. John McFall.|
§ Question accordingly agreed to.
Motion made, and Question put,
That the Bill be committed to a Special Committee.—[Mr. McCartney.]
§ The House divided: Ayes 244, Noes 312.770
|Division No. 13]||[10.15 pm|
|Abbott, Ms Diane||Dobson, Frank|
|Adams, Allen (Paisley N)||Doran, Frank|
|Allen, Graham||Douglas, Dick|
|Alton, David||Duffy, A. E. P.|
|Anderson, Donald||Dunnachie, Jimmy|
|Archer, Rt Hon Peter||Dunwoody, Hon Mrs Gwyneth|
|Armstrong, Hilary||Eadie, Alexander|
|Ashley, Rt Hon Jack||Evans, John (St Helens N)|
|Ashton, Joe||Ewing, Harry (Falkirk E)|
|Banks, Tony (Newham NW)||Ewing, Mrs Margaret (Moray)|
|Barnes, Harry (Derbyshire NE)||Fatchett, Derek|
|Barnes, Mrs Rosie (Greenwich)||Faulds, Andrew|
|Barron, Kevin||Fearn, Ronald|
|Battle, John||Field, Frank (Birkenhead)|
|Beckett, Margaret||Fields, Terry (L'pool B G'n)|
|Beggs, Roy||Fisher, Mark|
|Beith, A. J.||Flannery, Martin|
|Bell, Stuart||Flynn, Paul|
|Benn, Rt Hon Tony||Foot, Rt Hon Michael|
|Bennett, A. F. (D'nt'n & R'dish)||Forsythe, Clifford (Antrim S)|
|Bermingham, Gerald||Foster, Derek|
|Bidwell, Sydney||Fraser, John|
|Blair, Tony||Fyfe, Maria|
|Blunkett, David||Galloway, George|
|Boateng, Paul||Garrett, John (Norwich South)|
|Boyes, Roland||George, Bruce|
|Bradley, Keith||Gilbert, Rt Hon Dr John|
|Bray, Dr Jeremy||Godman, Dr Norman A.|
|Brown, Gordon (D'mline E)||Golding, Mrs Llin|
|Brown, Nicholas (Newcastle E)||Gordon, Mildred|
|Brown, Ron (Edinburgh Leith)||Gould, Bryan|
|Bruce, Malcolm (Gordon)||Graham, Thomas|
|Buchan, Norman||Grant, Bernie (Tottenham)|
|Buckley, George J.||Griffiths, Nigel (Edinburgh S)|
|Caborn, Richard||Griffiths, Win (Bridgend)|
|Callaghan, Jim||Grocott, Bruce|
|Campbell, Menzies (Fife NE)||Hardy, Peter|
|Campbell, Ron (Blyth Valley)||Harman, Ms Harriet|
|Campbell-Savours, D. N.||Hattersley, Rt Hon Roy|
|Canavan, Dennis||Haynes, Frank|
|Carlile, Alex (Mont'g)||Healey, Rt Hon Denis|
|Clark, Dr David (S Shields)||Heffer, Eric S.|
|Clarke, Tom (Monklands W)||Henderson, Doug|
|Clay, Bob||Hinchliffe, David|
|Clelland, David||Hoey, Ms Kate (Vauxhall)|
|Clwyd, Mrs Ann||Hogg, N. (C'nauld & Kilsyth)|
|Cohen, Harry||Home Robertson, John|
|Coleman, Donald||Hood, Jimmy|
|Cook, Frank (Stockton N)||Howarth, George (Knowsley N)|
|Cook, Robin (Livingston)||Howell, Rt Hon D. (S'heath)|
|Corbett, Robin||Howells, Geraint|
|Corbyn, Jeremy||Howells, Dr. Kim (Pontypridd)|
|Cousins, Jim||Hoyle, Doug|
|Cox, Tom||Hughes, John (Coventry NE)|
|Crowther, Stan||Hughes, Robert (Aberdeen N)|
|Cryer, Bob||Hughes, Simon (Southwark)|
|Cummings, John||Illsley, Eric|
|Cunliffe, Lawrence||Ingram, Adam|
|Cunningham, Dr John||Janner, Greville|
|Dalyell, Tam||Jones, Barry (Alyn & Deeside)|
|Darling, Alistair||Jones, leuan (Ynys Môn)|
|Davies, Rt Hon Denzil (Llanelli)||Jones, Martyn (Clwyd S W)|
|Davies, Ron (Caerphilly)||Kaufman, Rt Hon Gerald|
|Davis, Terry (B'ham Hodge H'l)||Kennedy, Charles|
|Dewar, Donald||Kinnock, Rt Hon Neil|
|Dixon, Don||Lambie, David|
|Leadbitter, Ted||Roberts, Allan (Bootle)|
|Leighton, Ron||Robertson, George|
|Lestor, Joan (Eccles)||Robinson, Geoffrey|
|Lewis, Terry||Rogers, Allan|
|Litherland, Robert||Rooker, Jeff|
|Livingstone, Ken||Ross, Ernie (Dundee W)|
|Livsey, Richard||Ross, William (Londonderry E)|
|Lloyd, Tony (Stretlord)||Rowlands, Ted|
|Lofthouse, Geoffrey||Ruddock, Joan|
|Loyden, Eddie||Salmond, Alex|
|McAllion, John||Sedgemore, Brian|
|McAvoy, Thomas||Sheerman, Barry|
|McCartney, Ian||Sheldon, Rt Hon Robert|
|McCrea, Rev William||Shore, Rt Hon Peter|
|Macdonald, Calum A.||Short, Clare|
|McKay, Allen (Barnsley West)||Sillars, Jim|
|McLeish, Henry||Skinner, Dennis|
|Maclennan, Robert||Smith, Andrew (Oxford E)|
|McNamara, Kevin||Smith, C. (Isl'ton & F'bury)|
|Madden, Max||Smith, J. P. (Vale of Glam)|
|Mahon, Mrs Alice||Smyth, Rev Martin (Belfast S)|
|Marek, Dr John||Soley, Clive|
|Marshall, Jim (Leicester S)||Spearing, Nigel|
|Martin, Michael J. (Springburn)||Steel, Rt Hon David|
|Martlew, Eric||Steinberg, Gerry|
|Maxton, John||Stott, Roger|
|Meacher, Michael||Strang, Gavin|
|Meale, Alan||Straw, Jack|
|Michael, Alun||Taylor, Mrs Ann (Dewsbury)|
|Michie, Bill (Sheffield Heeley)||Taylor, Matthew (Truro)|
|Mitchell, Austin (G't Grimsby)||Thomas, Dr Dafydd Elis|
|Molyneaux, Rt Hon James||Thompson, Jack (Wansbeck)|
|Moonie, Dr Lewis||Turner, Dennis|
|Morgan, Rhodri||Vaz, Keith|
|Morley, Elliot||Walker, A. Cecil (Belfast N)|
|Morris, Rt Hon A. (W'shawe)||Wall, Pat|
|Morris, Rt Hon J. (Aberavon)||Wallace, James|
|Morris, M (N'hampton S)||Walley, Joan|
|Mowlam, Marjorie||Wardell, Gareth (Gower)|
|Mullin, Chris||Wareing, Robert N.|
|Murphy, Paul||Watson, Mike (Glasgow, C)|
|Nellist, Dave||Welsh, Andrew (Angus E)|
|Oakes, Rt Hon Gordon||Welsh, Michael (Doncaster N)|
|O'Brien, William||Wigley, Dafydd|
|O'Neill, Martin||Williams, Rt Hon Alan|
|Orme, Rt Hon Stanley||Williams, Alan W. (Carm'then)|
|Parry, Robert||Wilson, Brian|
|Patchett, Terry||Winnick, David|
|Pendry, Tom||Winterton, Mrs Ann|
|Pike, Peter L.||Winterton, Nicholas|
|Powell, Ray (Ogmore)||Wise, Mrs Audrey|
|Prescott, John||Worthington, Tony|
|Quin, Ms Joyce||Wray, Jimmy|
|Radice, Giles||Young, David (Bolton SE)|
|Redmond, Martin||Tellers for the Ayes:|
|Rees, Rt Hon Merlyn||Mr. Ken Eastham and|
|Reid, Dr John||Mr. John McFall.|
|Adley, Robert||Bendall, Vivian|
|Aitken, Jonathan||Bennett, Nicholas (Pembroke)|
|Alexander, Richard||Benyon, W.|
|Alison, Rt Hon Michael||Bevan, David Gilroy|
|Allason, Rupert||Blaker, Rt Hon Sir Peter|
|Amess, David||Body, Sir Richard|
|Amos, Alan||Bonsor, Sir Nicholas|
|Arbuthnot, James||Boscawen, Hon Robert|
|Arnold, Jacques (Gravesham)||Boswell, Tim|
|Arnold, Tom (Hazel Grove)||Bottomley, Peter|
|Ashby, David||Bottomley, Mrs Virginia|
|Aspinwall, Jack||Bowden, A (Brighton K'pto'n)|
|Atkinson, David||Bowden, Gerald (Dulwich)|
|Baker, Rt Hon K. (Mole Valley)||Bowis, John|
|Baker, Nicholas (Dorset N)||Boyson, Rt Hon Dr Sir Rhodes|
|Baldry, Tony||Braine, Rt Hon Sir Bernard|
|Banks, Robert (Harrogate)||Brandon-Bravo, Martin|
|Batiste, Spencer||Brazier, Julian|
|Beaumont-Dark, Anthony||Bright, Graham|
|Bellingham, Henry||Brown, Michael (Brigg & Cl't's)|
|Browne, John (Winchester)||Grylls, Michael|
|Bruce, Ian (Dorset South)||Hague, William|
|Buck, Sir Antony||Hamilton, Hon Archie (Epsom)|
|Budgen, Nicholas||Hamilton, Neil (Tatton)|
|Burns, Simon||Hampson, Dr Keith|
|Burt, Alistair||Hanley, Jeremy|
|Butler, Chris||Hannam, John|
|Butterfill, John||Hargreaves, A. (B'ham H'll Gr')|
|Carlisle, John, (Luton N)||Hargreaves, Ken (Hyndburn)|
|Carlisle, Kenneth (Lincoln)||Harris, David|
|Carrington, Matthew||Haselhurst, Alan|
|Carttiss, Michael||Hawkins, Christopher|
|Cash, William||Hayes, Jerry|
|Channon, Rt Hon Paul||Hayhoe, Rt Hon Sir Barney|
|Chapman, Sydney||Hayward, Robert|
|Chope, Christopher||Heathcoat-Amory, David|
|Churchill, Mr||Heddle, John|
|Clark, Hon Alan (Plym'th S'n)||Heseltine, Rt Hon Michael|
|Clark, Dr Michael (Rochford)||Hicks, Mrs Maureen (Wolv' NE)|
|Clark, Sir W. (Croydon S)||Hicks, Robert (Cornwall SE)|
|Clarke, Rt Hon K. (Rushcliffe)||Higgins, Rt Hon Terence L.|
|Colvin, Michael||Hind, Kenneth|
|Conway, Derek||Hogg, Hon Douglas (Gr'th'm)|
|Coombs, Anthony (Wyre F'rest)||Holt, Richard|
|Coombs, Simon (Swindon)||Hordern, Sir Peter|
|Cope, Rt Hon John||Howard, Michael|
|Cormack, Patrick||Howarth, Alan (Strat'd-on-A)|
|Couchman, James||Howarth, G. (Cannock & B'wd)|
|Cran, James||Howe, Rt Hon Sir Geoffrey|
|Critchley, Julian||Howell, Rt Hon David (G'dford)|
|Currie, Mrs Edwina||Howell, Ralph (North Norfolk)|
|Davies, Q. (Stami'd & Spald'g)||Hughes, Robert G. (Harrow W)|
|Davis, David (Boothferry)||Hunt, David (Wirral W)|
|Day, Stephen||Hunter, Andrew|
|Devlin, Tim||Hurd, Rt Hon Douglas|
|Dorrell, Stephen||Irvine, Michael|
|Douglas-Hamilton, Lord James||Irving, Charles|
|Dover, Den||Jack, Michael|
|Dunn, Bob||Janman, Tim|
|Dykes, Hugh||Johnson Smith, Sir Geoffrey|
|Eggar, Tim||Jones, Gwilym (Cardiff N)|
|Emery, Sir Peter||Jones, Robert B (Herts W)|
|Evans, David (Welwyn Hatf'd)||Jopling, Rt Hon Michael|
|Evennett, David||Kellett-Bowman, Dame Elaine|
|Fairbairn, Sir Nicholas||Key, Robert|
|Favell, Tony||King, Roger (B'ham N'thfield)|
|Fenner, Dame Peggy||King, Rt Hon Tom (Bridgwater)|
|Field, Barry (Isle of Wight)||Kirkhope, Timothy|
|Finsberg, Sir Geoffrey||Knapman, Roger|
|Fishburn, John Dudley||Knight, Greg (Derby North)|
|Fookes, Dame Janet||Knight, Dame Jill (Edgbaston)|
|Forman, Nigel||Knowles, Michael|
|Forsyth, Michael (Stirling)||Knox, David|
|Forth, Eric||Lamont, Rt Hon Norman|
|Fowler, Rt Hon Norman||Latham, Michael|
|Franks, Cecil||Lawrence, Ivan|
|Freeman, Roger||Lee, John (Pendle)|
|French, Douglas||Leigh, Edward (Gainsbor'gh)|
|Gale, Roger||Lennox-Boyd, Hon Mark|
|Gardiner, George||Lightbown, David|
|Garel-Jones, Tristan||Lilley, Peter|
|Gill, Christopher||Lloyd, Sir Ian (Havant)|
|Glyn, Dr Alan||Lloyd, Peter (Fareham)|
|Goodson-Wickes, Dr Charles||Lord, Michael|
|Gorman, Mrs Teresa||Luce, Rt Hon Richard|
|Gorst, John||Lyell, Sir Nicholas|
|Gow, Ian||Macfarlane, Sir Neil|
|Grant, Sir Anthony (CambsSW)||MacGregor, Rt Hon John|
|Greenway, Harry (Ealing N)||MacKay, Andrew (E Berkshire)|
|Greenway, John (Ryedale)||McNair-Wilson, Sir Michael|
|Gregory, Conal||McNair-Wilson, Sir Patrick|
|Griffiths, Peter (Portsmouth N)||Major, Rt Hon John|
|Grist, Ian||Matins, Humfrey|
|Ground, Patrick||Mans, Keith|
|Maples, John||Shersby, Michael|
|Marland, Paul||Skeet, Sir Trevor|
|Marlow, Tony||Smith, Tim (Beaconsfield)|
|Marshall, John (Hendon S)||Soames, Hon Nicholas|
|Martin, David (Portsmouth S)||Speed, Keith|
|Maude, Hon Francis||Spicer, Michael (S Worcs)|
|Maxwell-Hyslop, Robin||Squire, Robin|
|Mayhew, Rt Hon Sir Patrick||Stanbrook, Ivor|
|Mellor, David||Stanley, Rt Hon Sir John|
|Mills, Iain||Steen, Anthony|
|Miscampbell, Norman||Stern, Michael|
|Mitchell, Andrew (Gedling)||Stevens, Lewis|
|Mitchell, Sir David||Stewart, Allan (Eastwood)|
|Moate, Roger||Stewart, Andy (Sherwood)|
|Monro, Sir Hector||Stewart, Rt Hon Ian (Herts N)|
|Montgomery, Sir Fergus||Stokes, Sir John|
|Moore, Rt Hon John||Stradling Thomas, Sir John|
|Morrison, Sir Charles||Sumberg, David|
|Moss, Malcolm||Summerson, Hugo|
|Moynihan, Hon Colin||Tapsell, Sir Peter|
|Neale, Gerrard||Taylor, Ian (Esher)|
|Nelson, Anthony;||Taylor, John M (Solihull)|
|Neubert, Michael||Taylor, Teddy (S'end E)|
|Newton, Rt Hon Tony||Tebbit, Rt Hon Norman|
|Nicholls, Patrick||Temple-Morris, Peter|
|Nicholson, David (Taunton)||Thatcher, Rt Hon Margaret|
|Nicholson, Emma (Devon West)||Thompson, D. (Calder Valley)|
|Norris, Steve||Thompson, Patrick (Norwich N)|
|Oppenheim, Phillip||Thornton, Malcolm|
|Page, Richard||Thurnham, Peter|
|Paice, James||Townsend, Cyril D. (B'heath)|
|Parkinson, Rt Hon Cecil||Tracey, Richard|
|Patnick, Irvine||Tredinnick, David|
|Patten, Rt Hon Chris (Bath)||Trippier, David|
|Patten, John (Oxford W)||Trotter, Neville|
|Pattie, Rt Hon Sir Geoffrey||Twinn, Dr Ian|
|Pawsey, James||Vaughan, Sir Gerard|
|Peacock, Mrs Elizabeth||Viggers, Peter|
|Porter, Barry (Wirral S)||Waddington, Rt Hon David|
|Porter, David (Waveney)||Wakeham, Rt Hon John|
|Portillo, Michael||Waldegrave, Hon William|
|Rathbone, Tim||Walden, George|
|Redwood, John||Walker, Bill (T'side North)|
|Renton, Rt Hon Tim||Waller, Gary|
|Rhodes James, Robert||Ward, John|
|Riddick, Graham||Wardle, Charles (Bexhill)|
|Ridley, Rt Hon Nicholas||Warren, Kenneth|
|Ridsdale, Sir Julian||Watts, John|
|Rifkind, Rt Hon Malcolm||Wells, Bowen|
|Roberts, Wyn (Conwy)||Wheeler, John|
|Roe, Mrs Marion||Whitney, Ray|
|Rossi, Sir Hugh||Widdecombe, Ann|
|Rowe, Andrew||Wiggin, Jerry|
|Rumbold, Mrs Angela||Wilshire, David|
|Ryder, Richard||Wolfson, Mark|
|Sackville, Hon Tom||Wood, Timothy|
|Sainsbury, Hon Tim||Woodcock, Dr. Mike|
|Scott, Rt Hon Nicholas||Yeo, Tim|
|Shaw, David (Dover)||Young, Sir George (Acton)|
|Shaw, Sir Giles (Pudsey)||Younger, Rt Hon George|
|Shaw, Sir Michael (Scarb')|
|Shelton, Sir William||Tellers for the Noes:|
|Shephard, Mrs G. (Norfolk SW)||Mr. Alastair Goodlad and|
|Shepherd, Colin (Hereford)||Mr. Tony Durant.|
§ Question accordingly negatived.
§ Bill committed to a Standing Committee pursuant to Standing Order No. 61 (Committal of Bills)ֵ