§ Mr. Robin Cook (Livingston)
I beg to move,That this House welcomes with enthusiasm the Prime Minister's pledge that no-one will go private again for medical treatment; invites the Secretary of State for Health to demonstrate his commitment to her pledge by withdrawing the provision for tax relief for private medical insurance, and by abandoning his proposals that self-governing hospitals should trade for private patients and that general practitioners should use practice budgets to purchase private treatment; notes that general practitioners on a ballot have rejected the contract offered by the Secretary of State by a majority of three to one; regrets that the Secretary of State has threatened to impose the new contract irrespective of this vote; and calls upon the Secretary of State to reopen negotiations on his proposal to increase capitation-based payments which will give doctors an incentive to seek longer patient lists.Tonight's debate is prompted by two important developments in the health debate last week. Half the motion is inspired by the Prime Minister, who last week addressed the 1992 Committee in visionary terms about the Government's intentions for the Health Service. [HON. MEMBERS: "1922."] I stand corrected. Plainly, the 1992 committee of the Conservative party will be smaller than the 1922 Committee.
I give assurances to Conservative Members, who may be worried about the Opposition quoting the Prime Minister in a Supply day debate, that this is likely to be the only time that we shall welcome anything that the Prime Minister has said. I suggest to Conservative Back Benchers who are unhappy with the Government's proposals for the National Health Service that this could be the easiest wicket on which to rebel. After tonight's debate, should they vote for the Labour motion, they will be able to look their Whips straight in the eyes and say that they voted to support the Prime Minister's pledge—and a very remarkable pledge it was. She said, "No one will ever go private again".
§ Mr. Cook
I am interested to hear the comments of the hon. Gentleman, to whom I am happy to give way in a moment. I went to the Library and asked for a copy of the Prime Minister's speech to the 1922 Committee. I was advised that I could not have a copy because it was confidential. Since then, I have been distressed to see that, in the Government amendment, the reference to the Prime Minister is deleted.
I understand that the Secretary of State could not have heard the speech, because I believe that, like me, he is not permitted to attend those meetings. Perhaps some kindly Back Bencher——
§ Mr. Cook
I have to confess that the hon. Gentleman made me uneasy when he began because I thought he said that he had taken to writing the Prime Minister's speeches on the Health Service, and that would be a sad loss to debates in the House.
If that is what the Prime Minister said, two questions obviously arise from it. The first is a small matter of whether, if it is what the Prime Minister said, she includes herself in the commitment. It is not clear, at the moment, whether she was implying the royal no one. The Prime Minister is much given to referring to herself as "one", but this would be the first time that she referred to herself as "no one". The truth is, as hon. Members on both sides of the House know if they have been round the doorsteps discussing it, that the public do not believe that they can trust the National Health Service in the hands of the Prime Minister because she takes good care never to trust herself in the hands of the NHS.
The second, and rather more important, question is whether the Secretary of State will sit down during the recess and rewrite the White Paper in the light of the Prime Minister's prediction according to the hon. Member for Harlow (Mr. Hayes). Certainly the White Paper needs urgent revision if she is right. For example, there is the proposal to provide for tax relief on private medical insurance. One can understand why the Secretary of State might be loth to let go of that commitment in the White Paper, because it is the only reference to the health needs of elderly people. Excise that and the White Paper will be absolutely about the needs of an age group who account for almost half of the entire health output of Britain. The Secretary of State must face reality. If no one need go private again, it would surely be cruel to deceive elderly people into paying for what they will not need. However, I note that shares in AMI Healthcare Group, the largest private hospital group, have leapt by a quarter in the month since the White Paper was published. There is not much faith there that no one will ever need to go private again.
Paragraph 9.6 of the White Paper says that general practitionerswill be able to use NHS funds to pay for treatment in the private sector".What is that doing there if nobody need go private again? Why can NHS funds not be used to pay for NHS treatment in NHS hospitals?
Then there is the matter of paragraph 3.6 of the White Paper, which provides that opt-out hospitals may trade for private patients. I hope that the Secretary of State will save us from the humbug that this proposal will bring money into the NHS. Providing for private patients in NHS hospitals takes beds, staff and even blood out of the NHS.
That has already happened. A leaflet that has been distributed by Hillingdon district health authority advertises the authority's fixed price scheme. One can jump the queue in Hillingdon for a fixed price. For £370 one can have what is described as "removal of lumps and bumps". For £3,500, one can have a total hip replacement. On reading that leaflet, I felt a sense of rising outrage that a great public service that once prided itself on treating patients according to need was so reduced to chasing money that it touted its facilities by offering a fast track to those who could pay.
Against that record, no one will ever believe the Secretary of State and the hon. Member for Harlow when they promise that it is their objective to make the public 909 service better than private treatment. Fortunately, there are those in the Health Service who share that concern about where the Health Service is going.
I turn now to the other development last week which has prompted this week's debate on health.
§ Mr. Nigel Spearing (Newham, South)
Does my hon. Friend agree that many people feel that the White Paper's ethics are distinctly rocky? This has driven me, as my hon. Friend may recall, to make a challenge at a public meeting in Newham town hall to any supporter of the Government to debate in my constituency, and his or hers, the neutral question—I hope that it is neutral—whether the Government's domestic policies, particular those relating to the Health Service, are compatible with Christian values. I have tried to make that challenge public, but have had no takers yet. I should be glad to meet Government supporters in Nottingham, Putney or anywhere else. I hope that Conservative Members will advertise that challenge far and wide, and that it will be taken up in the recess.
§ Mr. Cook
I well remember that occasion. At the end of of the debate, in order to be present for a vote at 10 o'clock in the House, I left Newham town hall by car and my hon. Friend left by bicycle. I arrived only two minutes ahead of him.
My hon. Friend made an eloquent and moving plea. It was a pity that the only way in which one could fill up the platform was with supporters of his case against the White Paper. I should like to share my hon. Friend's challenge to any member of the Government who wishes to go to Newham and take part in a public debate with my hon. Friend. I am sure that any such person will be made welcome by my hon. Friend—provided, of course, there is a reciprocal agreement by which my hon. Friend can go into that person's constituency and carry the message to his or her constituents.
My hon. Friend the Member for Newham, South (Mr. Spearing) intervened just as I was about to move on to a matter to which, I am delighted to hear, the Secretary of State wishes to come. Only a couple of months ago, the right hon. and learned Gentleman made a triumphal statement to the House that he had secured agreement with the British Medical Association on the GPs' contract. He said:I am glad to say that it has been my experience that … after a dispute is over, people appear to forget it entirely and no one can quite remember what the fuss was all about."—[Official Report, 5 May 1989; Vol. 152, c. 484.]On this occasion, the GPs have not forgotten entirely what the fuss was all about. Last week, they voted by 24.1 per cent. to accept the contract and by 75.9 per cent. to reject it. That is not the kind of result for which one needs a recount to get the picture.
On radio last week, I heard the Secretary of State commenting, no doubt under the pressure of interview, that good doctors had nothing to fear from the new contract, that only the lazy doctor need fear—all 75.9 per cent. of them, I suppose. It is not just laziness that has 910 prompted GPs to put the contract into the incinerator. It is worth examining, more seriously than the Secretary of State has attempted to do, why they said no.
There is much in what the Secretary of State proposes to which I could say yes. I could give a mark of five out of 10 on the 10 major proposals for change. For reasons to which I shall come, I do not quite regard that as a pass mark. For instance, I would welcome his proposal to pay more to GPs who make their own night visits.
§ Mr. Cook
I well understand—the right hon. and learned Gentleman says that the doctors are against that. I think that he is right. I shall come to those proposals about which he is wrong. His concession that those night visits may be shared with nine colleagues is generous, and it is not unreasonable to ask GPs to do one night in 10 on call.
I agree also with what I understand the Secretary of State is trying to do on targets for screening, but the way in which he is going about it is misconceived. The problem is that the targets set by the Secretary of State for full payment—90 per cent. for child immunisation and 80 per cent. for screening for cervical cancer—are so heroic, so far beyond the present figure for most practices, that there is a danger that many doctors will simply give up trying.
I noticed at Question Time today that the Secretary of State said that most practices met those targets. I have since checked on those figures for district health authorities. Only one in England has reached 90 per cent. immunisation for children, and that is High Wycombe.
§ Mr. Cook
The Secretary of State says that it is 70 per cent. I concede that most district health authorities certainly meet the target of 70 per cent. I am sure that, in return, he will concede that for 70 per cent. the doctors get only one third of the payment. Full payment starts at 90 per cent., and only one district health authority is eligible.
This is not a matter on which it is necessary to have a party political debate. I refer the Secretary of State to the full scientific article in a recent edition of the British Medical Journal by a woman GP who, after working in a practice that has placed special stress on cervical smears and has been running a recall system for 15 years, still has not reached the target of 80 per cent. of the target population. Moreover, that GP was working in a suburban surgery. Achieving that target would be even more difficult in inner-city areas.
I should like to have the attention of the Minister of State, the hon. and learned Member for Putney (Mr. Mellor), who, I well understand, will wish to impress himself on the powerful friend next to him—the Secretary of State. In a television debate, the Minister of State made a statement that at the time rendered me speechless. He said that there was no evidence that it was more difficult to meet screening targets in areas of social deprivation.
I have since been through the figures for district health authorities. The percentages of immunisation by district health authority reads like a map of Britain by socio-economic indicators. The three lowest areas of immunisation are Merseyside, inner London and Manchester, none of which reaches 70 per cent. The three highest districts are Huntingdon, Winchester and High Wycombe. The only conclusion that one can draw from 911 the way in which the Government have devised the centres for screening is that they are providing incentives for GPs to move into those areas that already have the most GPs and the fewest health problems.
It is not that the contract flopped on those matters. Anyone listening to GPs, rather than lecturing them, already knows what the key issue was: the proposal to increase the proportion received by GPs from capitation fees. GPs already get almost half their income from payments directly related to the numbers of patients. Under the proposal in the new contract, that proportion will increase from almost half to three fifths. This will give even more to those doctors who go for more patients, at the expense of those GPs who limit themselves to the number of patients that they can handle to a professional standard.
This is a flat reversal of a policy pursued for 20 years by successive Government, whether Labour or Conservative, which has aimed at reducing the number of people on patient lists. The Secretary of State proposes to turn the clock back, not to the last Labour Government, but to the Labour Administration before that. One must go back to 1966 before finding a time when the capitation element was so high.
The Secretary of State understands, of course, that more patients means more patient care. We know that he understands that, because he vigorously denies that his proposal can result in more people on each patient list. He claims that he is giving doctors the incentive to increase patient lists, while at the same time assuring patients that it cannot happen—that there will not be any more patients to go round, so the average will stay the same.
Unfortunately, I have to warn the Secretary of State that the number of GPs may not stay the same—at any rate, it will stop expanding. Already, practices from Devon to Glasgow have decided not to proceed with the additional partnership that they had intended to advertise. Their response to the Secretary of State's new contract is entirely rational. They are responding in Thatcherite terms to the financial incentives that they have been given to lengthen the patient list in the practice—although, as they understand, the result in terms of patient care is utterly perverse.
There is a simple way for the Secretary of State to demonstrate his good faith on this question of longer patient lists. He will be aware that the BMA, which he keeps telling us is opposed to any change, has proposed that the ceiling on patient lists should be reduced from 3,200 to 2,500. I ask the Secretary of State whether he will accept that reduction in the upper limit on patient lists. Will he take that obvious precaution to prevent GPs from doing what he assures us he does not want them to do—indeed, he keeps assuring us that they cannot do it—namely, going for longer patient lists? If he will not, there is an obvious conclusion to be drawn. The Secretary of State has designed, as a matter of policy, a contract that will sharpen the competition between GPs for patients, with an incentive to go for longer patient lists, and he has no intention of putting in their way an obstacle to prevent them from doing so.
The last word on the contract, however, must be left to an academic study which the Secretary of State himself chose as relevant to the new contract. On 27 June, in answer to a written question, the Secretary of State said:Recent research by York university's centre for economics has demonstrated the wide range of quality of 912 service to patients provided in different parts of the country under the old contract."—[Official Report, 27 June 1989; Vol. 155, c. 422.]The Secretary of State is perfectly correct that the study drew attention to the variations in quality provided by GPs and highlighted the fact that the poorer regions of Britain get a poorer service from GPs.
It is perhaps unfortunate that whoever drafted the reply for the Secretary of State did not draw his attention to the full press comments of the authors of the report, who said:The new contract … is likely to widen the gap even further … Our prediction is that in five to 10 years there will be an even greater difference in standards of service.It is a mark of desperation on the part of the Secretary of State to find friends for his new contract that he is driven to cite academics who believe that his contract will make matters worse.
This is a short debate, and I wish in conclusion to discuss the response of the Secretary of State to the result of the ballot. As I understand the Secretary of State's position, as far as he is concerned, the BMA need not have bothered balloting members. The GPs will get the contract whether they want it or not, because he will impose it on them. It does not count that 76 per cent. of GPs oppose the contract; nor, for that matter, does it count that, last month, the National Association of Health Authorities found in its opinion poll survey that 90 per cent. of patients were satisfied with GPs. But the Secretary of State reserves the right to know better than 76 per cent. of GPs and 90 per cent. of patients.
The Secretary of State will be aware that there is a small problem in imposing the contract. It is not for him to impose it; he requires a vote in the House in the autumn. I am happy to say that there has fallen into my hands a letter which turns out to be a letter from the Secretary of State to all his hon. Friends, which he ends by wishing them a good recess. Let me take this opportunity to associate myself with that wish to Conservative Back Benchers. I wish them a happy recess in their constituencies explaining to GPs why they propose to ignore the results of the ballot and vote to impose the contract all the same. Not that either they or we need be surprised by the Secretary of State's reaction: it is utterly characteristic and entirely in line with the attitude that he has adopted to the NHS since he returned to his post.
The Secretary of State presides over the largest resource of professional advice and scientific expertise anywhere in Britain. It is a matter of regret that he has shown no interest in listening to any of it. This year, it is the turn of the GPs. Last summer, it was the turn of the nurses who had imposed on them the guidelines in the regrading agreement. Last autumn, it was the turn of the opticians, who warned him that ending free eye tests would result in charges of more than £10 and a drop in the number of tests. I vividly remember the Secretary of State assuring the House that he did not believe them. This spring has been marked by the refusal of the Secretary of State to listen to the chorus of criticism of his White Paper from nurses, doctors, patients and the rest of the public.
The right hon. and learned Gentleman's own limited tolerance of criticism was expressed vividly in the circular that he sent out on consultation on the White Paper. This is how he defined consultation:I look forward to receiving contributions, constructive criticisms and alternative suggestions"—so far, so good— 913so long as they are aimed at putting the White Paper proposals into practice by 1991.In other words, consultation is welcome as long as those consulted agree with the proposals. The right hon. and learned Gentleman's impatience of any other criticism was perfectly caught this afternoon when he told my hon. Friend the Member for Halifax (Mrs. Mahon) that she was not qualified to vote on whether a hospital should opt out. The Secretary of State has defined a system of opting out that matches his view that his opinion is the only one that matters: he is the only person with a vote on whether a hospital should opt out.
It should not surprise anyone that the Secretary of State has chosen to ignore a defeat of three to one. It is of a piece with his management style, which, we are bound to suspect, he copies from the Prime Minister. They are both stubborn and opinionated in their own views and contemptuous and dismissive of the views of everyone else. It is a style of government of which the nation is now heartily sick, and I warn the Secretary of State that if he persists with it, he may succeed in his given task of undermining the NHS but he will almost certainly succeed in undermining support for the Government.
§ The Secretary of State for Health (Mr. Kenneth Clarke)
I beg to move, to leave out from "House" to the end of the Question and to add instead thereof:welcomes the Government's proposals for reform in the National Health Service which will bring all parts of the health service up to the very high standards now achieved by the best, put the needs of patients first and secure the best value for money; recognises that to make the health service more responsive to the needs of patients as much power and responsibility as possible need to be delegated to local level in future, whether in directly managed or self-governing National Health Service hospitals; looks forward to large general practitioner practices being able to apply for their own budgets to obtain a defined range of hospital services so as to improve the quality of service to their patients; and fully supports the Government's decision to proceed with the implementation of the general practitioners' new contract, the contents of which were agreed with the general practitioners' leaders on 4th May.The hon. Member for Livingston (Mr. Cook) has made his last speech before the recess, which, as he said, we all confidently expect to come shortly. The hon. Gentleman opened the debate rather like a football player who expected to be playing an end of season game before a rather desultory crowd. He produced a speech and an Opposition motion which simply do not contain any new or good ideas. He showed yet again that his role in echoing the criticism that exists outside the House of our NHS reforms is to represent the views of those who have absolutely no proposals of their own to introduce. The hon. Gentleman continues to do that.
I can recall being in opposition and I know of the difficulties involved in finding ways in which to fill the time on Supply days. The hon. Gentleman was reduced to going through his newspaper clippings to see what has happened in the health world over the past few weeks. He has composed an extraordinary motion combining a quotation from the Prime Minister at a meeting of the 1922 Committee with some of the newspaper reports that followed the GPs' ballot on their contract. His speech, though concise, hardly covered the great problems of the Health Service that we are tackling at the moment.
914 There is a problem with the quotation from the Prime Minister. As the hon. Gentleman said, I am not allowed to attend meetings of the 1922 Committee and, by singular good fortune, I seem unlikely to be attending a meeting of that committee for some little time yet. I have therefore had to rely on my hon. Friends for the quotation. Not for the first time, my hon. Friends do not entirely agree. My hon. Friend the Member for Harlow (Mr. Hayes) has helpfully given us his account of what was said at the meeting but the recollection of my hon. Friend the Member for Derby, North (Mr. Knight) is that the Prime Minister said, "The National Health Service will be so good that no one will want to go private again." [HON. MEMBERS: "Yes."] That recollection seems to be shared by the majority of my hon. Friends on the Back Benches.
I am not surprised by that quotation, although I was not there to hear it and I did not know that my right hon. Friend was going to make it. It touched on conversations that my right hon. Friend and I had from time to time during the review. It is obvious that in our reforms to improve the NHS we shall aim at the best standards achieved anywhere and pose a formidable challenge to the private sector to maintain its standards to keep its appeal to those patients who want to use it for health care.
We intend that the better National Health Service that we aim to create will not set itself lower standards or goals than the private sector aims to achieve. The private sector would have less to fear from an unreformed NHS coping with out-of-date organisation and management and coming under ever-increasing strain to keep up with demand, despite all the extra resources that the Government keep pouring into it.
Patients turn to the private sector for two reasons. First, they exercise their undoubted choice to opt for private medicine for their family and secondly because of their perception of the shortcomings and inadequacies of the NHS. People have an exaggerated view of those inadequacies because they are fed by Opposition spokesmen who seize on local problems in this giant service and give the impression that waiting lists and shortages are a universal problem, when they are usually the result of purely local problems.
It is not new for the Opposition to feed critical views of the Health Service to the general public. I have said before that the best allies of private medicine in the past 10 years have been Barbara Castle and the National Union of Public Employees, whose behaviour in the late 1970s was of particular help. The Labour Front Bench team continue that unintended support for the private sector by defending the NHS against any attempt to improve it and continually producing a highly coloured version of the difficulties facing patients. We shall tackle the problems of the Health Service, and as a result of our reforms it will be a much more powerful competitor of the private sector.
§ Mr. Allan Rogers (Rhondda)
The Secretary of State said that there were two reasons why people choose the private sector rather than the NHS. First, he said that they want to exercise their choice and secondly, that they perceived inadequacies in the NHS. Does he accept that one of the main reasons why people use the private sector is that they can jump the queue and get in early? They cheat the queue.
§ Mr. Clarke
That is why we need reforms to tackle the queues and to reduce waiting times. As my hon. Friend the 915 Minister of State said at Question Time, we could do that by making all operating theatres as efficient as the best. To resist reform is to preserve excessive waiting times and queues, which helps the private sector.
The hon. Member for Livingston included the quotation in his motion merely to make the unoriginal point about tax relief for the elderly, which we included in our White Paper. As he knows, the case for tax relief is based on our belief that, while we intend to make the NHS a competitor of the private sector and able to offer high standards, it is right that patients should have the choice. As society becomes increasingly affluent, people will have more disposable income and some will wish to choose private medicine for various reasons, including convenience and personal predilection. We have offered tax relief to address the particular injustice felt by many elderly people who chose private medical insurance during their working lives but then found that the premiums rose steeply in retirement, when their income dropped. I do not understand the disporportionate attack that is always made on the tax relief proposal, which has been widely welcomed by many elderly people and is a part of the White Paper that has caused the least fuss among the non-ideological public.
The hon. Gentleman raised the more substantial item of the GPs' contract. I am grateful to him for opening up that issue, because it enables me to explain it. I am grateful to him for conceding that he recognises the case for a new contract and that he sees merit in our proposals. He is therefore urging the General Medical Services Committee to accept the need for a performance-related contract which is more in tune with the needs of the late 1980s.
I would have preferred to reach an agreed contract with the GPs and the GMSC. My predecessors and I have bent over backwards to achieve just that. The origins of the new contract go back to the Green Paper of three years ago. Many public meetings were held as the basis for consultation. We had 19 meetings with the negotiators and 110 hours of discussion on 38 documents. Eventually, we reached agreement with the formidable team of GMSC negotiators representing GPs.
The negotiators commended our package to GPs. At a local medical committee conference, it was only just rejected by local medical committee representatives in a tight vote. Then a general ballot was held. So far as I can see, although the package continued to be commended, nobody made any attempt to campaign in support of the commendation. Few local medical committees tried to explain to GPs who had not followed the details where we were in the negotiations.
In the past few weeks I have met GPs from rural areas who thought that rural payments would be abolished and did not know that we had reinstituted seniority allowances in response to the negotiators' requests. As a result of widespread public campaigning against the reforms, there was a heavy vote against the commendation.
The Opposition must address the problem and say what we should do in response to that ballot. Undoubtedly, the Labour party will say that we should accept it and start all over again. That, indeed, is the position of the GMSC, which I met yesterday. I met exactly the same negotiators with whom I reached agreement on 4 May. At that time they left with what they regarded as a satisfactory package of arrangements which they commended to GPs. [Interruption.] I was at the meeting. The negotiators do not require the hon. Member for Peckham (Ms. Harman) 916 to speak on their behalf. They had agreed a satisfactory package which they commended to their members. Faced with a vote which did not endorse their commendation, they came back to me yesterday wishing to reopen negotiations on every item on which we had reached agreement on 4 May. [HON. MEMBERS: "Why not?"] They suggested a timetable that would take us until Christmas for reconsidering the whole matter.
The hon. Member for Livingston was good enough to say that he supports the principle of higher payments for the majority of practitioners who make their own night visits. The negotiators intend that to be the subject of fresh negotiations. He said that targets were a desirable principle, although he raised some points about the details, which I shall deal with in a moment. They wish to reopen negotiations about the basis for incentive payments for higher rates of vaccination and cervical cytology. They wish us to reconsider basic practice allowances although we had already made considerable changes. I asked whether the 26-hour availability for direct contact with patients each week was settled, but they said no, that could not be regarded as such. They wish to reopen negotiations on that as well as on capitation, to which the hon. Gentleman referred and to which I shall return.
The negotiators are in no position to agree to any changes. They already have many concessions in the bag; concessions which I made last time and which they offered to members. They now take them as read and wish me to contemplate further concessions although they have no negotiating mandate. Scarred by its experience, the GM SC did not feel able to say that it would be able to agree to any of this. Presumably, I was to make concessions on all those fronts, including those supported by the hon. Member for Livingston, and then it would put it to the local medical committees, and perhaps, in due course to another ballot of general practitioners.
§ Mr. Clarke
No, it is not democracy. I have to say that it is damn near anarchy.
I understand that in settling, in this case, the basis of payment to independent contractors, or more normally the terms and conditions of employees, that is a negotiation in which the person who pays and the person who is being paid have an interest. Obviously, it is right to seek a compromise between my role, which is to look after the interests of the patients and the service and to have a contract that stimulates higher standards, and the GMSC's legitimate role to have something that is acceptable to its members. If we concede everything and the GMSC keeps going back for a vote, we will wind up with a contract that is so completely dominated by those things that make life comfortable for the doctors and the medical profession that we will sacrifice all the aims of higher quality care, which must be a legitimate interest for a sensible and responsible Government to look after in such discussions.
§ Mr. Clarke
I shall give way in a moment, but I want first to deal with two matters that I mentioned, which appear to be the only major doubts of the hon. Member for Livingston—targets and capitation.
It is a fond belief on his part that they are the only matters that need to be reopened at the request of the GMSC. I have said that the 70 per cent. target could be hit by most practices in England. I believe that is so in the case of vaccination. I introduced that as a big concession last time, because it is comparatively easily obtained by most of our English practices. My understanding is, however, that many Welsh and Scottish practices will have to raise their performance to get there—as, too, will some English practices. Therefore, a lower target was justifiable and I made a concession. It will stimulate practices to raise their performances to those that are being readily achieved in wide parts of England.
The 90 per cent. target is a World Health Organisation target. It is always stated that our agreed aim is for the National Health Service to be one of the best health care systems in the world. I cannot accept that the performance targets for vaccinations in our National Health Service should be below the level accepted by the World Health Organisation. The hon. Member for Livingston may be right—I have not looked it up—in saying that only High Wycombe hits 90 per cent. Why on earth should High Wycombe be the only place in the United Kingdom where it is legitimate for the GPs to strive to reach the best international standards? I believe that the hon. Gentleman should be committed to my principle of a performance-based contract.
When people looked around for other reasons why the GPs rejected the contract, the capitation argument was raised. As the hon. Member for Livingston said, we are talking about a contract where capitation is by far the largest single element. We are moving from 48 per cent. to 60 per cent., although that includes some new elements that we are counting as capitation. I do not accept, for the reasons that the hon. Gentleman has given, that that will have the slightest effect on average lists. The situation in the 1960s must be compared with one where we will make it much easier for patients to change their practice and for them to have access to information about the kind of services that their doctors will provide. We believe that it is right to spread the work load more fairly and to reinforce the efforts of those GPs to attract and retain their patients. However, they will not do so if they build up enormous lists. Any GP with an average or near-average list will strive to get performance payments that arise under the other part of the contract.
The hon. Member for Livingston claimed that partners are being turned away in some practices and that the number of GPs is being reduced. If that is happening, it can only be because the GPs have been carried away with their own campaigning. The only reason for not replacing a partner who has retired is that GPs are taking the view that they can earn more with four partners in the practice than they can with five. They are, therefore, somewhat irresponsibly deciding to increase their work loads, not to replace a partner when he retires and to cut back on the amount of time that they give to their patients. However, GPs will not benefit from such actions. They will lose their patients to those other GPs who will be inspired by the contract to set themselves a reasonable work load and to go after the performance payments that we are making for a good delivery of service to patients.
§ Mr. Robin Cook
If the Secretary of State accepts that longer patient lists would be at the expense of patient care and that it is not his intention that GPs should go for longer patient lists, will he accept the proposal that the upper limit for patient lists should be reduced from 3,200 to 2,500? If not, why not?
The extent to which any given number of patients reduces or does not reduce the amount of time given to patients depends on the amount of time that the doctor puts into his practice. We know from the last study of GPs that the average commitment of a GP to his practice is 38 hours a week. The contract requirement is for a minimum of 26 hours direct availability to patients. I do not see, however, why a GP who wants to have a larger than average list could not make himself available for more than 26 hours and still provide an adequate standard of service.
Patients will judge for themselves whether the amount of time that they receive from their doctors is adequate. I hope that, as we open the eyes of more patients as to what can be achieved by modern general practice, they will be particularly attracted to those doctors who have good standards of vaccination, who go in for the health promotion and the prevention of disease that we are stimulating and who offer minor surgery and all the other advantages to patients.
§ Mr. Spearing
The Secretary of State has ranged at great speed over other matters, but I wish to take him back to his complaint that the doctors wished to take up matters after the ballot. Does he recall that about 40 years ago, when the Health Service was founded, one of the big issues was that doctors were to be independent contractors and not employees? Is not the Secretary of State's complaint completely invalid, because he must accept that they are independent professional contractors providing a professional service, not employees like people on the railways or on the docks?
§ Mr. Clarke
That works both ways. I accept that they are independent contractors. However, I do not accept the Labour party's claim that, if one is an independent contractor, one is entitled to dictate from one's own side of the table all the terms of the contract.
§ Mr. Clarke
That is exactly what the Labour party is saying. The motion says that, if the doctors do not want it, the matter should be reopened and we should carry on producing terms until they are wholly acceptable to the GMSC. Is the Labour party saying that, if they vote against it 60:40 next time, it might accept that some duty falls on the Government to ensure that the patients are looked after?
§ Mr. Clarke
There are two sides to the contract. The hon. Member for Newham, South (Mr. Spearing) is right to say that history repeats itself in many ways. The extraordinary way in which the Labour party—bereft of any ideas of its own on the Health Service—simply follows through newspaper cuttings of what the GMSC or the BMA is currently arguing is a strange reversal of previous form.
919 I shall not go back to the 1970s, when the Labour party had great battles with the doctors and the nurses and did not accept votes and the terms and conditions that they wished. I shall not go back either to the 1960s, when the Labour party had equally dramatic battles with the GPs, among others, and it settled the last contract when faced with industrial action by the GPs. It started with the whole National Health Service in 1946.
It is astonishing, when one looks at the present controversy, how much history has so far repeated itself. In March 1946, the BMA's main objection to the then Labour Government's White Paper was that it had not been consulted during the course of it being drawn up. Aneurin Bevan was repeatedly attacked for what was described as a dictatorial attitude and his insistence on imposing things on the profession. The BMA's main argument was that the new health centres should be introduced on an experimental basis and not introduced nationwide. A BMA member even compared Aneurin Bevan's proposals to a "regime which is now coming to its sorry end in Nuremburg". I regret to say that, in reply, Aneurin Bevan called thema small body of politically poisoned people".That is language to which my hon. Friend and myself would never resort.
About 56 per cent. of doctors opposed co-operation with Nye Bevan's proposed creation of the National Health Service. Indeed, they voted by 9:1 against accepting the terms and conditions offered in the Health Service. However, history has not repeated itself entirely, because I do not recall that the Labour party was on the side of the nine. Today's Labour party—the very much lesser figures who occupy their predecessor's shoes—are prepared to accept a re-run of history so far——
§ Mr. Winterton
I take my right hon. and learned Friend's remarks seriously. There is considerable sense in what he says. However, will he pay credit to the overwhelming majority of general practitioners who play a vital part in the health care of this country and will he admit that they have done so since the foundation of the National Health Service? Will he also admit that the overwhelming majority of people in this country have confidence in our general practitioners?
I hope that, later in his constructive speech, my right hon. and learned Friend will say that he is prepared to enter into on-going discussions with the general practitioners to seek a satisfactory solution which, I believe, will be in the interests, not only of the doctors but of the patients.
§ Mr. Clarke
I am grateful for part of my hon. Friend's advice because I should acknowledge that our general practitioners provide a valuable service to the public and are committed to the National Health Service. Many of them voted as they did, believing that they would lose money through our proposals, when they will not. We are proposing to reward the services and work load that the 920 best doctors already operate. Many of them will benefit from our proposals. It is up to the GMSC and ourselves—or certainly it should be—to explain yet again to the doctors what we have agreed. As I made clear yesterday, I am prepared to listen to the GMSC if it comes forward with any proposals, and to explain the difficulties.
§ Mr. Clarke
Yesterday I was faced with negotiators who have now lost all their negotiating mandate. There is nothing that they can conceivably agree to. They do not know what they want and wish to reopen the whole thing over a prolonged time scale, presumably then resorting—as the Opposition wish—to another attempt to ascertain whether that is acceptable.
§ Dame Elaine Kellett-Bowman
Is my right hon. and learned Friend aware that the trend that he referred to about five minutes ago of patients transferring to doctors who offer a better service is already happening in my constituency, where some go-ahead GPs have set up exceptionally good premises, with a well-man and well-woman clinic, a hyper-tension clinic, their own night service and a 24-hour on-call service? Patients are already transferring to that practice from practices that do not supply such facilities. The doctors who are supplying these facilities will be infinitely better off in the future because at the moment they are providing those facilities out of sheer professionalism, but in the future they will be paid for what they are doing.
§ Mr. Clarke
My hon. Friend knows and supports the fact that we will make it easier for patients to change practices and that we will make it possible for them to be given more attractive information about what their practice offers.
The position of the Opposition and of some people in the profession is that rewards to attractive practices, such as my hon. Friend has just described, should not be so great in order to protect the position of those who are not offering new services or achieving the higher standards. That is not a glorious position for either the Opposition or the profession to accept. Indeed, it was not the position adoped by the GMSC. I pay tribute to the negotiators that I faced on 4 May, because they drove a hard bargain on behalf of their GPs. They got me to make concessions which, frankly, I would not otherwise have been minded to make, and they came up with a fair package. We should now explain to the doctors that we have achieved a fair balance in the interests of the patients as well as of themselves.
We are drawn over the history of these matters partly because we are going over the history of the Labour party's objections to our reforms as they pick them up as we go along. However, history needs not repeat itself. Indeed, it is not doing so, because the Labour party is on the wrong side of the barricades at the moment. As I keep saying to the BMA, the barricades should come down. It is a needless and continuing controversy——
§ Mr. Clarke
If the BMA would abandon its extremely indiscreet newspaper campaign, if its members would stop frightening their elderly patients and if we got back to the 921 undoubted agreement that exists between us on the future of the National Health Service and the principles upon which it is based, we could make progress.
Behind all the newspaper cuttings which the hon. Member for Livingston draws upon and the continuing controversy over the contract, the fact is that the common interest in the Service between many doctors and other professionals and the Government, and the common interest among most people in this country in seeing a better Health Service, is being put into effect. Yet again, as on previous occasions, I must advise the hon. Gentleman that he will be horrified to hear that the implementation of our White Paper reforms is going smoothly and well.
I shall shortly be sending members of all parties a briefing pack giving them all the detailed information that they require. The pack has recently been sent to managers and itemises in considerable detail the progress that has been made in preparing for the reforms and in putting them into place.
The review has already changed the climate in the Health Service to an extent that I would never had expected. I have never known a service which, in the past, has been so resistant to change, engaging in planning for so much change on such a wide scale.
Although all our debates are dominated by our unfortunate problems with the medical profession, we should remember that there are many other people in the Service. The chairmen and the managers of the National Health Service authorities are extremely keen on our reforms and are pressing on with them purposefully and well. There are wide agreements between doctors and nurses, who have not been mentioned so far, on a number of systems——
§ Mr. Clarke
I shall remind the House yet again that the doctors and the nurses—indeed, the great bulk of both professions—support the need to introduce new financial management systems. They support the need for clinical audit as a form of quality control. They all support the need to devise better methods of distributing our resources so that the money follows the patient. We are still discussing the details of our contract system.
§ Mr. Clarke
In my judgment about 80 per cent. of our White Paper proposals have achieved pretty universal acceptance and are now being put into place.
§ Mr. Clarke
There continues to be controversy about self-governing hospitals and about GPs' practice budgets. They are the very systems that are causing most controversy, but they are also the areas in which we are proceeding most cautiously. We have said that we will expand them where we have people who wish to make a go of it, who see the potential and who are prepared to work hard with us. I expect only a limited number in 1991. However, as the volunteers develop those ideas, I believe that their great potential will be shown and it will be recognised that that 922 is the way to organise both hospitals and practices to take advantage of the new systems, and that that will eventually move the debate on.
§ Mr. Maxwell-Hyslop
I am grateful. Would my right hon. and learned Friend tell the House why the letter from Mr. Nichol in his Department, which said that expressions of interest in going to National Health trust status by hospitals should be referred to regional health authorities for their comments before being sent to his Department when, in fact, those authorities have been completely bypassed, and that the expressions of interest have been sent to his Department without being placed before the South Western regional health authority, for instance, whose members have had no opportunity therefore to comment on them, contrary to the letter which was sent out?
§ Mr. Cryer
On a point of order, Mr. Deputy Speaker. I wonder whether we could have a brief Adjournment. The Minister of State has been giving information to the Secretary of State who clearly has not a clue about the point that has been raised and he obviously needs some conversation with the specific Minister so that he can answer his hon. Friend.
§ Mr. Deputy Speaker (Sir Paul Dean)
Order. The House is anxious to get on with the debate. I call Mr. Secretary Clarke.
§ Mr. Clarke
I know that the hon. Member for Bradford, South (Mr. Cryer) is always desperate to get his name into Hansard, but I have never known him reduced to quite that desperation before.
Duncan Nichol, the chief executive of the Health Service, is perfectly entitled to ask for expressions of interest in self-governing status. Such expressions of interest are being handled at regional level in the first place and are then being passed on to us with the comments and judgment of the regional health authority management.
I understand that there is some controversy in the south-west about exactly who has seen them, but I have no doubt that that matter could properly be sorted out by the south western regional health authority, which is responsible for managing its own affairs. The process followed by Mr. Duncan Nichol, the chief executive of the Health Service, was perfectly proper and carried out with my knowledge and approval. He produced 178 expressions of interest in self-governing status from people who saw the potential of what we are proposing for their particular units.
The debate will move on as implementation proceeds. I have no doubt that a momentum for change will build up inside the Health Service and will at last oblige the Opposition to move on and to face up to the fact that the actions of my right hon. Friends and myself are the actions 923 of friends of the National Health Service who see the way in which it should be reformed to improve the standards of service for patients in future years.
I believe that the Labour party and its allies and the more reactionary people in the professions and elsewhere will be overtaken by great events in the National Health Service over the coming years. The debate will be regarded as a footnote to the events taking place at the moment. I believe that the GPs' contract will shortly be resolved to the satisfaction of the best doctors and certainly their patients. That will be only the first step in a great process of reform which the Labour party cannot stop and of which we will be extremely proud when we have completed it.
§ Mr. William McKelvey (Kilmarnock and Loudoun)
I make a brief foray into the debate on behalf of Opposition Back-Bench Members to say that today the alternative select committee on Scottish affairs published its first report on the Health Service in Scotland. I recommend that the Secretary of State reads the document, which contradicts much of what he said. The vast majority of the evidence that we collected from people in Scotland working in and for the Health Service, from those who have benefited from the Health Service and from medical practitioners bears out much of what was said by my hon. Friend the Member for Livingston (Mr. Cook) from the Opposition Front Bench.
Much of the document is relevant only to Scotland, and I shall not bore the House with details in which hon. Members may not be particularly interested. But there are great similarities between the Health Service in Scotland and in England and great comparisons are made in our document. I shall read out some of the document, a copy of which is in the Library. Additional copies can be purchased from my good self at the price of £1.50. The reason for the charge is that the alternative select committee for Scottish affairs has to provide its own funds for its investigations, due to the failure of the House to set up a proper Select Committee on Scottish Affairs. As we are not allowed to be financed by the establishment, perhaps on Thursday the new Leader of the House will be convinced to attempt to get Scottish Conservative Back-Bench Members interested in the Health Service and all Scottish affairs, and to organise a proper Select Committee to look into these matters.
We did quite well with the resources that we had, and the document is quite well presented. In its evidence to the committee, the British Medical Association voiced some of its worries. It said:The introduction of an extended internal market, could have a number of adverse effects for consumers:The document continued
- 1. More patients would have to travel more often.
- 2. There could be particular problems for the elderly of those who have young children and friends/relatives could find visiting more difficult.
- 3. Post-operative follow up at out-patient clinics might not be carried out by the same consultant who performed the surgery."The Committee was also unconvinced by the assertion that the form of internal market being proposed would increase 'consumer' choice. At present the decision as to where treatment will take place is made individually between the patient and his or her GP or consultant. The patient's relatives may also be involved, especially if the patient is mentally ill, mentally handicapped or elderly. If Health 924 Boards entered into trading agreements with each other or with third parties to provide blocks of patient services, this individual choice would inevitably be reduced.That is quite the opposite of what the Secretary of State was saying at the Dispatch Box. That difference should be noted.
The report continued:Some witnesses raised concern that English codes of practice were inappropriate for Scotland. The Scottish Association of Local Health Councils pointed out that Scottish lists sizes are approximately 1,600, whereas English list sizes are approximately 2,000, that is 25 per cent. larger. The minimum list size for a General Practitioner to receive a budgetary allowance is 1,100. However there are increasing concerns that this is far too small.I know that discussions are taking place, and perhaps agreement is being reached on these matters.
The report continued:North American researchers have shown how volatile such budgeting would be if implemented at this level (for example, R. Scheffler writing in the Lancet, 1989). Alain Enthoven, the American economist who first proposed the concept of the internal market, has recently suggested in the British Medical Journal that the minimum size would have to be 50,000 if the scheme was to be operational. The Committee is concerned that if the minimum list size which determines the viability of budgetary-based trading is not known, then the proposals themselves will not be viable. The Committee recommends that some degree of experimentation is undertaken before any policy is implemented.I picked up in my mail the "Parliamentary Newsheet" from the Market Research Society—a document which I seldom read or quote. It contained an interesting article entitled "GPs' reaction to the White paper".
It said:Recent research by the British Pharmaceutical Market Research Group has found that GPs have become considerably more negative in response to the Government's White Paper proposals in the period since those proposals were first published. This is the overall finding of a study of 466 GPs.An earlier study was conducted immediately after the publication of the White Paper and revealed that half of GPs questioned disagreed that there were any patient benefits. That figure has now risen to 84 per cent. disagreeing that patients would benefit overall.That was despite, or perhaps because of, the Government's propaganda on the White Paper, and their explanations, which were certainly not plausible to general practitioners or to members of the public.
The most mail that I have had for a considerable time comes from ordinary people who write to me—not the photocopied letters or postcards provided by general practitioners—with real concern that the Government are not genuinely attempting to improve the lot of patients in the National Health Service. My constituents are worried that we are turning the National Health Service into a profit-making business and putting that before patient care. I have received hundreds of letters, which I shall eventually dispatch to the Secretary of State, as I have promised my constituents, so that he can read some of the comments in them.
When the Secretary of State outlined his discussions with the British Medical Association, and said that an agreement had been reached by its representatives and then overturned by a small majority at its subsequent conference, he did not provide the figures. I agree that there was a small majority. On 21 June 1989, a special conference of local medical committees voted against by 166 to 150. In anybody's language that was a majority, so 925 the representatives of the local medical committees did not agree with the General Medical Services Committee, which had agreed the deal with the Secretary of State.
The representatives of the local medical committees then insisted that a referendum was held of all general practitioners. I assume that they would have had to insist on that, whatever decision the majority had taken. Had the numbers been reversed, would the Secretary of State have said today that the majority was very narrow? Would the Secretary of State have demanded that, as the majority had accepted it, the majority should rule, and that the acceptance should be final and a burden on the rest of the medical practitioners?
When the general practitioners examined the offer which had been agreed by the GMSC negotiators, they disagreed completely with the representations made on acceptance. About 82.1 per cent. of doctors who work in the National Health Service voted and, of those, 24 per cent. voted to accept. There was a massive majority and the more the Secretary of State hurls insults at general practitioners rather than trying to explain the deal, the worse matters will become.
I hope that, as a mere Back-Bench Member, I may have the temerity to offer some advice to the Secretary of State. There are many people whose integrity one can attack. It is difficult to attack an hon. Member's integrity in the House, as it is not allowed, but outside the House, the integrity of Members of Parliament is attacked daily by their constituents; they seem to be fair game. It would be extremely difficult if one was to start to attack the integrity of some of the professional people whom we must regard with respect. In Scotland, we may get away with attacking the legal profession—sometimes that is quite fashionable. We may even get away with attacking ministers of religion, depending on which side of the fence we are on and the company we are keeping at the time.
However, neither in Scotland nor in the whole of Great Britain will one get away with attacking the integrity of doctors working in the National Health Service, who put in extraordinarily long hours on behalf of their patients, who look after the sick and the elderly and who do their best to look after the handicapped, often with services that are stretched to the limit. The public do not need a propaganda exercise to tell them that the doctors are under attack when the Secretary of State goes on television to say that doctors are reaching for their wallets.
The elderly in particular depend on their general practitioners, often in the middle of the night, when they are under stress and when there are epidemics of flu, for example. Elderly people feel passionately strongly for those who give them such good service, and they appreciate the kindness when they are under severe stress. I am afraid that on this occasion, as on other occasions, the Secretary of State has made a severe gaffe. He would do better to try to resolve the position by getting the general practitioners round the table to start afresh, if necessary.
As long ago as 1985, the general practitioners in the British Medical Association were seeking meetings with the Secretary of State on negotiations for a new contract. If such negotiations were resumed, if the Secretary of State took into consideration the genuine feelings of members of the public who, from the responses to our review, are 926 almost 100 per cent. in support not only of the National Health Service, but of those who work in it, and if we tried to use the money that we have to inject more cash into the National Health Service, and use and monitor it properly, instead of trying to make the National Health Service cheaper—to make those who work at the Cinderella end of the National Health Service pay the price for the money that has to be saved to buy equipment that should have been provided anyway—I shall believe that we are making the real progress that people demand and will demand through the ballot box at the next election.
§ Mr. John Greenway (Ryedale)
It is worth stressing that the Government's record on the National Health Service and their proposals for the future of that service are arguably the most misrepresented feature of their policy. Over the past 10 years, we have seen resources increase by 40 per cent. in real terms. Organisation for Economic Co-operation and Development figures now show that we are talking of 6.1 per cent. of gross domestic product spent on health care, as opposed to 5.3 per cent. 10 years ago. That is a tribute to the efforts the Government have made.
I am sorry to see that the hon. Member for Livingston (Mr. Cook) has left the Chamber. He alone is responsible for the most blatant misrepresentation of the Government's reforms. Even before the White Paper was published, he said that there were plans for hospitals to opt out of the NHS. There are no such plans. I see in the longer term—perhaps a decade and a half—a system in which there will be commissioning agents and bodies providing the service on a self-governing basis, whether hospitals or community services.
The Opposition motion seeks to exploit last week's vote by GPs to reject the contract agreed on 4 May between my right hon. and learned Friend the Secretary of State and the General Medical Services Committee. I must declare a personal interest in the matter in the sense that, as my hon. Friends are aware, the chairman of the General Medical Services Committee, Dr. Michael Wilson, is my own GP and a personal friend. I have had opportunities to discuss the matter with him on a number of occasions to a greater extent than one would normally expect as a Back-Bench Conservative Member.
I am pleased that my right hon. and learned Friend referred to the negotiations which took place in the weeks leading up to 4 May and the events of 4 May. There is no doubt that a fair and reasonable compromise was reached in those negotiations. My right hon. and learned Friend will accept that the many representations from hon. Members of all parties about features of the first version of the contract were helpful, especially in relation to rural practice payments, part-time allowances and targets for screening and immunisation.
I was interested to hear my right hon. and learned Friend's remark about yesterday's discussion, from which some believe that all the contract is up for renegotiation. Clearly, that is not possible. If I heard my right hon. and learned Friend correctly, he said that if there were some specific details in the contract on which further discussion might be appropriate, we should enter into further negotiations on them. However, there can be only a few. I have asked the chairman of the GMSC to let me and colleagues know whether there are any particular points that they feel are still a problem. I say that because I do not 927 believe that it does either side of the argument any benefit to perpetuate a war of words. We now need constructive proposals for the future of the Health Service, and we must take the White Paper proposals forward as quickly as we can.
Conservative Members have had many letters that reflect the misinformation and misrepresentation that abounds about the White Paper. I received one letter from a lady who said:I have been told by a visitor that when the new NHS starts, my GP will have a limited amount of money to spend on his patients. Because of this, when the money runs out, he will not be able to pay the District Nurses.Fortunately, I was able quickly to send her a reply from the district general manager of the York health authority, in which he said that he could reassure the ladycompletely that there will be no risk, whatsoever, of reducing our District Nursing Service … there are plans for a substantial increase in the number of nurses and physiotherapists and occupational therapists.It goes on to say that there is every sign that the district health authorities would be able to increase community services because, in the world which the White Paper envisages, theywill have much more time to focus on determining what the public actually want and will get hold of the purse strings so as to be able to ensure that they get it.At the 1922 Committee meeting last week, the Prime Minister stated a clear objective that we would want to see—namely, a National Health Service that is so good that people will not want private treatment. That is an objective for the future. Nevertheless, yet again it shows the Government's clear commitment to improving the NHS for the benefit of patients. In those circumstances, in trying to help doctors and their representatives to achieve the best for the NHS, Conservative Members have a right to ask them to reconsider whether the slogan of their current campaign, "SOS for the NHS", is appropriate. There is a meeting going on in York tonight under that very banner. It is sad that misrepresentations that will create yet more fear and anxiety in the minds of vulnerable patients are still being perpetuated, despite the comments of my right hon. Friend the Prime Minister.
We need a constructive debate. Patients are rightly asked what difference the White Paper proposals would make for them. District health authorities will have a much stronger brief to find out from patients what they consider should be provided, rather than rely entirely on staff saying what they think they should have. In the York health authority area, several changes are to be implemented over the next two years, taking very much the same stance as the White Paper, to improve the Health Service, make it more responsive to patients, and cut waiting lists. That would inevitably mean changes for the staff. Perhaps one can begin to understand why some staff elements are opposed to further development towards a more flexible response.
Flexibility is one of the key strengths of the White Paper. It is not prescriptive. It provides freedom to develop the service that a regional health authority considers best for its region. Only today I spoke to the chairman of Yorkshire regional health authority, and it is his view that we in Yorkshire can develop the kind of service that we believe is best for Yorkshire. That is because the White Paper offers opportunities. As I have already said, it is not prescriptive.
In their misrepresentation of the Government's proposals, the Opposition have attempted to give the 928 impression that the changes in the White Paper will be steamrollered through. That is not the case. The more one discusses these plans with district and regional health authorities and with FPCs, the more it becomes clear that they are long-term reforms. The implementation of the proposals will take time. It is clear also that, initially, it 'will be largely experimental.
§ Ms. Harriet Harman (Peckham)
Will the hon. Gentleman support people in Yorkshire who want a say before any of their hospitals become self-governing NHS hospital trusts and opt out of the district health authority?
§ Mr. Greenway
They are not going to opt out of the district health authority. As I understand it from the working papers that have been issued, the district health authority will still have power to decide where contracts are placed.
§ Mr. Greenway
The answer is that, until there are proposals for a certain hospital to take self-governing status, nobody knows what the consultation requirements will be.
§ Mr. Greenway
There will be improved opportunities for CHCs when health authorities are slimmed down in the way the White Paper proposes. If there were any kind of ballot, referendum, or public opinion test about the White Paper proposals, it would be difficult to see how the public could express a clear view, given the degree of misrepresentation about the White Paper proposals.
§ Mr. Greenway
I will not give way. I must get on, as other hon. Members wish to speak.
It is difficult to reconcile hon. Members' arguments on radio and television that the Government are steamrolling through the White Paper proposals, when every serious major structural change will be voluntary. Following my right hon. and learned Friend's statement two weeks ago about community care—we are to implement by April 1991 a positive and absolute change, when local social services departments will have responsibility for community care—we are accused of prevarication and delay. It will not be too many weeks or months before some social services directors begin to think that perhaps 1991 is too soon. Clearly, people will argue for or against the While Paper according to how it suits their political persuasions. I am much more concerned that we should now advance the proposals and take the next necessary steps to put the much-needed and imaginative reforms into place.
Task forces will have to be set up by regions to examine the opportunity for each hospital that has expressed an interest in self-governing status. From my discussions about what might happen in our area in Yorkshire, it is clear that consultants, district general managers and their management teams want more information. I understand that an additional working paper will be issued shortly. I should be most grateful if my hon. Friend the Minister of 929 State would refer to the timetable that he envisages. We need to know how the trust will increase choice, which hospitals may want to be self-governing, how the management of self-governing hospitals will work, and what discussions about contract details must take place with the district health authorities.
In other words, before any hospital becomes self-governing, we need to establish whether a proposed self-governing hospital can deliver something that improves the current arrangements. In answer to the hon. Member for Peckham (Ms. Harman), when we have got that far and we can publicise those arrangements, the public will have a much clearer impression of what is proposed.
§ Mr. Greenway
What I recommend will depend entirely on what is proposed. There is a community hospital in my constituency to which I referred my right hon. and learned Friend during Question Time several weeks ago——
§ Mr. Greenway
No, he is not going to close it. That hospital has expressed an interest in self-government. The doctors concerned have expressed a clear interest in having their own practice budget, combined with self-governing status for the community hospital. The Yorkshire regional health authority chairman and the family practitioner committee clerk have expressed the view that that is an exciting prospect.
In answer to the point by the hon. Member for Peckham, it is too early to tell whether that proposal can become a reality for that hospital. We need the information that I have mentioned, and we need to look at each case. That is why I am asking my hon. Friend the Minister of State to tell the House what further proposals there are for the additional working papers.
§ Ms. Harman
The hon. Gentleman misunderstands my question. I did not ask whether he would recommend that a hospital in his constituency should become self-governing. I asked whether he would recommend that people in his constituency should have a say in whether that hospital becomes self-governing.
§ Mr. Greenway
The Friends of Malton Hospital is an active association which, I am sure, would want to test local opinion on opting out. My right hon. and learned Friend the Secretary of State has made it clear that any hospital that wishes to become self-governing must provide clear information on whether that will be to the benefit of the patients. There will have to be a proper management structure. At this stage, it is not valid to ask people about their reactions to the proposals when the necessary additional information is not available.
Once the contract for GPs is settled, health authorities will need to encourage their bigger practices to adopt a budget. My impression is that GPs are aware that they will face a choice between adopting a budget and being left behind. By voting against the contract last week, they have perpetuated the confusion about the contract and the 930 White Paper. It is difficult not to conclude that the confusion of the two issues is a delaying tactic by some members of the medical profession.
It must be recognised that some elements of the Government's plans require more detailed explanation. That is especially so for indicative drug budgets. Initially, they will need to be very indicative if the reassurance that patients will not go without medicine and appliances is to be honoured. We must also take care not to discourage pharmaceutical research. Nevertheless, one question about drug budgets needs to be asked: why the Government are aiming to curb the worst excesses of drugs spending only by GPs and not by hospitals. The answer, of course, is that hospitals already have proper arrangements for generic prescribing to curb spending.
When the proposals in the White Paper are in place, there will be an opportunity for regional health authorities to hold the budget for drugs. That will create the opportunity for bulk purchasing. Will such opportunities be exploited? What purchasing role is envisaged for regional pharmaceutical officers appointed by regional health authorities? Surely their role should include ensuring value for money for regional health authorities as well as protecting the pharmacists.
There was some discussion earlier about how to square the circle between the Government's desire to introduce tax relief or private medical insurance for pensioners with the stated objective of my right hon. Friend the Prime Minister, to which I have already referred. Opposition Members may be interested—I can obtain copies for them if they are—in Post Magazine The Insurance Weekly last week, which published a series of articles about the future of private medical insurance. One article deals with the reasons why some people prefer private medical care. It states:Why do people choose to go for private treatment when there is a free National Health Service? Market research indicates the reasons are that they can enter hospital quickly and they can choose their admission date, and thus avoid holidays and particular business commitments. They have a choice of which hospital they wish to be treated in, and they can choose their specialist when there is no choice on the NHS. They can have a single room with telephone and their own bathroom and there are flexible visiting hours for family, colleagues and friends.It then states—this is the key point:The NHS is making improvements as private hospitals have demonstrated how the patient environment can be improved.Putting the patient first, as the White Paper states, is the purpose of the reforms.
I welcome the opportunity that the House has been given to debate these matters tonight. However, in securing this debate, the Opposition have scored something of an own goal. The vote against the contract last week was a sad embarrassment for the General Medical Services Committee, not for the Government. As my right hon. and learned Friend said, if he is forced to impose a contract, it will be the contract agreed to by the GMSC.
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
The hon. Member for Ryedale (Mr. Greenway) made an interesting speech, although he looked very uncomfortable throughout most of it, especially when he was referring to the potential closure or opting-out of hospitals in his area.
931 I understood the hon. Gentleman to say that he was in favour of the Secretary of State renegotiating certain aspects of the proposed GP contract. I agree with that. He referred to his distinguished constituent Dr. Wilson, chairman of the General Medical Services Committee, who negotiated the contract that was so resoundingly rejected in the ballot. I am sure that Dr. Wilson conducted his negotiations in good faith and that he recommended the deal to GPs only because he thought that he could not get the Secretary of State to move an inch further. It remains to be seen whether he is right, but certainly the Secretary of State appears to be setting his face against any further movement—despite the advice of the hon. Member for Ryedale.
It is silly nonsense for good and useful hospitals such as Malton. in the hon. Gentleman's constituency, to consider opting out jus t to preserve their existence. I am sure that Dr. Wilson would agree that it would be better to turn it into a community hospital, run by GPs, to serve the local community.
I do not agree with the hon. Gentleman that the Opposition have shot themselves in the foot. The debate is both timely and important because of the result of the GPs' ballot last week. I shall concentrate my brief remarks on that. More than anything else, the profession is suffering from the Secretary of State's adopted attitude during the negotiations. I for one was surprised by the size of the vote to reject the proposed contract. It might, however, have been different had the right hon. and learned Gentleman been a little more conciliatory during the negotiations. He used insults when GPs needed answers; he used threats when he should have negotiated. He lost the argument not only because of the detail but because of his hostility to people's genuine concerns. It would be a major breakthrough if he accepted that doctors and patients have genuine concerns that need to be dealt with rather than sneered at.
The proposed contract is not entirely about pay and conditions of service; it goes much wider. It embraces the whole future of the development of primary care. I profoundly reject the Government's view that the row is simply one about how much income GPs will receive in the future. I object to the Secretary of State writing letters to Members of Parliament which include sentences such as:The current argument over the GPs' contract which is often confused with the White Paper arises from contract negotiations involving doctors' salaries.A great deal of the argument is about the future of primary care—and, for rural areas, the very existence of primary health care. The Government are attempting to switch the focus of the argument and make pay the issue, so that they can use salaries as a weapon to cut costs and to impose their vision of a market-led NHS.
Doctors would respond positively to a new and radically different contract. They are not interested only in pay and conditions. As evidence of that, as far back as 1985, the eminent Dr. Wilson wrote to the Department expressing his disappointment at the speed of progress on the contract. At that time he called for the development ofa comprehensive system of paediatric surveillance, by extending the cervical screening programmes and by encouraging GPs to undertake minor surgery for their NHS patients.In that letter, Dr. Wilson outlined other proposals, including reducing the maximum list size, improving incentives to appoint additional partners to practices, 932 encouraging the development of GP community hospitals such as the one in Malton under threat of closure. ending arbitrary restrictions on patient choice——
§ Mr. John Greenway
Will the hon. Gentleman accept from me that the chairmen of Scarborough health authority and Yorkshire regional health authority have categorically stated that Malton community hospital is not under threat of closure? There is only a review of the services of the peripheral units within Scarborough district. The hospital is not under threat of closure.
§ Mr. Kirkwood
I accept that. It is always dangerous to stray into another Member's constituency issues. I shall only say, in Mr. Asquith's famous words, that we should all just wait and see.
In 1985, Dr. Wilson was in the business of trying to promote some of the very matters that arise in the current draft contract. The list that he sent to the Government also included improving services in isolated rural communities. Those proposals could have been the basis of an exciting new and agreed blueprint for the future of primary care. Instead, because of the Government's ineptitude in handling negotiations, the contract will mean that GPs will spend less time with individual patients and less time on preventive medicine and health promotion. It will be extremely difficult to make the contract work in rural areas at all.
My constituency is a rural area and no one there is in favour of using competition as a way of improving primary care in rural areas. The Government's disinterest in the development of primary care is illustrated on the first page of the proposed contract document, where it says that central to the Government's plan for improving general medical services isincreasing competition between the providers of the services.None of my constituents who have heard of that new proposal believes that competition is central to his other hopes for the development of primary health care in the NHS. The existence of facilities is the crucial factor. There are few practices within easy reach of my constituents or competing hospitals to which they can turn. I do not see how the new proposals sit easily with the provision of primary care in rural areas.
That applies in particular to how the proposals will tend to increase list sizes. Two years ago, when the original White Paper on primary care "Promoting Better Health" was published, we warned that establishing a direct link between the number of patients on a GP's list and GPs' remuneration would have severe consequences in rural areas. Since then, the position has been made worse. There is now much more emphasis on the income available to GPs in rural areas being related to the size of their lists.
In my constituency, the proportion of total income derived by GPs is in the region of 27 per cent. and the contract that we are debating takes that to 60 per cent.—55 per cent. plus marginal changes. That will have a catastrophic effect on income. I understand that the rural practice allowances are still under consideration and that the so-called tartan contract has been extended to cover other parts of the United Kingdom. But we cannot escape the fundamental problem in rural areas in Scotland that general practitioners currently receive 27 per cent. of their income from capitation fees; but under the new scheme that will be at least 55 per cent.
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)
Rural practice allowances are still being discussed. There has been no decision. We recognise and understand the pressures on rural practice in England, and an announcement will be made in due course.
§ Mr. Kirkwood
I am deeply concerned about rural practice in England, but I also have more than a passing interest in rural practice in Scotland. I accept that the Government made a concession, and I said that it was welcome at the time, but the effect in Scotland will be dire. Some practices face a massive loss in income and may go out of business. That will lead to doctors retiring early and to some practices not taking on new partners or waiting a year or two before deciding to do so. I accept that in wealthy areas some practices will have the means to attract entirely new patients; that is what the Government are trying to achieve.
Let me deal now with the effect of increased list sizes on prevention. Average list sizes will inevitably increase because of the fall in the number of GPs for the reasons that I have just explained. Within that average size there will be stark changes that will tend to act to the detriment of patients. Doctors will have less time with individual patients and less time for time-consuming preventive medicine and health promotion. Nor will there be time for doctors to visit factories and schools or to take the health promotion message to those areas which are missing out. If the increase in the link between pay and the number of patients is not designed to increase list sizes, what do the Government think they are doing increasing the capitation income?
I welcome the fact that, as the Minister said, the system of rural practice payments, is set to continue in England and Wales. We hope that that is true. They were properly taken out of the negotiations and, as I said at the time, we welcome that. However, will the Minister confirm that so far there has been no decision to impose changes to the rural practices payments and that he will continue to consult? Even if there are no other negotiations on the contract details, which the Secretary of State seems to be saying is the case, will discussions at least continue on that aspect of the rural practices payments scheme?
What other important areas will be changed by the draft regulations on rural areas that the Minister discussed with the doctors? There is great concern. I cannot believe that he does not know that already. People such as Dr. Farrow, the chairman of the rural practices committee of the General Medical Services Committee, described the original proposals asa devious blow and would probably result in the rape of the rural practice.Dr. John Ball, the chairman of the general medical committee, a Government-appointed committee, said recently that even if rural practice payments continue in their present form, the new proposals would mean that half the English and Welsh practices that have fewer than 1,500 patients will not survive. In Scotland, where list sizes are lower, 25 per cent. of practices would not survive. Those are the sort of terms that we are talking of.
Finally, let me deal with the unrealistic nature of target payments that are being proposed. The Borders area health board has achieved 92 per cent. immunisation. It has always given proper priority to achieving a high immunisation rate, which is in the interests of everyone. However, the Government system of performance-related 934 pay is causing concern further south. The current targets for screening and immunisation remain unrealistic, and will be made more so because of the extra time spent dealing with the bureaucracy inherent in the contract. The systems of paediatric and geriatric surveillance that the contract stipulates are time-consuming and will produce very little reward in return for a high degree of effort.
The Government's system, even in its modified form, will not work. It will be difficult to decide on the base number of patients. FPC and general practitioners' lists rarely agree because of the lists' ever-changing nature. GPs in deprived areas will be penalised because the migratory population that they serve will make it difficult to trace target groups, and even then they must be convinced of the need for screening and other provisions. Cultural differences mean that many women are anyway reluctant to undergo smear testing.
There is also a need for exclusions from immunisation. I refer to whooping cough and the pertussis vaccination that is the subject of medical controversy of which the Minister is surely aware. A number of patients have medical histories that prohibit them from receiving vaccinations against whooping cough, and they should be excluded from any calculation of a general practitioner's vaccination target. Evidently I did not explain that point very clearly, because the Minister's brow is furrowed. Nevertheless the Government's system of target payments for cervical screening and immunisation schemes are unrealistic.
The Secretary of State must return to the conference table to renegotiate the terms of the new contract. It- he does not, it will be the first contract in history that has not been implemented by agreement, and we shall move into a period of non-co-operation by general practitioners that will not be in the interests of the Government, doctors or patients. Certainly it will not be in the interests of people living in rural areas. I hope that the Government will properly consider all those matters when giving the right hon. and learned Gentleman future instructions as to whether to continue negotiating with the General Medical Services Council.
§ 9.1 pm
§ Mr. Jerry Hayes (Harlow)
The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) says that the Government should return to the negotiating table. The truth is that the Government reached an agreement with the General Medical Services Council and British Medical Association negotiators that was welcomed by Dr. Michael Wilson and recommended for acceptance by the BMA's membership in true trade union style. The trouble is that, in true trade union style, Dr. Wilson and the BMA so whipped up the blood of the association's members that they rejected the agreement. Only a few weeks after sensible negotiations, and after sensible concessions were made by Ministers, the BMA said, "This sort of agreement comes from the jaws of Hades," and the doctors became upset.
The hon. Member for Livingston (Mr. Cook) was right, for once, to bring to the attention of the House the serious difficulties facing the Health Service, particularly in respect of waiting lists. It may be helpful if I quote the BMA's chairman on that issue:The sum of human misery represented by those record figures is a scandal without parallel in any technically developed country.935 I am certain that the hon. Member for Livingston and his right hon. and hon. Friends agree with that sentiment, as will the rest of the House. But it was expressed by Dr. James Cameron, chairman of the BMA, in 1978. Nothing changes very much. Lord Donoughue, writing in his memoirs about Labour Government cuts—I do not want to go too much into old history—commented:It was the usual rag bag of random cuts in public investment … cuts in education, the National Health and public industry investment were imposed in full … Half the cuts were in capital investment.I shall offer one more quotation from the past:I do not believe that the problemof soaring waiting listswould be solved by any means by simply holding on to a large number of small, uneconomic hospitals."—[Official Report, 10 May 1977; Vol. 931, c. 1087.]One can imagine what the response of the hon. Member for Livingston and his right hon. and hon. Friends would be if that remark had been made by my right hon. and learned Friend the Secretary of State, or by my hon. and learned Friend the Minister. In fact, that statement was made by the then Labour Secretary of State for Social Services, David Ennals.
What has changed, however, is the amount of money that is pumped into the Health Service. I do not necessarily agree with the argument that relates such expenditure to gross domestic product, but it is used from time to time. When the right hon. Member for Plymouth, Devonport (Dr. Owen), who is not now in the Chamber, was Health Minister in the halycon days of the Wilson Government, that Government were spending 4.8 per cent. of GDP on health. In the days of David Ennals and the Callaghan Government, the figure was 5.3 per cent. Now, in the wicked days of the Thatcher junta, we are spending 6.1 per cent., and that does not include private health care. Nor does it take into account the fact that the economy is positively booming, and not on the rocks as it was in the days of the last Labour Government.
The trouble is that none of us knows where the money is going. We do not know the cost of treatment and operations, and if we do not know that, how on earth can we plan for the future? That is the essence of the reforms in the White Paper, and what we should be discussing this evening.
It is probably the exception to the rule, but I have read the motion very carefully. It has all the balance of a wet blancmange. At one moment the hon. Member for Livingston (Mr. Cook) wobbles on the subject of the Prime Minister; at another he wobbles on private health insurance. Not so long ago, it was easy for the hon. Gentleman to have a crack at the Prime Minister for using private health care. The fact is that we have a democracy, and people have the right to choose: that is the basis of Government policy, although the hon. Gentleman disagrees with it. My right hon. Friend the Prime Minister has done something very important in stating publicly that the Government's aim is to make the Health Service so good that people will neither want nor need to use private medicine. As the hon. Gentleman said, they use it now to jump queues. The White Paper proposals will stop the queues forming in the first place.
I cannot understand the Opposition's paranoia about private practice. I could understand that paranoia if the Government were proposing a Health Service that was not free at the point of delivery; I could understand it if they were proposing a Health Service that would not be funded 936 primarily from taxation. Those, however, are the major principles behind the proposed reforms, as is made categorically clear.
The West Essex health authority, in my constituency, has one of the 22 longest waiting lists in the country. My people are waiting two years for hernia operations.
§ Mr. Hayes
I do not consider it right or fair that my constituents should have to wait two years for a hip or cataract operation, when the health authority could have the opportunity of giving the patient the choice of going a little further up the road and having the operation done privately—provided that the patient does not have to pay for it and the health authority does not have to provide any more money. That strikes me as absolute common sense. We are proposing to allow people choice and the chance of having their pain and suffering removed quickly.
Judging by what we see on television and in the newspapers, hear on the radio and, indeed, hear from Opposition Members, one would think that the medical profession was 100 per cent. against the proposals. But those of us who go around the country speaking to the presidents of the royal colleges, to general practitioners and to hospital consultants can tell Opposition Members that those people—including the British Medical Association and the Joint Consultative Council—are in favour of medical audit. They have been pushing for it for years. They are also in favour of resource management: many of them have been pushing for that for years. They are in favour of money travelling with the patient, because they know that it will lead to the abolition of the efficiency trap.
Without those three fundamental foundation stones of policy, there will not be self-governing hospitals or GPs' voluntary practice budgets. If self-governing hospitals are as wicked as some people say, people will not want to take up the proposal. If voluntary budgets are as hopeless as some people say, GPs will not put their names in for them. It is a matter of choice. There is agreement about the fundamental reforms of medical audit, money travelling with the patient and resource management, and as the Secretary of State said earlier, those constitute 80 per cent. of the proposals.
I was bemused by something said about the GPs' contract. Many hon. Members have talked to a large number of GPs over the past few weeks. Anyone who has read the letter from Dr. Michael Wilson will see that they are in favour of the main thrust of the contract and have been pushing for many of the major proposals of the contract for a number of years. However, I am saddened when GPs tell me that they cannot see the point of visiting someone over the age of 75. They say that it is a waste of time. I cannot understand GPs who ask why on earth they should bother about screening when it simply means that they will find more things wrong with the patient. I cannot understand GPs who ask why they should have to immunise in the way the Government say, even though our figures are well below what the World Health Organisation advocates. That is absolutely wrong.
The Opposition were right to have some doubts about private medical insurance. However, they could have had more doubts if the Government were planning to offer overall tax relief for private medicine. That would be 937 totally wrong because it would withdraw a great deal of funding from the Health Service. That is not the case. The Government are trying to help the elderly, many of whom may have been trade unionists, who had many options open to them through their companies and who find as soon as they retire that those options stop. It is all a matter of choice.
I am not criticising the hon. Member for Peckham (Ms. Harman), but when she goes home tonight she will go back to a nanny. There is nothing wrong with the hon. Lady having a nanny to look after her children. She does not receive tax relief for it, although some say that she should. She is probably not satisfied with the sort of cover available to her children in the community. However, it is her choice. There is not a great Labour party campaign against nannies and there is not a whacking great trade union of nannies which pays the Labour party. Therefore, it is hypocritical for the Labour party to criticise the Government's proposals in this way.
I have read the motion carefully. I hope that the hon. Members for Livingston and for Peckham will look carefully at the first line and welcome with enthusiasm the Prime Minister's pledge and support what she has been saying, as it is a laudable aim.
§ Mr. Ian McCartney (Makerfield)
Having listened to the hon. Member for Harlow (Mr. Hayes), I have decided to tear up my original speech. The hon. Gentleman and I have one thing in common—we are both members of the Select Committee on Social Services, which has considered the review being proposed by the Government. Its final report will be produced on 10 August. I am rightly bound by the rules of the House not to discuss its contents, although they have been widely discussed in The Independent, The Guardian and other newspapers.
Whatever the recommendations of the Committee, its members—including many Conservative Members—were influenced by the evidence received through cross-examination, personal interview and other means when considering carefully the Government's proposals. Throughout the Committee's investigations, the attitude of the Secretary of State, which he displayed today, was sometimes foolish and sometimes insulting. With one exception, he displayed the same attitude to and perceptions about the working role of the Committee, despite the attempts of its members to try to tease out of him the Government's intentions for implementing their proposals.
The hon. Member for Harlow is a barrister. He proved tonight that if a barrister is given a brief he will argue that black is white. On 24 May, the Committee produced an interim report based on evidence received and the cross-examination of the Secretary of State and his senior officials. The hon. Member for Harlow signed that report. Time will not allow me to go through all the report's conclusions, so I shall read only two with which the hon. Member for Harlow agreed. The report says:'''A programme of persistent improvement … will provide a more effective way forward for the National Health Service than the search for a radical reconstruction of the service.'The hon. Member for Harlow agreed with the report's final conclusion, which says: 938If the Government's proposed timetable for introducing the vastly greater changes to the health service proposed in the White Paper is adhered to, we have serious fears that the stability of services and continuity of patient care may suffer during the years of transition to a new, untested system. As we said in our Report last year:'the strengths of the NHS should not be cast aside in a short-term effort to remedy some of its weaknesses'.That remains our considered view.That was the considered view of the hon. Member for Harlow on 24 May. I am saying not that he is trying to bring his profession into disrepute, but that in the white heat of argument this evening——
§ Mr. McCartney
I will give way in a minute.
The hon. Gentleman is trying to protect the Government, which is an honourable intention for a Conservative Member, but he is suffering from amnesia about the evidence that he assisted in taking, which he supported only a few weeks ago.
§ Mr. Hayes
The hon. Gentleman should read the report carefully. Although I am unable to talk about the report until 10 August, a minority report will be produced in due course. Everything with which I agreed in the report is a matter of public record. I have never said that I wholeheartedly agree with the Government's timetable. The part of the report to which the hon. Gentleman referred was written after we had heard from the Secretary of State. As will be apparent from the next report, the Secretary of State made it clear that the projects will be pilot projects in all but name. He further said that they would be evolved and run in, which satisfied me, and I hope will satisfy the hon. Gentleman. I should be grateful if he did not misrepresent the work of a respectable Committee.
§ Mr. McCartney
Far be it from me, a member of the Committee, to misrepresent it. I fear that, following the example of many barristers in tight corners, the hon. Gentleman is wriggling. The report in question was produced and voted on after interviews with the Secretary of State, accompanied by officials of his Department, on two occasions.
§ Mr. McCartney
I have made my point, and the hon. Gentleman will have to be content to allow history to determine whether my or his version is more acceptable to the nation—if indeed the nation decides to take note of what either of us has said.
Rather than being acceptable to the communities covered by the district health authorities, the review is provoking panic in many areas. For example, I have in my area the Wigan health authority, one of the largest metropolitan areas in Britain in terms of population and geographical size, with four parliamentary constituencies. It contains a number of district hospitals.
That authority has reached the interim conclusion not to support the concept of opting out, but it is fearful that competition will mean that the district hospitals will not be able to compete in the ever-increasing scramble for resources. The health authority takes the view that resources have been cut consistently every year by the Conservatives through the north-west regional authorities and through political appointments such as the chairmen of the region and district health authorities.
939 In other words, the district health authority's political chairman and the politically appointed district general manager have come up with a radical new idea following the decision not to opt out. Their idea is to close all our district general hospitals. Their proposal would asset-strip and sell off the land to whatever speculator would like to purchase Whelley, Billinge, Atherleigh and Astley hospitals and the Royal Albert Edward infirmary in Wigan. Their argument for asset-stripping such a large organisation of its district resources is to amalgamate them into one component.
Within the last 48 hours, on the ground of an emergency financial crisis, it has been decided to close one of our hospitals which cares for the mentally confused elderly and people suffering from senile dementia. Because it is claimed that an emergency exists, it is proposed not to consult the community health council, the patients' representatives or the patients' relatives.
I understand that, perhaps even this evening, those patients are being moved out into the private sector. The community health team, the social services and those involved in the care of the people in that hospital have not been consulted about the adequacy or otherwise of the alternative arrangements in the private sector. Astley hospital is to close following an announcement in recent days.
A few months ago, a Minister came to Wigan to make a triumphant speech about the local Royal Albert Edward infirmary, stating that that hospital was safe in the Government's hands and that a multi-million-pound development project would go ahead. On that occasion, my hon. Friend the Member for Wigan (Mr. Stott) and I stood outside in the rain trying to make the point that a scheme was afoot to close that hospital. That was greeted with denials. Last week the health authority, in closed session, was informed that the Wigan Royal Albert Edward infirmary was indeed to close.
Assurances were given by the regional chairman, and even by the Department, that new developments taking place at Wigan infirmary would continue. We were assured that it would have a place in the 1990s as a modern district general hospital. Last week, the authority was informed that it was to close.
Not three years ago, the Department said that Billinge hospital would be developed in the 1990s on a district basis with the latest maternity facilities. We were also assured that it would have facilities for the short-term care of the mentally ill. On that basis, we agreed to the closure of a nursing facility in Leigh. That was closed and sold off for a housing development.
It was announced that weekend facilities at Billinge maternity hospital would close, and there is a long-term proposal that the maternity unit at Billinge hospital will close completely. It does not service just the Wigan health area, but also parts of the St. Helens and Knowsley health authority area, which are two of the most socially and economically deprived areas in the north-west region, which is one of the most socially deprived regions in the United Kingdom.
The facilities for the mentally confused at Billinge hospital are so overstretched that Wigan borough council social services department is having to retain patients who would, under normal conditions, be contained in the units at Billinge and at other facilities at the Leigh end of the authority. Because of the cash crisis, the social services department is having to take on the nursing requirements 940 of the mentally confused and the elderly ambulant, in growing numbers. That is the reality of, and the background to, the Government's proposals.
Not one part of the Government's proposals has shown that there will be any new financial resources available to my authority. What is happening, in advance of the proposals, is an asset-stripping job on a grand scale. Public assets worth hundreds of millions of pounds will he sold, and not one local person will be asked if they would like Wigan hospital, Billinge hospital, Leigh infirmary, Atterleigh hospital and Astley hospital to remain open.
None of us is in the ball game of keeping open hospitals that need to be closed if alternatives are provided, but we are opposed to the naked opportunism of those politically motivated people in the Health Service—people who have been appointed by Conservative Members and Conservative party members—who are asset-stripping on their behalf in advance of the Health Service reviews.
I ask the Secretary of State—with whom I have clashed several times—to institute an immediate inquiry into why Wigan health authority, on the grounds of an emergency. is taking patients out of hospitals and dumping them into the private sector, without any consultation with the social services or with those people who are currently responsible for looking after them. The least that the Secretary of State can do is give them a commitment that he will look into that within the next 24 hours.
I hope that, when the report is produced on 10 August, the Secretary of State will respond effectively to it.
§ Mrs. Audrey Wise (Preston)
I have listened with the utmost attention, as my hon. Friend represents a constituency in the north-west, to the catalogue of disasters that are befalling his area. I do not want to compete with him by raising larger issues, as he has done, but I would like to draw my hon. Friend's attention to a small but significant matter which has occurred in my area, which shows the madness caused by the so-called search for efficiency.
Preston district health authority has saved the magnificent sum of £1,500 during the past year by cutting the availability of free incontinence pads for elderly ladies. Whether we look at the large scale, as my hon. Friend has done, or at the small scale, as I have done, the picture is the same.
§ Mr. McCartney
My hon. Friend is correct. On the day that the former Under-Secretary visited Wigan and salmon sandwiches and a huge banquet were provided in Billinge hospital, babies were being born and the supply of nappies had to be restricted. That shows the Government's priorities.
I hope that the Secretary of State will, after 10 August, take into account the views in the majority report, and that he will assure the public and Opposition Members that he will not ride roughshod over the doctors, the midwives and the nation, who are totally opposed to the proposals.
§ Mr. Tony Baldry (Banbury)
I hope that the House will understand if, given the short time left in the debate, I do not propose to give way as much as I would like.
I think that hon. Members agree that the ultimate purpose of the National Health Service must be to improve services to patients. The White Paper's proposals will do that by giving doctors and medical staff more 941 control, by cutting central administration controls, devolving managerial power and by allowing general practitioners to become budget holders and hospitals to become self-governing—all within a framework of a publicly funded Health Service. In that way, patients will come first. The ambition of everyone must be to ensure that each and every patient in the NHS is treated as an individual.
Central to the NHS, as with every publicly funded service, must be money. It is interesting that, during the debate, we have heard little about money. The Opposition's motion must be the first motion on the NHS tabled by the Leader of the Opposition that has not alleged that the NHS is underfunded. That is perhaps because the Opposition have recognised that, whatever funding proposal they put forward, the Government will always more than match it.
Over the past 10 years, the Government have persistently and diligently provided more money for the NHS. In 1978–79 the Health Service budget was £7.75 billion and in 1989–90 it is about £26 billion. National Health Service spending has increased by 36 per cent. more than inflation and has grown more rapidly than the rate of growth of the real economy. Health spending has risen from 4.8 per cent. of GDP 10 years ago to 6.1 per cent. now. If we reverted to the funding of the NHS when the Labour party was in government, we would have to cut the number of doctors and dentists by about 14,000, the number of nurses and midwives by 67,000 and the number of hospital patients by 1.5 million.
Of course, the National Health Service always faces fresh challenges. For example, 70 per cent. of NHS costs are labour costs, and there has been a dramatic and welcome increase in the number of NHS employees over the past 10 years—5,800 more doctors and dentists. Their pay has grown 25 per cent. more than inflation since 1979. Nurses, whose pay fell under Labour—they received increases below the rate of inflation for three years—have seen their pay rise by 45 per cent. more than inflation since 1979.
As well as trying to ensure that doctors and nurses and those working in the NHS are well remunerated, there are also the challenges of an ageing population and of medical advance. In response, the Government will clearly have to provide ever more money for the NHS, but we all have an interest in ensuring that that money is well spent. As my right hon. and learned Friend the Secretary of State has said many times, the NHS is not a business, but clearly it can be more businesslike.
It is right that the Government should devolve greater powers and responsibility to local levels. For far too long, the NHS has been over-administered and under-managed. This has led, for example, to the Public Accounts Committee discovering, according to a report published last year, that in the five districts whose operating theatre usage was studied, only 72 per cent. of available sessions were regularly scheduled for use and of those about 23 per cent. were cancelled, often at short notice. Consequently, only half the daytime operating theatre sessions were used—no wonder we continue to have long waiting lists for cold surgery. The Public Accounts Committee concluded:Traditional practice and habits, framed for the convenience of consultants and staff must be reviewed as necessary.942 Furthermore, all too often the lunatic situation arises that if a hospital does more work it simply runs out of money more quickly. That is a lunatic efficiency trap. The proposed internal market will replace that efficiency trap with a much better system whereby the more contracts that are won to provide services, the more work is done and the more money secured. Hospitals that increase their referrals will also increase their income.
Let us be clear that there is a consensus on the need for an internal market. In a speech a year ago at Guy's hospital, the hon. Member for Livingston (Mr. Cook) said:Personally, I can see merit in greater flexibility that permits health authorities to convert cross-boundary flows of patients with cross-boundary flows of cash.That is exactly what the internal market is about—correlating cross-boundary flows of patients with cross-boundary flows of cash.
The right hon.Member for Plymouth, Devonport (Dr. Owen) observed thatbringing the disciplines of the internal market into the NHS is the most important single reform I would advocate, for it can work with the grain of the NHS and not weaken its ethical basis.As the Prime Minister has made clear, the internal market has nothing to do with privatising health services but everything to do with improving them.
That leads us to the background of the general practitioners' contract and the recent debate. The House should recollect that the GPs' draft contract has had a long gestation period. We have almost forgotten, in the mists of time, the Green Paper "Promoting Health Care—An Agenda", which came out in April 1986. That Green Paper was followed by the White Paper "Promoting Better Health" in November 1987 and that, in turn, led to long negotiations with representatives of the GPs on the detailed proposals.
All hon. Members will have had a letter from Dr. Wilson factually reporting that the general practitioners have voted against accepting that contract. Interestingly, no argument was advanced in that letter to explain why general practitioners had rejected the contract. It would have been very difficult for Dr. Wilson to advance such arguments, because the General Medical Services Committee contract was the very contract that he and the other negotiators had recommended for their own members.
I am looking forward to a happy recess because the general practitioners in Oxfordshire voted in support of the proposed contract.
§ Mr. Baldry
No, there is very little time and I made it clear at the start of my speech that I did not intend to give way. The hon. Gentleman, who was not even present then, can hardly expect to intervene now.
It is difficult for Dr. Wilson and the GMSC to suggest that a contract that they negotiated and agreed is flawed in some way. I have yet to see, and I suspect that other hon. Members have yet to see, any detailed proposals from the GMSC on how the contract should be improved.
The background to the contract is that spending on GP services has risen by 50 per cent. over and above inflation during the past 10 years. The number of GPs in practice is up by 20 per cent. and their support staff are up by 50 per 943 cent. Despite that, real concerns remain about the present GPs' contract because it does not sufficiently reward zeal or quality and it is not sufficiently sensitive to patients.
It seems to be suggested that by increasing the proportion of doctors' remuneration that comes from capitation, we shall force doctors to take on more patients and undermine the quality of care. The case for making a significant proportion of GPs' income dependent on capitation is not new. That case was made by one of the authors of the National Health Service, Nye Bevan himself, on the founding of the NHS. He said:I cannot dispense with the principle that the payment of a doctor must in some degree be a reward for zeal, and there must he some degree of punishment for lack of it. Therefore, it is proposed that capitation should remain the main source from which a doctor will obtain his remuneration."—[Official Report, 30 April 1946; Vol. 42, c. 55.]Nye Bevan saw capitation as one of the underlying principles on which general practitioners should be rewarded. Moreover, nothing in the Government's proposals would increase doctors' average list size. Patients will register with the practice of a doctor who they think gives the right quality of care and the right amount of time. GPs' list sizes are falling from an average 2,200 to under 2,000 now. Just as it is impossible to invent new patients, so it is mathematically impossible to increase the average list size.
I hope that, during the summer, GPs will reflect that the contract that they have been offered is a good one and that many concessions have been made by my right hon. and hon. Friends in the Government, after listening to representations that they undoubtedly received from hon. Members on both sides of the House. While the Government's health proposals will not solve everything, they will make several important advances, extend patient choice, encourage enterprise in hospitals and among GPs and improve the quality of patient care and treatment in the framework of a publicly financed Health Service.
§ Ms. Harriet Harman (Peckham)
It was evident from the Secretary of State's speech that he did not welcome the debate this afternoon, but he rose to the occasion with his usual combination of trying to distract attention from the real issues and a dose of abuse for the doctors. [Interruption.] Hon. Members who were present will agree that that is a fair description of his speech.
Our main concern about the contract is the incentive that it provides to GPs to increase the number of patients on their lists. Successive Governments have encouraged GPs to reduce the number of patients on their lists. That was for the good reason that, if GPs are to make the correct diagnosis, give appropriate treatment and prescriptions, and manage long-term illnesses properly and sensitively, they require time. Doctors want more time for each patient and patients want more time from their doctor. Yet the Government will make good doctors into bad doctors by paying them to take more patients on to their lists, so that each patient will have less time.
Most people are happy with their GP. A poll in The Daily Telegraph showed that 80 per cent. of people were happy. The 20 per cent. who said that they were not happy said that the doctor always seemed rushed, did not have time to explain and was not interested in them as a person. Increased patient list sizes will increase dissatisfaction with GPs. Studies of what patients want from general practice 944 consistently show that they want a doctor who listens, understands, takes trouble and is prepared to explain. In other words, they want a doctor who has time for them.
Not only doctors take the view that an increase in the percentage of doctors' pay attributable to capitation will result in increased list sizes. The Patients Association, the Association of Community Health Councils and a range of other voluntary organisations and academic institutions that have no vested interest and no axe to grind believe that that will be the effect. So do organisations such as the Centre for Policy on Aging, Age Concern, the Health Visitors' Association and the National Children's Bureau. The Government are alone in believing that performance relates to the number of patients treated rather than the quality of care.
The Government believe that the Health Service centres on cost rather than on care. That is why they are obsessed with the GPs who refer more than the average number of patients to hospital, but are blithely unconcerned about the GPs who under-refer and whose patients suffer because they are not referred to hospital.
The Government are obsessed, too, with GPs who prescribe more than the average for their patients, but they are blithely unconcerned about patients who suffer because their GPs under-prescribe. They are not concerned with the appropriateness of the referral or the prescription; all they are concerned about is the cost. Their real interest is in cash, not care. Their prime concern is a healthy bank balance, not a healthy patient, and the doctors know that.
We have seen what cash limits have done to hospital services and how hospital services have been squeezed. We all know that cash limits will come down on family doctors. The Health and Medicines Act 1988 put in place cash limits on ancillary services for GPs' practices and practice premises. The White Paper plans to cash-limit the rest of GP services—prescriptions and referrals to hospital.
I do not see any shaking of heads, but the Government have up to the present day been denying cash limits on GP services. However, it is clear that they will be cash-limited. I shall use an example that makes it clear that that is what is intended by the White Paper. When a patient goes to the accident and emergency department and is subsequently admitted to hospital, the bill for that treatment will go to the hospital, if it is an opted-out hospital, or to the district health authority. When a patient is referred to hospital and is admitted on the basis of a GP's referral, the GP's practice budget will have to bear the cost of that treatment.
The Government are afraid that GPs faced with a cash-limited budget, who see a patient who needs treatment in hospital, will, instead of referring him to the out-patient department, advise him to go to the accident and emergency department, because then the bill will be paid by the hospital of the district health authority. That is why, in working paper 3, the Government are advising hospitals to have watchdogs in their accident and emergency departments to see whether the hapless patients are real accident or emergency cases or whether they are refugees from cash-limited GP budget holders. That is. clear evidence that GP's practices will be cash-limited. The Government anticipate that GPs will try to escape the cash limit by advising their patients to go to accident and emergency departments rather than referring them to hospitals in the normal way.
945 The most important difference that the Government have with just about everyone else is the substance of the proposals in the contract and the White Paper. We cannot let the debate pass without a comment on the way in which the Secretary of State has handled the issue. Doctors and the public have disagreed with him. His hon. Friend the Member for Ryedale (Mr. Greenway) said that the public were too thick to be allowed to have a say on the White Paper. On "Any Questions" a couple of weeks ago, when a doctor disagreed with him about the White Paper proposals, all the Secretary of State could do was to rubbish him and to say, "You have not read the White Paper." He has accused GPs of reaching for their wallets. Anyone who disagrees with him is accused of misunderstanding the proposals. Those people who want change other than that which he is proposing are told that they want no change at all.
The problem is that the Government have not been prepared to listen to those people who work in the Health Service, who use the Health Service and who have been crying out for change. That shows not just sluggishness or bullying, although it certainly shows that, but it shows the Government's inability, refusal and unpreparedness to listen to views that do not fit in with their ideological dogma. It is that same authoritarianism that will prevent people from having a say in whether their hospital opts out.
The Prime Minister has said that she will make the Health Service so good that no one will want to use private health care. Nobody believes that, but if that were the case, we should welcome it. However, as the Prime Minister wants competition and market forces in health care, it is clear that that statement has no credibility.
When we return to the House in the autumn, the Government will try to impose the new contract on the doctors, despite a ballot in which there was a vote of three to one against. We are told that there will be no new discussions. We will oppose the Government's attempt to force a contract on the GPs. The Secretary of State will have to fight his contract through. Any time that Conservative Members vote to impose the new contract, that will simply serve to remind their constituents how little they now have in common with their Member of Parliament.
The more the Government berate the doctors, the more they widen the gulf between Government and public opinion because people do not accept that doctors are stupid or greedy. They do not accept that doctors are interested only in their pockets, not in their patients. When Conservative Members return to their constituencies for the recess, they will discover the huge consensus against the Government's proposals. There is literally nowhere in the country where they will find support for the contract or the White Paper. There are no places to which the Government can run with this proposal.
We often hear talk of Tory heartlands, but even the Tory heartlands are opposed to these proposals—to the contract and to the White Paper. There are no Tory heartlands when it comes to the National Health Service. When Conservative Members vote tonight, they will simply be voting to increase the gulf between themselves and the people they are supposed to represent.
§ The Minister of State, Department of Health (Mr. David Mellor)
I begin by thanking my hon. Friends the Members for Ryedale (Mr. Greenway), for Harlow (Mr. Hayes) and for Banbury (Mr. Baldry) for their supportive speeches. My hon. Friends' penetrating speeches have made my task easier. I must advise especially my hon. Friend the Member for Ryedale that I should like to write to him on the specific points that he raised because time is pressing and I want to make other points tonight.
It is clear that the Labour party has cobbled together an end-of-term assault on the Government based on the lowest common denominator of opposition to some of the moves to reform the Health Service. It is interesting that the hon. Member for Peckham (Ms. Harman) laboured so mightily to denounce a contract which, for the first time, offers the better doctors rewards for doing more to treat their patients.
What can be wrong with a contract which, for the first time, introduces basic payments to include opportunistic screening and check-up invitations for the healthy every few years to give us a chance to be a service for health, not just for sickness? What is wrong with a proposal that all newly registered patients should be offered a check-up? What is wrong with a proposal that doctors should be paid a higher capitation payment for having elderly patients on their lists—an argument that is totally distorted by the suggestion that the contract will somehow provide a disincentive to treat the elderly when the opposite is the case?
What is wrong with extra payments for looking after the very young and for immunising them against preventable diseases when our record on immunisation is far too low compared with that of many other countries and leaves a great deal to be desired? What is wrong—I should have thought that this point would be of particular interest to Opposition Members—with extra payments for doctors who practise in deprived areas to try to do something about the inequalities of health standards that so many research projects have shown exist in some inner-city practices and practices elsewhere?
It seems astonishing that, in the cynical cosy-up between the Labour party and the BMA, all those facts should be disregarded while both the hon. Members for Livingston (Mr. Cook) and for Peckham—the Opposition's Front-Bench spokesmen—have done nothing more than parrot the BMA's case. Indeed, that was taken to absurd lengths by the hon. Member for Livingston when he set out to prove that it is not possible to reach targets of 70 per cent. in inner-city areas. Nothing could be further from the truth. It is perfectly possible, as the public health laboratory service study showed in 1985, given proper incentives, for everyone in the country, wherever they live, to have the opportunity, and to take it up, to have their children immunized. It seems extraordinary that Labour Members should share the patronising view that somehow people who live in inner-city areas are less interested in the health care of their children. When places such as Doncaster and Rotherham, which are not exactly bastions of the middle class, can achieve 90 per cent. immunisation rates for polio, why cannot other parts of the country do the same? For the first time, we are giving people an incentive to do that.
As the York university study showed only too clearly, the problem at the moment is that innovative practises sit 947 alongside those which are practising the medicine of 20 years ago, but there is no difference in the remuneration to the innovative practice. How are we to redress the imbalance in quality between one group of GP practices and another unless we have a contract which, for the first time, rewards good performances? I am astonished that that view cannot be shared on both sides of the Chamber, as all our constituents will gain from the introduction of such a contract.
It is even more astonishing that the Labour party should see fit to put forward the BMA's obstructive arguments against the contract, since whenever any Government have sought to make changes, whether those changes were right or wrong, they have run into difficulties with the BMA.
§ Mr. Mellor
The hon. Gentleman says that it is not true, but I shall demonstrate that it is.
In the past 25 years there have been two substantial periods of Labour Government. In the 1964 Parliament it took four months of a Labour Government before the BMA, in February 1965, was advising its members to give three months notice of termination of their contract with the NHS. That is the background against which the contract that we are now replacing was put into place by the Labour Government. In the 1974 Parliament, it took 18 months before the BMA council was condemning what the then Labour Government were doing as unsound and a threat to fundamental freedoms. In 1977 Mr. Anthony Grabbham, now Sir Anthony Grabbham, a spokesman for the BMA then as now, said of Labour's pay policy:It is a catalogue of broken promises, a cynical disregard of agreement and progressive emasculation of review body procedures all leading to inexorable degradation of consultants' status.The attempt to suggest a common cause between the BMA and the Labour party is specious, and the mess of potage which Labour Members have sold is the rights of their constituents to a good and consistent policy of health care that modern reforms can bring about.
Once again, we have heard so much from the Opposition, but not a word about a coherent alternative to address the NHS's central problems. The Opposition motion specifically criticises the Prime Minister's words when she set out the aspiration that she wants to see the National Health Service so good that people will not need private medicine. I consider that to be a perfectly estimable aspiration. It provides an interesting contrast with the Labour party. In the 1970s, the Labour party was prepared to drive the Health Service into total disarray to abolish private medicine. Its latest policy document shows that it seems to have learnt very little from that. The problems of the National Health Service, such as the long waiting lists which have caused some people to go private, are not the source of proper analysis by the Labour party, but simply used as a crude stick with which to beat the Government.
In a free society where people must have the right to make private provision out of taxed income if they choose, the best way is to make them feel that they do not need to do that. One way to make people sure that they do not need to do that is to cut waiting times. We have research that shows that if every district health authority was able to use its operating theatres as effectively as the average, 948 we could get rid of long waiting times overnight. That will come about only if a coherent set of proposals is pursued, which involves not only additional resources for the National Health Service, but a proper and sensible way of ensuring that those resources are set in the right management framework. I hope that the House will reject the Labour party's opportunistic motion tonight.
§ Question put, That the original words stand part of the Question:——
§ The House divided: Ayes 207, Noes 315951
|Division No. 321]||[10 pm|
|Adams, Allen (Paisley N)||Ewing, Mrs Margaret (Moray)|
|Allen, Graham||Fatchett, Derek|
|Alton, David||Fearn, Ronald|
|Archer, Rt Hon Peter||Field, Frank (Birkenhead)|
|Armstrong, Hilary||Fields, Terry (L'pool B G'n)|
|Ashdown, Rt Hon Paddy||Fisher, Mark|
|Ashley, Rt Hon Jack||Flannery, Martin|
|Ashton, Joe||Flynn, Paul|
|Banks, Tony (Newham NW)||Foot, Rt Hon Michael|
|Barnes, Harry (Derbyshire NE)||Forsythe, Clifford (Antrim S)|
|Barnes, Mrs Rosie (Greenwich)||Foster, Derek|
|Barron, Kevin||Fraser, John|
|Battle, John||Galbraith, Sam|
|Beckett, Margaret||Galloway, George|
|Beggs, Roy||Garrett, John (Norwich South)|
|Bell, Stuart||George, Bruce|
|Benn, Rt Hon Tony||Gilbert, Rt Hon Dr John|
|Bennett, A. F. (D'nt'n & R'dish)||Godman, Dr Norman A.|
|Bidwell, Sydney||Gordon, Mildred|
|Blair, Tony||Gould, Bryan|
|Blunkett, David||Graham, Thomas|
|Boateng, Paul||Grant, Bernie (Tottenham)|
|Boyes, Roland||Griffiths, Nigel (Edinburgh S)|
|Bradley, Keith||Griffiths, Win (Bridgend)|
|Bray, Dr Jeremy||Grocott, Bruce|
|Brown, Nicholas (Newcastle E)||Hardy, Peter|
|Buckley, George J.||Harman, Ms Harriet|
|Caborn, Richard||Hattersley, Rt Hon Roy|
|Callaghan, Jim||Heffer, Eric S.|
|Campbell, Menzies (Fife NE)||Henderson, Doug|
|Campbell, Ron (Blyth Valley)||Hinchliffe, David|
|Campbell-Savours, D. N.||Hoey, Ms Kate (Vauxhall)|
|Canavan, Dennis||Hogg, N. (C'nauld & Kilsyth)|
|Cartwright, John||Home Robertson, John|
|Clark, Dr David (S Shields)||Hood, Jimmy|
|Clarke, Tom (Monklands W)||Howarth, George (Knowsley N)|
|Clelland, David||Howell, Rt Hon D. (S'heath)|
|Clwyd, Mrs Ann||Hoyle, Doug|
|Cohen, Harry||Hughes, John (Coventry NE)|
|Coleman, Donald||Hughes, Robert (Aberdeen N)|
|Cook, Frank (Stockton N)||Hughes, Simon (Southwark)|
|Cook, Robin (Livingston)||Illsley, Eric|
|Corbett, Robin||Ingram, Adam|
|Corbyn, Jeremy||Janner, Greville|
|Cousins, Jim||Jones, Barry (Alyn & Deeside)|
|Crowther, Stan||Jones, Martyn (Clwyd S W)|
|Cryer, Bob||Kilfedder, James|
|Cummings, John||Kinnock, Rt Hon Neil|
|Cunliffe, Lawrence||Kirkwood, Archy|
|Cunningham, Dr John||Leadbitter, Ted|
|Darling, Alistair||Leighton, Ron|
|Davies, Rt Hon Denzil (Llanelli)||Litherland, Robert|
|Davies, Ron (Caerphilly)||Livsey, Richard|
|Davis, Terry (B'ham Hodge H'l)||Lloyd, Tony (Stretford)|
|Dixon, Don||Lofthouse, Geoffrey|
|Dobson, Frank||Loyden, Eddie|
|Doran, Frank||McAllion, John|
|Douglas, Dick||McAvoy, Thomas|
|Duffy, A. E. P.||McCartney, Ian|
|Dunnachie, Jimmy||Macdonald, Calum A.|
|Dunwoody, Hon Mrs Gwyneth||McKay, Allen (Barnsley West)|
|Eadie, Alexander||McKelvey, William|
|Eastham, Ken||McLeish, Henry|
|Evans, John (St Helens N)||McNamara, Kevin|
|Ewing, Harry (Falkirk E)||McWilliam, John|
|Madden, Max||Sheldon, Rt Hon Robert|
|Mahon, Mrs Alice||Shore, Rt Hon Peter|
|Marshall, Jim (Leicester S)||Short, Clare|
|Martin, Michael J. (Springburn)||Sillars, Jim|
|Martlew, Eric||Skinner, Dennis|
|Meacher, Michael||Smith, Andrew (Oxford E)|
|Meale, Alan||Smith, C. (Isl'ton & F'bury)|
|Michael, Alun||Smith, Rt Hon J. (Monk'ds E)|
|Michie, Bill (Sheffield Heeley)||Smith, J. P. (Vale of Glam)|
|Morgan, Rhodri||Soley, Clive|
|Morley, Elliot||Spearing, Nigel|
|Morris, Rt Hon A. (W'shawe)||Steel, Rt Hon David|
|Morris, Rt Hon J. (Aberavon)||Steinberg, Gerry|
|Mowlam, Marjorie||Stott, Roger|
|Mullin, Chris||Straw, Jack|
|Murphy, Paul||Taylor, Mrs Ann (Dewsbury)|
|Nellist, Dave||Taylor, Matthew (Truro)|
|O'Brien, William||Thompson, Jack (Wansbeck)|
|Orme, Rt Hon Stanley||Turner, Dennis|
|Owen, Rt Hon Dr David||Vaz, Keith|
|Patchett, Terry||Walker, A. Cecil (Belfast N)|
|Pendry, Tom||Wall, Pat|
|Pike, Peter L.||Wallace, James|
|Powell, Ray (Ogmore)||Walley, Joan|
|Prescott, John||Warden, Gareth (Gower)|
|Primarolo, Dawn||Wareing, Robert N.|
|Quin, Ms Joyce||Watson, Mike (Glasgow, C)|
|Radice, Giles||Welsh, Andrew (Angus E)|
|Randall, Stuart||Welsh, Michael (Doncaster N)|
|Redmond, Martin||Williams, Rt Hon Alan|
|Rees, Rt Hon Merlyn||Williams, Alan W. (Carm'then)|
|Richardson, Jo||Wilson, Brian|
|Roberts, Allan (Bootle)||Winnick, David|
|Robinson, Geoffrey||Wise, Mrs Audrey|
|Rogers, Allan||Worthington, Tony|
|Rooker, Jeff||Wray, Jimmy|
|Ross, Ernie (Dundee W)|
|Ross, William (Londonderry E)||Tellers for the Ayes:|
|Rowlands, Ted||Mr. Frank Haynes and Mrs. Llin Golding.|
|Adley, Robert||Brandon-Bravo, Martin|
|Aitken, Jonathan||Brazier, Julian|
|Alexander, Richard||Bright, Graham|
|Alison, Rt Hon Michael||Brown, Michael (Brigg & Cl't's)|
|Allason, Rupert||Browne, John (Winchester)|
|Amess, David||Buchanan-Smith, Rt Hon Alick|
|Amos, Alan||Buck, Sir Antony|
|Arbuthnot, James||Budgen, Nicholas|
|Arnold, Jacques (Gravesham)||Burns, Simon|
|Arnold, Tom (Hazel Grove)||Burt, Alistair|
|Ashby, David||Butcher, John|
|Atkins, Robert||Butler, Chris|
|Atkinson, David||Butterfill, John|
|Baker, Rt Hon K. (Mole Valley)||Carlisle, John, (Luton N)|
|Baker, Nicholas (Dorset N)||Carlisle, Kenneth (Lincoln)|
|Baldry, Tony||Carrington, Matthew|
|Batiste, Spencer||Carttiss, Michael|
|Beaumont-Dark, Anthony||Cash, William|
|Bellingham, Henry||Chapman, Sydney|
|Bendall, Vivian||Chope, Christopher|
|Bennett, Nicholas (Pembroke)||Churchill, Mr|
|Benyon, W.||Clark, Hon Alan (Plym'th S'n)|
|Bevan, David Gilroy||Clark, Dr Michael (Rochford)|
|Biffen, Rt Hon John||Clark, Sir W. (Croydon S)|
|Blackburn, Dr John G.||Clarke, Rt Hon K. (Rushcliffe)|
|Blaker, Rt Hon Sir Peter||Conway, Derek|
|Body, Sir Richard||Coombs, Anthony (Wyre F'rest)|
|Bonsor, Sir Nicholas||Coombs, Simon (Swindon)|
|Boscawen, Hon Robert||Couchman, James|
|Boswell, Tim||Cran, James|
|Bottomley, Peter||Currie, Mrs Edwina|
|Bottomley, Mrs Virginia||Curry, David|
|Bowden, A (Brighton K'pto'n)||Davies, Q. (Stamf'd & Spald'g)|
|Bowden, Gerald (Dulwich)||Davis, David (Boothferry)|
|Bowis, John||Day, Stephen|
|Boyson, Rt Hon Dr Sir Rhodes||Devlin, Tim|
|Braine, Rt Hon Sir Bernard||Dorrell, Stephen|
|Douglas-Hamilton, Lord James||Key, Robert|
|Dover, Den||King, Roger (B'ham N'thfield)|
|Dunn, Bob||Kirkhope, Timothy|
|Dykes, Hugh||Knapman, Roger|
|Eggar, Tim||Knight, Greg (Derby North)|
|Emery, Sir Peter||Knowles, Michael|
|Evans, David (Welwyn Hatf'd)||Knox, David|
|Fairbairn, Sir Nicholas||Lamont, Rt Hon Norman|
|Fallon, Michael||Lang, Ian|
|Favell, Tony||Latham, Michael|
|Fenner, Dame Peggy||Lawrence, Ivan|
|Field, Barry (Isle of Wight)||Lawson, Rt Hon Nigel|
|Finsberg, Sir Geoffrey||Lee, John (Pendle)|
|Fishburn, John Dudley||Lennox-Boyd, Hon Mark|
|Forman, Nigel||Lester, Jim (Broxtowe)|
|Forsyth, Michael (Stirling)||Lightbown, David|
|Forth, Eric||Lilley, Peter|
|Fowler, Rt Hon Norman||Lloyd, Sir Ian (Havant)|
|Franks, Cecil||Lloyd, Peter (Fareham)|
|Freeman, Roger||Lord, Michael|
|French, Douglas||Luce, Rt Hon Richard|
|Gale, Roger||Lyell, Sir Nicholas|
|Gardiner, George||McCrindle, Robert|
|Garel-Jones, Tristan||Macfarlane, Sir Neil|
|Gill, Christopher||MacKay, Andrew (E Berkshire)|
|Glyn, Dr Alan||Maclean, David|
|Goodson-Wickes, Dr Charles||McLoughlin, Patrick|
|Gorman, Mrs Teresa||McNair-Wilson, Sir Michael|
|Gorst, John||McNair-Wilson, Sir Patrick|
|Gow, Ian||Madel, David|
|Grant, Sir Anthony (CambsSW)||Malins, Humfrey|
|Greenway, Harry (Ealing N)||Maples, John|
|Greenway, John (Ryedale)||Marland, Paul|
|Gregory, Conal||Marlow, Tony|
|Griffiths, Sir Eldon (Bury St E')||Marshall, John (Hendon S)|
|Griffiths, Peter (Portsmouth N)||Martin, David (Portsmouth S)|
|Ground, Patrick||Mates, Michael|
|Gummer, Rt Hon John Selwyn||Maude, Hon Francis|
|Hague, William||Mawhinney, Dr Brian|
|Hamilton, Neil (Tatton)||Maxwell-Hyslop, Robin|
|Hampson, Dr Keith||Mayhew, Rt Hon Sir Patrick|
|Hanley, Jeremy||Mellor, David|
|Hannam, John||Miller, Sir Hal|
|Hargreaves, A. (B'ham H'll Gr')||Mills, Iain|
|Hargreaves, Ken (Hyndburn)||Mitchell, Andrew (Gedling)|
|Harris, David||Mitchell, Sir David|
|Haselhurst, Alan||Moate, Roger|
|Hawkins, Christopher||Monro, Sir Hector|
|Hayes, Jerry||Montgomery, Sir Fergus|
|Hayhoe, Rt Hon Sir Barney||Morrison, Sir Charles|
|Heathcoat-Amory, David||Moss, Malcolm|
|Heddle, John||Moynihan, Hon Colin|
|Hicks, Mrs Maureen (Wolv' NE)||Mudd, David|
|Hicks, Robert (Cornwall SE)||Neale, Gerrard|
|Higgins, Rt Hon Terence L||Nelson, Anthony|
|Hill, James||Neubert, Michael|
|Hind, Kenneth||Newton, Rt Hon Tony|
|Hogg, Hon Douglas (Gr'th'm)||Nicholls, Patrick|
|Holt, Richard||Nicholson, David (Taunton)|
|Howard, Michael||Nicholson, Emma (Devon West)|
|Howarth, Alan (Strat'd-on-A)||Norris, Steve|
|Howarth, G. (Cannock & B'wd)||Onslow, Rt Hon Cranley|
|Howe, Rt Hon Sir Geoffrey||Oppenheim, Phillip|
|Howell, Rt Hon David (G'dford)||Page, Richard|
|Howell, Ralph (North Norfolk)||Paice, James|
|Hughes, Robert G. (Harrow W)||Parkinson, Rt Hon Cecil|
|Hunt, David (Wirral W)||Patnick, Irvine|
|Hunt, Sir John (Ravensbourne)||Patten, Rt Hon Chris (Bath)|
|Hunter, Andrew||Patten, John (Oxford W)|
|Hurd, Rt Hon Douglas||Pawsey, James|
|Irvine, Michael||Peacock, Mrs Elizabeth|
|Jack, Michael||Porter, Barry (Wirral S)|
|Jackson, Robert||Porter, David (Waveney)|
|Janman, Tim||Portillo, Michael|
|Jessel, Toby||Powell, William (Corby)|
|Johnson Smith, Sir Geoffrey||Price, Sir David|
|Jones, Gwilym (Cardiff N)||Raffan, Keith|
|Jones, Robert B (Herts W)||Raison, Rt Hon Timothy|
|Jopling, Rt Hon Michael||Rathbone, Tim|
|Kellett-Bowman, Dame Elaine||Redwood, John|
|Renton, Tim||Summerson, Hugo|
|Rhodes James, Robert||Tapsell, Sir Peter|
|Riddick, Graham||Taylor, Ian (Esher)|
|Ridley, Rt Hon Nicholas||Taylor, John M (Solihull)|
|Ridsdale, Sir Julian||Taylor, Teddy (S'end E)|
|Rifkind, Rt Hon Malcolm||Tebbit, Rt Hon Norman|
|Roberts, Wyn (Conwy)||Temple-Morris, Peter|
|Roe, Mrs Marion||Thatcher, Rt Hon Margaret|
|Rossi, Sir Hugh||Thompson, D. (Calder Valley)|
|Rost, Peter||Thompson, Patrick (Norwich N)|
|Rowe, Andrew||Thorne, Neil|
|Rumbold, Mrs Angela||Thurnham, Peter|
|Sackville, Hon Tom||Townend, John (Bridlington)|
|Sainsbury, Hon Tim||Townsend, Cyril D. (B'heath)|
|Sayeed, Jonathan||Tracey, Richard|
|Scott, Rt Hon Nicholas||Tredinnick, David|
|Shaw, David (Dover)||Trippier, David|
|Shaw, Sir Giles (Pudsey)||Twinn, Dr Ian|
|Shaw, Sir Michael (Scarb')||Vaughan, Sir Gerard|
|Shelton, Sir William||Waddington, Rt Hon David|
|Shephard, Mrs G. (Norfolk SW)||Wakeham, Rt Hon John|
|Shepherd, Colin (Hereford)||Waldegrave, Hon William|
|Shersby, Michael||Walden, George|
|Skeet, Sir Trevor||Walker, Bill (T'side North)|
|Smith, Sir Dudley (Warwick)||Waller, Gary|
|Smith, Tim (Beaconsfield)||Wardle, Charles (Bexhill)|
|Soames, Hon Nicholas||Warren, Kenneth|
|Speed, Keith||Wheeler, John|
|Speller, Tony||Whitney, Ray|
|Spicer, Sir Jim (Dorset W)||Widdecombe, Ann|
|Spicer, Michael (S Worcs)||Wiggin, Jerry|
|Squire, Robin||Wilkinson, John|
|Stanbrook, Ivor||Winterton, Mrs Ann|
|Stanley, Rt Hon Sir John||Winterton, Nicholas|
|Steen, Anthony||Wolfson, Mark|
|Stern, Michael||Wood, Timothy|
|Stevens, Lewis||Woodcock, Dr. Mike|
|Stewart, Allan (Eastwood)||Young, Sir George (Acton)|
|Stewart, Andy (Sherwood)|
|Stewart, Rt Hon Ian (Herts N)||Tellers for the Noes:|
|Stokes, Sir John||Mr. AJastair Goodlad and Mr. Tony Durant.|
|Stradling Thomas, Sir John|
§ Question accordingly negatived.
§ Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments), and agreed to.
§ MR. SPEAKER forthwith declared the main Question, as amended, to be agreed to.
That this House welcomes the Government's proposals for reform in the National Health Service which will bring all parts of the health service up to the very high standards now achieved by the best, put the needs of patients first and secure the best value for money; recognises that to make the health service more responsive to the needs of patients as much power and responsibility as possible need to be delegated to local level in future whether in directly managed or self-governing National Health Service hospitals; looks forward to large general practitioner practices being able to apply for their own budgets to obtain a defined range of hospital services so as to improve the quality of service to their patients; and fully supports the Government's decision to proceed with the implementation of the general practitioners' new contract, the contents of which were agreed with the general practitioners' leaders on 4th May.