§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Dorrell.]1.54 am
§ Sir Peter Hordern (Horsham)
During the past 20 years there have been two reforms of the National Health Service—in its administration rather than in its substance. When the Government's proposals for the present reforms were produced, they deserved more serious consideration than they have subsequently received. Judging by some of the hysterical reaction to the Government's proposals, one would think that the Government were out to dismember the NHS completely.
I very much regret the tone as well as the substance of some of the reactions. However, those who are in the front line of the reforms have reacted somewhat differently. A substantial number of hospitals and large practices have expressed interest in going it alone and in accepting proposals. When the nature of the proposals is known and the propaganda has blown over, the proposed reforms will be judged on their merits and found acceptable.
Because the NHS is a national service free at the point of delivery, many people think that it is wrong to attempt reform, because reform represents some kind of threat to the principle of the NHS. However, the shortcomings of the NHS are there for all to see. There are long waiting lists for operations, there are shabby practices and hospitals and overworked general practitioners and hospital doctors. We have only to consider the outcry whenever it is proposed to close an old hospital—even if it is out of date and inefficient—and to open a new one in its place to understand how hard it is to win acceptance for any reform of the NHS which involves change. The general impression seems to be that there is nothing wrong with the system which a lot more money would not put right. That impression is fostered not simply by the Labour party, as we might expect, but by the British Medical Association, which is a professional body manned by professionals.
It is a mistake to expect too much of any trade union which exists for the benefit of its members. However, until I saw its recent advertisement, I had thought that the BMA would conduct itself in a professional manner. Of course, history is against any such hope. We need only remember that the BMA was wholly opposed to the NHS when it was founded. However, by listening to it now, we might think that it had invented it.
Every doctor must take the Hippocratic oath, the most serious professional pledge in existence and one which all doctors aspire to live up to. What was Hippocrates like? Harvey's Oxford Companion to Classical Literature says this of him:Hippocrates supported a true scientific spirit, insisted on the permanence of the relation of cause to effect and the necessity of careful observation of medical facts. He was regarded by his contemporaries and successors as a perfect type of physician, learned, humane, calm, pure of mind, grave and reticent.I do not think that any of those adjectives could be applied to the BMA today.
The BMA's advertisement which appeared in The Observer of 4 June states that the Government want the general practitioners' practices with more than 11,000 patients to take over budgets, including the purchase of hospital treatment. It states that GPs would have to 311 negotiate contracts with hospitals, shop around for the best buys and plan their budgets accordingly. The BMA would not have published that advertisement unless it meant people to think that doctors would be forced to take over budgets and negotiate contracts. Nowhere is there any suggestion that it is entirely up to large practices to run their own practices. Similarly, there is no suggestion that, having done so, they cannot do otherwise. I have never heard of the freedom to adopt an alternative course described as having to negotiate contracts, as though the freedom to escape a centrally controlled system was a challenge to the state.
Perhaps one should dismiss all this talk as hyperbole, but there is worse. The advertisement said:Since there is no new money in the system, GPs will be expected to take on the burden of rationing the scarce resources.That raises a different issue, for there are no qualifying words about real increases, allowing for increases in inflation—just a simple statement that there is no new money in the system.
The House should take this seriously. What is the truth? The public expenditure White Paper states in paragraph 9 on page 5:Public expenditure on the NHS is planned to increase in 1989–90 by £1.3 billion compared with the estimated outturn for 1988–89. When the effects of reduced employer's superannuation contributions are taken into account this amounts to a cash increase of nearly £1.6 billion. In addition health authorities' new cost improvement plans are expected to provide a further £25 million. The total increase in resources will thereby amount to some £1.8 billion, equivalent to a cash increase of 9½ per cent.Paragraph 12 tells us that further increases are planned in 1990–91 and 1991–92, increasing the NHS total gross expenditure to more than £23 billion—an expected 44 per cent. real terms increase on 1978–79. That is all that I need to quote to demolish what the BMA said about there being no increase in cash.
What conclusion can one draw from that deceitful advertisement—for that is what it is? We should remember that the Government have no money of their own. Increases in spending can be made only through increases in revenue from taxation, and that can come only through the hard work and enterprise of the British people. So when the BMA says "no new money" it diminishes us all because it is an especially damaging untruth.
The BMA says that our general practitioners are under pressure and that our young hospital doctors are having to work unreasonably long hours, but that has always been the case. Are there not enough people in the NHS? It is worth reminding ourselves of the progress that has been made. In 1961, 575,000 people were employed in the NHS; in 1988, the figure was 1.22 million. One in 18 families in the land has someone who works for the Health Service. That is a very large figure, and makes the Health Service the largest employer in the western world. We may not have enough general practitioners, but we have 25,000 now compared with 21,000 10 years ago—an increase of nearly 20 per cent. The average list that doctors must manage has decreased from 2,312 to 2,020, which is a 12 per cent. reduction. Last year in our hospitals, 5.3 million patients were treated, which is 1 million more than in 1978. Last year we treated 7.6 million out-patients, as compared with 6.7 million in 1978. On any test, whether immunisation uptake or the continued fall in the 312 standardised mortality ratio for a wide variety of potentially avoidable causes of death, there has been an improvement over the position of 10 years ago.
All the evidence shows a substantial improvement in the services of the NHS. It does not show some of the faults of the system which are inevitable in an organisation as large as the NHS. Although it may be the largest service in the western world, it probably has the longest waiting lists. I speak from the experience of some years as a member of the Public Accounts Committee. I cannot recall a year when the Comptroller and Auditor-General and the National Audit Office did not discover an outstanding example of waste. Until recently, the Department had no idea how many people were recruited for the Health Service or what they did until two years after the event. I can remember an occasion after the review and reform of 1973 when 50,000 administrators were taken on in the space of 18 months, but that was not discovered until two years later.
The National Audit Office's recent reports show that 28 per cent. of operating theatres available during weekdays were unstaffed—23 per cent. because of cancelled sessions. There were wide variations between districts, but when the districts were taken together it was found that only 50 to 60 per cent. of available theatre time was used. Had the theatre time been properly used in the five authorities examined, another 11,000 operations could have taken place. In another report, 20 per cent. of districts confirmed that at least 40 per cent. of the land that they owned could have been disposed of. Another report on the need to evaluate the effectiveness of clinical care showed that there were marked variations between health authorities in the number of deaths due to avoidable factors.
Such faults are inevitable in any large system. They show the need for greater autonomy within the system and greater responsibility, too. I do not believe that anyone reading and understanding those reports could believe that the Health Service is not ripe for review. I deeply regret the fact that the reviews have not been treated as seriously as they should have been, by the BMA in particular.
One has only to consider the cost of drugs, which has increased from £805 million in 1978–79 to £2,167 million in 1987–88—about 10 per cent. of the National Health Service budget. Yet the doctors may not even know the cost of the drugs that they prescribe, which is why prescription costs vary by as much as 50 per cent. from one practice to another. How can that be right? Under the Government's proposals, the district health authorities and the larger practices will be able to make contracts with health authorities outside their own areas, which will make the hospitals increasingly customer-orientated, rather than producer-orientated as they are at present.
It might be better still if GPs could refer their patients wherever they want, but that is less important than the other considerations that I have mentioned.
It is never right to accept waste, especially in a service as large and important as the National Health Service. Yet waste is endemic in the system. The reason why it makes sense to allow some competition for services and to set benchmarks is not that that will save money—because there will be more money—but because it will ensure that the money is spent to better effect. Advances in medicine and the growing number of elderly people will continue to place increasing demands on the Health Service and we must meet those demands as best we can.
313 We in this House have a duty to ensure that public money is properly spent for the benefit of the public. Forty years after the foundation of the Health Service, it is clear that waste and inefficiency have occurred too often and on too great a scale to allow them to continue unchecked. That is why the Government's proposals should be supported, and the BMA's campaign rejected.
In a day or two, the council of the BMA is to decide whether to accept the proposals for the doctors' contracts. I wish that the decision could have been reached in an atmosphere of calm study of the proposals, rather than being the victim of a thoroughly salacious and disgraceful advertising campaign.
§ 2.8 am
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)
The House owes a great debt of gratitude to my hon. Friend the Member for Horsham (Sir P. Hordern) for introducing such an excellent debate. The record will show that, at 2 o'clock in the morning, the House was unusually full for an Adjournment debate, because of the presence of my hon. Friends the Members for Hertford and Stortford (Mr. Wells), for Upminster (Sir N. Bonsor), for Basingstoke (Mr. Hunter), for Norwich, North (Mr. Thompson) and for Amber Valley (Mr. Oppenheim)—he has now left the Chamber—and my hon. Friend the Member for Loughborough (Mr. Dorrell), whom I take for granted! This is a sign of how strongly the House feels about this subject.
I agree very much with my hon. Friend the Member for Horsham. Much misunderstanding has been created about "Working for Patients". I agree that some of it has been deliberately created and that it is unhelpful to a constructive and rational discussion of our proposals.
It may help my hon. Friends if I dwell on five basic misunderstandings about the White Paper, two of which were mentioned by my hon. Friend the Member for Horsham. The first is the false claim put about that doctors will have less time to deal with their patients. That cannot be mathematically true in total. There is a fixed number of patients. It seems likely, given the number of doctors in training, that the number of doctors in general practice will increase in the coming years. As my hon. Friend said, there has been a significant increase in the number of doctors. That must mean that, rather than increasing, the average list size may decrease. The implication is that doctors will not have less time on average to deal with patients but will perhaps have a little more. Some doctors will choose to gain more patients and, because of their energy, performance and reputation, will gain more at the margin. That must mean that other doctors in the locality will lose patients. That is right. The contract will soon be discussed by the Conference of Local Medical Committees and it is important that it carefully consider the general principle running through the contract, that we intend to reward hard work and performance in a common aim, which is shared with the Government—better treatment of patients.
Secondly, it is said by some that patients will be sent around the country in search of operations. A member of the British Medical Association used a colourful phrase—he said that patients would be sent around the country in their pyjamas with cheques pinned to their breast pockets: that would be money following the patient. It is nonsense. It is important to change the funding 314 mechanism and the flow of money in the system in such a way that money can follow sensible patient referrals. In other words, the doctor, patient, district health authority and receiving hospital all agree that it is in the best interests of a patient for elective surgery or cold surgery—for example, a hip replacement or operations on varicose veins or a hernia—if that patient is sent a little further than the district general hospital to get the operation done more quickly. We have no intention of sending patients against their will all over the country or excessive distances for urgent operations. This measure in the White Paper is designed to reduce the disparity in waiting times throughout the country and to help patients.
Thirdly, it has been said that patients will be denied drugs that they need from their general practitioner, not only in month 11 or 12 but in month one. That is untrue. My right hon. and learned Friend the Secretary of State has made it plain that we have no intention of cash-limiting general practitioners, either individually or collectively. We will introduce what we call indicative drug budgets. They will provide a guideline for general practitioners as to how much they should prescribe. Our proposals for indicative drug budgets are a sensible way, in co-operation with the general practitioner, of exercising better control, because over-prescribing—particularly of tranquillisers—is not in the best interests of patients.
Fourthly, it is suggested that hospitals will opt out of the Health Service and that the Government are about to dismember the NHS. That too is absolutely untrue. My right hon. Friend the Prime Minister and my right hon. and learned Friend the Secretary of State made it plain that we are not about to privatise the Health Service. It will remain free at the point of delivery and financed mainly by taxation. Hospitals will not opt out by choosing self-governing status but will simply have delegated to them greater responsibility for managing their own affairs.
Earlier today, I attended together with my right hon. and learned Friend the Secretary of State and my hon. Friend the Minister a successful conference at Church house, Westminster, for those interested in self-government. The large audience was drawn from the 200 hospitals and other units that expressed interest in self-government. The conference was designed to allow my right hon. and learned Friend an opportunity to explain his ideas in more detail.
Our proposals are not about opting out or about dismantling the Health Service but concern delegating to those who work most closely with patients, responsibility for employment, pay, and the further development of the service. That must be in the patient's interest. As self-governing hospitals will no longer be subject to interference from regional health authorities or from the Government, they will have no one but themselves to blame if a mistake is made. We want them to develop a sense of responsibility and pride in running their own hospitals. We will finance them with a fair share of taxpayers' money, but we want them to bring their services closer to the community in every sense.
Fifthly, it has been suggested that the Health Service will go in search only of what are called profitable patients, and that unprofitable patients—whatever that might mean—will be denied care by general practitioners or hospitals. That too is nonsense. We are not moving to the American system of cash passing between the patient and the provider of health care. We have set our face against that. As far as the patient is concerned, ours is a cashless system, 315 free at the point of delivery and financed from general taxation. Therefore, the concept of a profitable or unprofitable patient is not one that we recognise.
Let me briefly explain why it is nonsense to claim that "unprofitable patients" will be denied proper care. We are so changing the capitation fees payable to general practitioners for providing services to patients that they will rise with the age of the patient. That will encourage GPs to add to their lists and to care for the elderly. Also, the indicative drug budgets, which will affect the majority of general practitioners—those who do not choose to control their own practice budgets—will be specifically tailored to reflect the age profile of the patient list, the relative health of the patients on that list, and their special drug needs and requirements.
Therefore, how can it be claimed that doctors will in any way have a disincentive to take on patients and a real incentive to deny care to those with special health needs? Such a claim is nonsense and a calumny against the medical profession whose own ethics, as my hon. Friend clearly stated, compel the doctor to care for any patient, whatever his or her condition.
As to hospitals, our critics fail to understand or to take on board the exciting concept of dividing responsibility between the purchaser of health care—the district health authority or the general practitioner's practice budget—and the health care provider, which is the hospital. The district health authority, as the guardian of the health requirements of all existing and prospective patients living within its province, will be responsible for the care of every individual. It will be the responsibility of the health authority—properly funded, under our new system of resource allocation—to ensure that hospital care is available locally for the core services that we shall define more carefully and closely in the months to come.
Let me list the issues on which I hope the medical profession and the Department of Health are agreed. First, I hope that we are all agreed on one aim in the reform of the Health Service—which, after all, has not enjoyed as 316 radical a series of necessary reforms as that which we propose in 40 years. We have a common aim: to improve patient information and choice. We shall do that by giving doctors the right to advertise, ensuring that GPs provide existing and prospective patients with more information and enabling patients to change doctors more easily.
Secondly, we want to improve the quantity and quality of health care. We want to improve the quantity by continuing the rate of growth in real expenditure on the Health Service. My hon. Friend rightly said that the Government had increased expenditure by some 40 per cent., which was reflected in the number of doctors and front-line staff, and the Government will continue to increase the amount of real resources.
Quality is also vitally important. I hope that the medical profession agrees with us that medical audit—and, indeed, the use of contracts between the purchaser and the provider of health care, stipulating the minimum standards required—will serve the patient's interests.
Finally, I hope that the medical profession agrees with our desire for a drive for even greater efficiency, at the same time as an increase in resources. We have a relatively efficient health-care system compared with many other western European nations: we devote a slightly smaller proportion of our GDP to our Health Service than some of those countries devote to theirs, but we provide a good service. We can and should do better, however, and one of the key elements of an improved performance is the delegation of responsibility to self-governing hospitals, GP practice budget-holders and the reformed, slimline, business-like district health authorities and family practitioner committees.
I agree with my hon. Friend. I hope that cooler heads and reason will prevail, and that we will all work together —both sides of the House, the medical profession and the Department of Health—to achieve our long-term and most important aim: to put patients first, and to improve the quantity and quality of health care.
Question put and agreed to.
Adjourned accordingly at twenty-two minutes past Two o'clock.