NHS White Paper (Doctors' Response)

HC Deb 02 May 1989 vol 152 cc25-80 3.43 pm

Mr. Robin Cook (Livingston)

I beg to move, That this House, noting that every independent organisation representing medical opinion has recorded the deep concern of doctors at the White Paper 'Working for Patients', and recognising that the concern of doctors arises from the serious threat to their patients reflected in Her Majesty's Government's determination to introduce market forces into health care, regrets that Ministers have failed to respond to informed criticism other than by impugning the motives of their critics; affirms its support for the basic principles of the National Health Service that patients should receive the treatment they need, not the treatment they or their doctor can afford; and calls upon Her Majesty's Government to prove its proposals by pilot projects before imposing them on the profession, and to postpone any legislation for a structural change in the National Health Service until it can be first submitted to the electorate in a General Election.

Mr. Speaker

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

Mr. Cook

When the former Secretary of State for Health, the right hon. Member for Croydon, Central (Mr. Moore) announced the review to a rather startled nation, he said that the impact on the nation's health could be as dramatic as the discovery of penicillin. The outcome of the review had a dramatic and electrifying effect on the medical profession. It was so dramatic and electrifying that it has been rejected by every organisation representing medical opinion, not just by the British Medical Association.

I noted at last week's Health Question Time that the BMA held a special place in the affections of Conservative Members. That place is somewhere between the National Union of Mineworkers and members of the national dock labour scheme. The review has also been rejected by the joint consultants committee, representing ten royal colleges. It was also rejected by the Royal College of Nursing. Almost exactly a year ago, that college gave the Secretary of State's predecessor a standing ovation.

Some of the opposition from organisations representing medical opinion does not seem to have been anticipated. A fortnight ago, in reply to a question, the Prime Minister quoted, approvingly, a doctor who said that the White Paper embodies so much of what the Royal College has been working for over the years."—[Official Report; 11 April 1989; Vol. 150 c. 736.] Six days later, the Royal College of General Practitioners voted, by 49 votes to one, to reject the White Paper.

In a statement explaining why it could not support the White Paper, the college said: As an academic body, it must state that, just as it opposes medical treatment based on guess, so it must regret the treatment of a whole health service on hunch. Even those who have tried desperately to like the White Paper have found it a forbidding task. The Institute of Health Services Management, which represents overwhelmingly members on short-term fee contracts to the Government, did the best that it could, but even it could not avoid coming out with the statement that the White Paper was likely to produce in the Health Service "confusion and fragmentation."

Nor is it only the institutions that have come out against the White Paper. The notion that a few activists in those bodies are manipulating the membership is pure fantasy. Dozens—scores—of doctors' meetings have been held around the country, but not one has found a majority in favour of the White Paper. I shall mention only one of those meetings: in Barnet, 170 doctors, including doctors from the Prime Minister's constituency, assented unanimously to the proposition that the White Paper could not work.

I know that Conservative Members are well aware of the strength of feeling among doctors: I know that because I keep being sent the letters that they have sent back to doctors who write to them. I treasure particularly a letter from the hon. Member for Milton Keynes (Mr. Benyon), who wrote to a general practitioner in his constituency, replying to his comments on the White Paper: I must tell you that I have never read such unhelpful, negative and totally conservative comment. I like the hon. Gentleman's equation of "negative" and "unhelpful" with "conservative". I have always suspected the hon. Gentleman of being something of a dissident on the Conservative Benches. I assure him that his general practitioner is happy to agree with his phraseology—that the White Paper is negative, unhelpful and conservative.

I notice that the amendment tabled by the Prime Minister and her right hon. Friends welcomes the widespread medical support for the objectives of the White Paper". We must handle that phrase with care. The objectives of the White Paper, as stated in it, are unexceptionable: broadly speaking, it is in favour of patients living longer and against their dying. However, I challenge the Secretary of State—it is the first of a few challenges that I shall issue to him in my speech—to produce the name of a single medical organisation that has welcomed the proposals in the White Paper.

In case the Secretary of State rises to the challenge by responding that the Conservative Medical Society has welcomed the proposals, let me tell him that that particular case is rather suspect, as there is some doubt about whether it carried out the ballot of its members before announcing its decision.

Mr. Jerry Hayes (Harlow)

The hon. Gentleman has specifically mentioned medical organisations. Is that so that he can leave out the National Association of Health Authorities in England and Wales, which welcomed the report, or does he consider it rather inconsequential to take into account the views of those who actually run the Health Service?

Mr. Cook

If the hon. Gentleman reads the comments of the National Association of Health Authorities, he will find that they are much more carefully balanced than he has suggested. It is, however, hardly surprising that members of health authorities have welcomed the Government's proposals, as the Government have spent the past 10 years stuffing those health authorities with their placemen and placewomen.

The Secretary of State's response to this overwhelming opposition is to insist that none of it will stop him. As he said in a lecture to the Royal College of Nursing, these changes will happen whether we like them or not, and whatever we say. It may surprise hon. Members, given the defiant ring of that statement, to learn that we are at present in a consultative period. The extent to which the right hon. and learned Gentleman is willing to enter into a dialogue with doctors during that consultative period was discovered by doctors in the Vale of Glamorgan last week, when he pushed his way through them, leaving behind the sole intelligible question on which he had consulted them: "Where is my car?"

In this alleged consultation, the Secretary of State is displaying an arrogance which sits uncomfortably with his supposed role as an accountable Minister in a democratic country. In a week in which we ruefully reflect on what 10 years of the present Prime Minister have meant for the nation, I warn the Secretary of State that the nation is heartily sick of this style of hectoring, opinionated government.

Mr. Tony Favell (Stockport)

Does it really come as any surprise to the hon. Gentleman that the general practitioners oppose the White Paper? After all, has he found many barristers in favour of the Lord Chancellor's proposals, or many scheme dockers who favour the abolition of the dock labour scheme?

Mr. Cook

The odd thing is that I remember that, on 31 January, the Secretary of State, when unveiling the £1 million package to communicate to doctors and to medical opinion how useful and wonderful his proposals were, said nothing about doctors being against the proposals or that he expected general practitioners to be against them. On the contrary, everything said at the time to defend the £1 million expenditure was about how important it was to communicate these ideas so that people employed in the Health Service could understand and agree with them. The people involved certainly understood, but whether or not they agreed with the proposals is an entirely different matter.

Since this point has been raised, I can say to the Secretary of State that, as a result of one of his six consultations with the West Middlesex hospital, on the night of his presentation of 31 January we were able to recruit seven people to the Labour party who applied on the spot for membership.

Dame Jill Knight (Birmingham, Edgbaston)

Is the hon. Gentleman able to cite a single instance of any reform suggested by any Government to the National Health Service, from its inception 40 years ago, to which the doctors have had no objection?

Mr. Cook

It is perfectly true that a number of concerned doctors in 1948 opposed the setting up of the NHS, as did the Conservative party at that time. However, it is certainly not the case that doctors are opposed to all changes in the Health Service.

Mr. Robert McCrindle (Brentwood and Ongar)

rose—

Mr. Cook

I have given way generously to hon. Gentlemen and the hon. Lady, but, as I am conscious that this is a three-hour debate and that other hon. Members will wish to speak, I must decline to give way on this occasion.

To comprehend the bitterness of general practitioners, it is necessary to understand how they have been deceived by this Government. For a year, the representatives of general practitioners have been negotiating on the practitioners' contract. In the course of that year, the representatives were repeatedly assured that nothing in the White Paper would affect general practitioners and their contract. That assurance was repeated at a meeting on 21 December last year.

General practitioners first heard that the assurance was inoperative on 18 January, when the Department of Health cancelled the February meeting of the negotiators in order to give general practitioners time to consider how the White Paper would affect the practitioners' contract. A fortnight later they received the White Paper, which contained two major departures. First, it has thrown into reverse the drive by successive Governments to encourage general practitioners to take fewer patients on their list. Instead, the new contract proposes to increase the per capita element by a third, rewarding those general practitioners who hoard patients and penalising those who want to keep the list to a number to whom they can give individual attention.

That departure will have an impact on general practitioners and an even bigger impact on their patients. More patients on every list means less time for each patient. It is purely double-speak for the Secretary of State to describe this measure as encouraging general practitioners to take on more patients in order to improve the quality of service to each patient.

The second major change that general practitioners discovered on reading the White Paper was that the Secretary of State proposes to entice GPs in larger practices into practice budgets. The essential problem with practice budgets is that they will result in a conflict of interest. When GPs see a patient now, they have to ask themselves only what treatment the patient needs. In future, with a practice budget, they will have to ask themselves a second question: what treatment can the practice afford? It is because of that conflict of interest that there will be a suspicion in the mind of the patient that he or she is not being recommended for the best treatment. It will destroy the trust of the patient in his or her doctor. As one doctor expressed it graphically, when a patient looks into the eyes of his or her GP, the patient wants to see reflected in those eyes his own anguish, not the calculations of an accountant.

Another major proposal in the White Paper which has also caused concern to doctors is that hospitals should opt out of—

The Secretary of State for Health (Mr. Kenneth Clarke)

The hon. Gentleman implies that the White Paper was an act of bad faith over the negotiations on the contract, because we introduced two changes. Will he pause in his reading of his Tavistock house brief to explain that an increase in the capitation element of the contract was floated in the White Paper on primary health care 18 months earlier? That was nothing new. Furthermore, GP practice budgets have nothing to do with the negotiation of the GP contract. On what grounds does the hon. Gentleman support the BMA's assertion, which it appears to have given him, that the White Paper interrupted the 12 months of negotiations on the GP contract?

Mr. Cook

The right hon. and learned Gentleman is being characteristically offensive by suggesting that I have come to the House armed with a brief from Tavistock house or anywhere else. I do not claim for myself much credit, but I claim for myself the credit of preparing my own speeches; they are not prepared for me. I take issue with the tone of the right hon. and learned Gentleman's question and the abuse with which it was accompanied. If he wishes to make more rapid progress, the House should be treated as a place for open debate, not as a place for abuse.

The right hon. and learned Gentleman asked two questions. I shall respond first to his second question. He cannot claim that the practice budget proposal does not have a bearing on the GP contract. Such an argument is Jesuitical. His claim that it was foreshadowed 18 months ago in the White Paper will not stand up to examination. The Government said in that White Paper that they intended to increase the capitation proportion from 47 per cent. to 50 per cent. The January White Paper said that the Government intended to increase the proportion from 47 per cent. to 60 per cent. There is a big difference between the two figures.

The other major proposal in the White Paper that is causing concern to doctors is that hospitals should opt out of local authority control, that they should be free standing, that they should not be accountable to the local health authority, that no local council members should be able to serve on the governing body and ask difficult questions and that their only obligation should be to make ends meet by marketing their services. As the joint consultants committee observed: These proposals inevitably change the prime aim of the management of these hospitals from the provision of adequate care to the community as a whole to the financial success of the hospital. What will it mean when hospitals have to change their prime management aim from the provision of care to the community to the financial success of the hospital? The long-term consequences of that financial pressure have been obligingly spelt out by the director of the private Lister hospital. He has asked what lessons can be learned from his experience of running a private hospital by those hospitals that choose to opt out. Helpfully having asked that question, he then provides the answers. In his article he writes: The opt-out hospital will need to make firm decisions as to which services to promote and which are uncompetitive. Some specialties may have to go. The problem of unsuccessful specialties will be a real one. For how long could one carry a loss-making specialty including its medical team? I invite the House to note the revealing way in which the director of the Lister hospital defines an unsuccessful specialty. An unsuccessful specialty is not one which offers poor quality of care or care that patients do not need in the community; an unsuccessful specialty is a loss-making specialty. That is the reality of what will happen with the opt-out hospitals. Care will be defined according to which specialty can provide the most generous mark-up on the treatment, not the care that is most needed by the community.

What happens to hospitals if they fail to move with the times and persist in offering loss-making specialties? The disaster of the Lister hospital has a neat phrase: they will be "shaken out of the market". Not closed, mark you, but shaken out of the market. It is a pity that the director of the Lister hospital has not been working for the Department of Health for the last 10 years; otherwise, we could have learnt that the 300 hospitals closed under this Government were not closed but shaken out of the market and the 20,000 beds we have lost in the last 10 years were not cut, but shaken out of the market. Also shaken out of the market, of course, is any commitment to the National Heath Service as a public service to every community in which there is a district general hospital providing ready access to a comprehensive range of medical services.

The right hon. Gentleman is not just nurturing a threat to the Health Service: what he is proposing is an affront to our democracy. He has sent an instruction to every regional health authority to provide by next Monday a list of volunteer hospitals for opt-out. They in turn are instructing unit general managers to volunteer for opt-out. I do not doubt that by Monday the right hon. Gentleman will have his list of volunteers. What I find thoroughly offensive is what he proposes will happen next, which is that he, and he alone, will then decide whether they opt out. The decision on opt-out will be taken in a smoke-filled room, and most of the smoke will come from the Secretary of State's cigar.

What happened to all the talk of greater local decision-making? What happened to the promises of patient choice? If the Secretary of State is serious about choice in local decision-making, why not give local people the choice of whether their hospital opts out?

I issue my second challenge. If the right hon. and learned Gentleman seriously believes opt-out is so good, let him put it to the vote of the local community. Let it be decided by the local community which that hospital serves and which in many cases was the community which once upon a time paid for the buildings that the Secretary of State proposes to give away.

There is an obvious comparison with the speed with which the Secretary of Stale is proceeding in his White Paper. His proposals were conceived in haste and are now being imposed with premature haste. Just over a year ago, the right hon. Gentleman's predecessor received the Griffiths report on community care. There has been no progress there, no timetable for consultation, no urgent circulars to regional managers and no promise of legislation in the next Parliament.

I give the Secretary of State my third challenge. His Government owe us a debate on the White Paper in Government time. Having taken so long to find that time, before he comes back to the House to debate this White Paper, let us have his Government's response to the Griffiths report on community care, so we can put it side by side with the White Paper and see what sense they make together. It is almost three years since the National Audit Office observed that, in community care, doing nothing is not an option. That is precisely what the right hon. Gentleman has chosen to do, and we all know why. It is because Sir Roy Griffiths had the bad taste to point out that, if we are serious about developing the health and social services which will enable the elderly and the handicapped to live full and rewarding lives in the community, we must provide extra resources and responsibilities to the local authority which delivers those services to the community.

Labour councils have a clearer understanding than the right hon. and learned Gentleman of what elderly people need to keep them in the community and to keep them healthy. Yesterday, I released a league table that ranked local authorities by the number of home helps per thousand elderly people. Only one solitary Conservative council made it into the top 20 councils in that league table. Conversely, not one majority Labour council was to be found in the bottom 20. That is the difference between our parties' understanding of community care.

If Conservative Members consider that observation too partisan, I can offer them an observation with which they will agree. The record of the Democrats is even worse than theirs. Out of seven councils under Democratic administration, a clear majority are in the bottom 20 of that league table. That record shows that the Labour party understands the changing direction which health and social services need to meet the challenge of the rapid growth in very elderly people. Instead, the White Paper offers us the fatuous irrelevance of tax relief on private medical cover for the elderly.

We need to integrate the hospital and primary care services to get into the communities the diagnostic skills we keep locked up in our hospitals. Instead, the White Paper proposes that those hospitals will opt out and that consultants will meet GPs mainly to price a contract. We need to change the Health Service from a rescue service into a service that promotes health and prevents ill health. The White Paper contains not a single proposal for health promotion. It is full of measures that will cost treating illness but puts no price on health. I have outlined the basis of Labour's programme for health, which we shall be publishing this month at a launch cost rather less than the 1.5 million that the right hon. and learned Gentleman spent on the White Paper.

The fundamental difference between our proposals and the Secretary of State's White Paper is that our proposals will rest on our commitment to a Health Service in which resources are allocated by medical and social need and are not marketed by commercial demand.

I conclude with my final challenge to the Secretary of State. I noted that the Minister of State observed that the Government have been elected to govern and will not shirk the task of government. No one can deny that the Government have been elected to govern, but no one, not even the Government, can claim that they were elected to carry out such changes to the NHS. Where in the last Conservative manifesto were those proposals spelt out to the electorate? Where in the last manifesto were the electorate warned that hospitals would be encouraged to opt out and GPs encouraged to volunteer for cash limits? My final challenge to the Secretary of State is this: if he is so convinced that his proposals are right for the nation, that they will produce a better Health Service and more choice for patients, let us put it to the test of electoral opinion and find out whether Conservative Members are elected to govern while chained to those policies. If he puts it to the electorate, I assure the Secretary of State of our full co-operation in spelling it out to the electorate so that they thoroughly understand what the right hon. and learned Gentleman is proposing. In the meantime, I ask the right hon. and learned Gentleman, as it is our right to ask in this democratic Chamber, to put off legislation on these drastic changes until we have put them to an electoral contest.

I do not doubt that the Secretary of State will win the vote tonight. He has already lost the public debate. He came to office with no mandate for such changes. Since taking office, he has been unable to win any support for them. If he persists in abusing his majority in Parliament to push them through, he will not only destroy the trust between patients and doctors; he will undermine the faith of those patients in this place as a democratic institution.

4.8 pm

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 widespread medical support for the objectives of the White Paper "Working for Patients" and believes that the proposals in that White Paper will enable the health service and individual doctors to respond better to the needs and wishes of patients, extend patient choice, delegate responsibility to where the services are provided and secure the best value for money; affirms its support for the basic principles of the National Health Service which will be strengthened by the early implementation of the White Paper proposals; and looks forward to the constructive contributions from medical organisations to achieve that. By a curious turn of events, this is the first debate on the National Health Service in which the hon. Member for Livingston (Mr. Cook) and I have taken part since I came to my present office last July, with the exception of some exchanges on the dental and optical charges, which he will recall. We are shortly to have a debate in Government time on the White Paper reforms, so we are about to make up for that and to discuss Health Service matters at considerable length.

The Opposition have chosen to found their motion on the subject of the doctors' opposition to the National Health Service reforms. I shall concentrate on that and save many of my remarks for the debate on the White Paper. I want to talk about the points raised by doctors, some against and some in favour of the White Paper. I shall explain the present position to the House and examine the sudden, new relationship between the Labour party and the doctors. I do not believe that the opposition of the two groups to the reforms is based on the same premises. The Labour party's sudden discovery of the doctors' position is nothing other than political opportunism, because it sees a dispute apparently breaking out.

The House should begin the debate on the basis that the best members of the medical profession are interested in the Health Service above all from the point of view of their own patients. One of the tests that the best members of the medical profession will apply, just as the public outside will, is what the overall impact of the reforms will be on the way in which the Health Service delivers care to patients. When one examines the highly complex proposals which I and the Government have put forward, one has to try to form a picture of the effect on the Health Service in four or five years' time—or more—and how patients will appreciate what the reforms have done to improve the service for them. The one simple aim of the Government is that the National Health Service should be made a better Health Service from the point of view of patients and their families. That is the yardstick that should be applied to each proposal that the Government are putting forward.

We have a long way to go before the reforms come fully into effect, but in a few years' time, when patients look back on the battles over the review, they will see that the principles of the Health Service remain intact, that, the service remains free and financed by the taxpayer and that it is delivered according to medical priority and need. But they will find that many other changes have taken place in a Health Service run in a more business-like and efficient way, because it will be run in a more consumer-conscious way as well. The Health Service will be keeping up to date.

Patients tend to approach the Health Service firstly through the agency of general practice and most of us look, for ourselves and our families, to our GP as our continual health adviser and as our guide to the rest of the system. From now on, patients will be freer to decide which practice they wish to join and they will be able to make that choice on the basis of much better information. At present, people choose their GP—with whom, I accept, they are usually fully satisfied—on the basis of word of mouth recommendations from neighbours. Many of us do not have much experience of what general practice is like outside the practices that we have experienced ourselves. In future, practices will produce information leaflets. Thanks to the Monopolies and Mergers Commission, practices will be able to advertise if they wish and will put before patients and would-be patients the services offered to families, the opening times of the surgery and any other particular features.

Mr. John Battle (Leeds, West)

Will the Secretary of State give way?

Mr. Clarke

I shall give way in a moment when I have given some more examples of what patients will find coming out of the reforms. Patients will probably choose the practices that offer high standards and new services, which we are encouraging by the new contract I intend to negotiate with the British Medical Association. I shall return to the subject of the contract negotiations in a moment.

The hon. Member for Livingston said that nothing in our proposals dealt with the promotion of health and the prevention of disease which, as he rightly said, have to be part of the policy for the future of the Health Service. The new contract proposals, which we have been discussing with the BMA for so long, are founded heavily on just such principles. In four or five years' time, patients will expect to receive from their practices regular health checks, offered to all patients if they so wish, and especially better and more regular contact with older patients over the age of 75. There will also be regular surveillance by GPs of children under the age of five. Under our proposals, there should also be high levels of immunisation against disease for children and screening of female cancers. Those are some of the aims that we have set out.

There will also be more personal visits by doctors from the practice that the patient joins instead of excessive use of a deputising service out of hours. As a result of our wider reforms, when a patient visits a GP he will be given better information than now about where the waiting times are longest in his locality and about the medical quality of the service being provided by the hospital.

Whether or not a GP has a practice budget, he will have more contact with and more influence over the developments of the hospital and community services in his area because he will be in contact with his district health authority. General practitioners are not in contact now with their DHAs about referral patterns. In future how the DHAs use their money to place contracts with hospitals will reflect the referral practices of the local GPs. We are bringing GPs and DHAs together to collaborate.

If a patient has a GP with his own practice budget, the patient will be attending the practice of a general practitioner who has access to taxpayers' money on a scale not known before to doctors, which will mean that the doctor can take into account the quality of care, waiting times, and the preference of the patient when determining how health authority money is used in that area.

Those are big changes in general practice, and when patients evaluate those improvements we shall have a more considered view of our proposals—

Mr. Allen McKay (Barnsley, West and Penistone)

rose—

Mr. Clarke

I turn now to the hospital and community services. Patients will find that management of all hospitals will be delegated much more to the local people, to the doctors, the nurses and managers in the hospital itself— that is, to people who are closer to patient care than the people in the hierarchy of bureaucracy that we have now. Those people will decide on the use of resources, the management of the hospital and on the development of the service in their town.

Units will have resources coming in with the patient to match the work that they are doing. They will receive money in response to the demands made by the district health authorities and the GPs, who will refer patients and provide the necessary funds using their budgets. The system of encouraging hospitals to attract resources to their areas of strength will tend to bring the quality of all services up to the level of the best. Competition between them will bring down waiting times as well as raising the quality of the outturn from different specialists.

When we have finished our reforms, all hospitals will strive to please GPs and patients with the other things that they should all have now, such as reliable appointment systems, clear and sensitive explanations to patients of what is happening to them and of what is going to happen, and a whole range of optional extras and amenities available to patients who want to pay for them.

That is what the patient will appreciate. I do not believe that the Labour party will be wholly content, looking back, to realise that, because of what seemed a monetary political advantage, it has placed itself in a position whereby it opposes the development of general practice, the giving of more local autonomy to hospital and community services and the opportunity of making a better Health Service for patients.

Mr. Battle

rose—

Mr. Kevin Barron (Rother Valley)

rose—

Mr. Clarke

I give way to the hon. Member for Leeds, West (Mr. Battle).

Mr. Battle

How does the Secretary of State square all that he has just said with the push in the opposite direction from the Treasury, which is offering tax incentives to elderly people to move out of the National Health Service and in the direction of private practice? Is such a move the Secretary of State's real intention?

Mr. Clarke

Last year we obtained from the Treasury an extra £2,000 million for the services and an extra £1,000 million or thereabouts for the nurses' grading. We ended the autumn settlement last year with spending plans 5 per cent. above inflation. Under this Government spending on the National Health Service is now second in the league of spending on public departments. We now spend more on the NHS than we do on the Ministry of Defence. It is obvious that spending on the Health Service will increase rapidly, but to say that spending more money is, in itself, a form of health care policy and that we should ignore inefficiences and the need to raise quality or to make the service more responsive is not an adequate policy, whether it be the policy of the Opposition or of any part of the medical profession. Anything that induces people who want to spend their own money in retirement to provide for some of their health care, such as for elective surgery, thereby reducing pressure on the Health Service, does no harm to the Health Service but enables us to make better use of the money that we obtain.

The Opposition's motion is about doctors. I have dealt with the benefits to patients, and there will be great benefit to doctors as well. It is all very well to say that there is no support from any organisation representing doctors. There are not all that many organisations representing doctors. What tends to happen is that there are endless sub-committees of the same organisation which keep doing the same thing.

I was at a BMA meeting at Tavistock house this morning. It was a meeting of the general manager branch, but all the participants were doctors, and the majority of those asking questions were in favour of these reforms.

Mr. Frank Dobson (Holborn and St. Pancras)

The right and learned Gentleman appointed them all.

Mr. Clarke

I did not appoint a solitary one. The hon. Gentleman was, in his time, an extremely effective spokesman on health matters but he has forgotten that the general managers of health authorities are appointed by district health authorities. The unit managers, who were about two thirds of those present this morning, are also appointed by the district health authority and I do not have the gift of a solitary general management post at my disposal.

As I say, they are in favour of benefits for patients above all, but there are benefits for doctors, too.

Mr. Dobson

Is it not true that all these apparently independent general managers/doctors to whom the right and learned Gentleman talked today are on three-year contracts and notes are taken by officials in that Box as to who does or does not collaborate?

Mr. Clarke

This Opposition motion talks about members of the Government traducing the motives of those who disagree with them. That is something, I strongly argue, that I have not done, and nor has my right hon. Friend. The hon. Gentleman referred to the opinion of the National Association of Health Authorities in England and Wales, which is in favour of our proposals, and immediately insisted that it is a collection of placemen. An awful lot of card-carrying members of the Labour party in that association will be very surprised to hear that. I cite to the hon. Member that I have attended a meeting this morning organised by the BMA to discuss with a number of doctors their reaction to the White Paper and that most of them were in favour, and many of them strongly in favour, of the broad principles of the White Paper and he says that they are all on three-year contracts.

The Opposition are deaf except to what they regard as the short-term political opportunity to join in a row which they do not wholly understand.

Mr. Andrew Rowe (Mid-Kent)

Is my right hon. and learned Friend aware that in the autumn of last year my local hospital closed a ward because the surgeons operating therein were working so effectively and quickly that, in their attempt to reduce their waiting list, they overstepped their budget within about three months? That is an absurdity and they are very much in favour of changing the system to make it impossible for it to happen again.

Mr. Clarke

I entirely agree with my hon. Friend. That is one of the principal benefits from what we are proposing that doctors immediately appreciated. At the moment, there is what is sometimes called the efficiency trap, where a hospital is so much in demand and organises itself so well that it increases its work load but, because we only distribute the money by formula, it is told to stop. Indeed, I think they are gilding the lily somewhat, but only recently some Birmingham consultants claimed that they were told to go and play golf rather than carry on doing their work.

I have not met for some weeks now a member of the medical profession who does not think that it is an improvement to provide that, when patients are attracted from district health authorities or general practitioners, the resources will go with them, and that that is a much more sensible way of proceeding.

Doctors also see other advantages. The point of the general practitioners' contract, which I trust we can settle, is that those who work hardest, introduce new services and reach good standards will be rewarded best. Many GPs think that aim is wholly desirable. Indeed, the BMA does not differ from me in my aims for the contract. Those GPs with practice budgets will, as I have already said, have much greater influence over where NHS funds can be used for the benefit of their patients. For doctors in hospital and community services there will be relief from the absurd situation that tends to hit the best—the situation which my hon. Friend the Member for Mid-Kent (Mr. Rowe) described.

They will also find that more responsibility has been delegated to their hospitals. As clinicians, they will be more involved, they will have more influence over management decisions and they will carry more responsibility for the decisions. I find everywhere that doctors welcome the introduction of what I would regard, as a layman, as quality control and what the doctors call medical audit, whereby they can systematically ensure that standards are properly set for the service and are monitored so that the medical standards remain extremely high.

Mr. Max Madden (Bradford, West)

Will the right hon. and learned Gentleman give way?

Mr. Clarke

I shall carry on giving way steadily, but, as this is a short debate, I apologise that I cannot give way to all.

Given my description of the aim of the reforms and my belief in their benefits, it is surprising that the present bitter controversy has arisen between the Government and, on the one hand, the Labour party—and, to some extent the centre parties as well—and, on the other, the British Medical opposition—British Medical Association—[Interruption.] That is certainly my most Freudian slip of the tongue so far. Although they are both in opposition, there are a limited number of similarities between the Labour party and the BMA. One thing they have in common is that both of them denounced the proposals and began to campaign against them before they were even published. Returning to the letter from my hon. Friend the Member for Milton Keynes (Mr. Benyon) that was quoted by the hon. Member for Livingston, it appears that both the Labour party and the BMA can be described as conservative with a small "c". Their reaction to change of all kinds is remarkably similar. However, they are not natural allies. I have found in discussions with them that they come to such a person as myself with the precise nature of their complaints from opposite ends of the political and every other spectrum.

It is not surprising to find that the Labour party and the BMA do not always agree. They never have before. In response to an intervention from my hon. Friend the Member for Stockport (Mr. Favell), the hon. Member for Livingston implied that nowadays the BMA's views determined, Labour party policy. No doubt, the Bar Council will determine its policy on law reform, just as the Transport and General Workers Union will determine its policy on the dock labour scheme. It was never thus for the doctors. The BMA was nine to one against the foundation of the National Health Service. Aneurin Bevan did not follow the line of the hon. Member for Livingston.

In the mid-1970s, the disputes between the Labour Government and the BMA and the medical profession over private practice were described by a recent historian of the Health Service as being the most bitter in the entire history of the National Health Service. When Barbara Castle was opposed by all the medical organisations, I do not remember the Labour party saying that that settled the argument. It would not. Obviously, the Labour party's arguments do not now coincide with those of the doctors' organisations, and this unholy alliance will not hold together for too long.

So far the Labour party's campaign has been far less important to me and the public than that conducted by the BMA. The issue of so-called privatisation chosen by the hon. Member for Livingston has been a kind of barmy irrelevance to the actual issues to which the Labour party pledged itself. I believe that it is still pledging itself in by-elections to fight the privatisation of the National Health Service. That reminds me of an old story, which I will not relate at length, about the man in the railway compartment who had a device for keeping away elephants. He was sure it worked because no elephants got into his compartment. The Labour party is campaigning against the privatisation of the National Health Service. It will succeed. It is a noble campaign. It will sail on and meet no obstacles, because nobody has ever proposed privatising the Health Service. It is not threatened with privatisation. It is an irrelevant non-issue.

The campaign of the BMA—the doctors' campaign—to which the motion refers has been quite different. The hottest issue is obviously the question of the GPs' contract, coupled to some extent with the indicative drug budgets that we have described. The occasion of the debate is the present heat in relationships between the Government and parts of the BMA. It provoked the GPs' leaflet campaign and it was the subject of last week's conference of local medical committees, which I am glad to say finally brought to an end all talk of a resignation from the Health Service —which struck me as an odd way to show one's commitment to the service—but still talked of sanctions, and of using non-co-operation with our reforms to improve the Health Service unless they had the sort of contract of remuneration that they wanted. I do riot believe that that is the view of every doctor.

It is important to sort out the GP contract. We have a debate on the White Paper coming up shortly, but the contract is the immediate issue. I believe that getting a better GP contract will have more effect on raising the quality of health care in this country than most of the other things we have attempted to do in the Health Service for a long time. That contract has been in the air for a long time, and it was clearly trailed in the primary health care Green Paper and subsequent White Paper. We have had long discussions about it.

I do not believe that anyone can be opposed to the idea of having a contract that is up to date and linked to hard work and good performance. We will pay more to the most hard-working GPs and we will set standards of service to patients for all our GPs. The policy of the contract is to build on the strength of British general practice and it is no threat to or attack on it.

Today, GPs, to whom I and the House are seeking to appeal, are better trained than their predecessors because general practice is now recognised as a specialty in its own right. There are more GPs than ever before—up from about 25,000 to about 30,000 during the lifetime of this Government. They have fewer patients each to look after than ever before, with average list sizes falling from 2,286 to 2,020 in England over the last 10 years, on average, a drop of 12 per cent. And they are better paid than ever before. This year's review body increase of 8 per cent. was the highest of any review body group and took their earnings increase 25 per cent. ahead of inflation since 1979.

I think that GPs should be paid well and my proposals are no threat to their average earnings—a suspicion to which I addressed myself forcefully only a few weeks ago. The total payment to GPs currently has been settled by the Government and I approve of it. The total payment out of the contract to the average GP is about £60,000 per annum, including all fees and allowances. The average salary element is set at £31,000, but that average includes part-timers, semi-retired and low-earning GPs. My published new contract proposals show how a GP with an average list could have his earnings potential raised from £43,000 to £47,000.

My proposals would increase the earning figures for the more hard-working GPs arid those who hit the targets. I am in favour of paying good GPs very well and I am entitled to say that the incurable suspicion that, somehow, we shall try to reduce those earnings is wrong. What I say to the House and to the doctors—I am sure that the public would agree—is that such earnings are justified for professional men, but they mean that the Government are entitled to specify the work load of doctors, to encourage new services to patients and to set standards of health promotion and disease prevention for which to aim. The contract should pay good rewards and, in return, should set out the high professional standards at which the hard-working professional men and women should aim.

We are not aiming for all GPs to have bigger lists—that is a mathematical impossibility—as the contract is capitation-based now. We are aiming for new and better services for elderly patients. That is why one of our offers is to pay so much more to the doctor for each elderly patient that he takes on. The capitation for patients over 75 will go up sharply so long as the doctor maintains contact, at least once a year, with each old person. It is important to explain what we are discussing with the BMA. We aim for better medical supervision of our young people. That is why we are offering a new, generous payment to every doctor who introduces a surveillance system for the under-fives on his or her list.

I hope that we are all agreed that the NHS should keep up with the best international standards of immunisation, which represents disease prevention, and of female cancer screening, which also represents disease prevention. We pay all doctors for whatever immunisation and cervical cancer screening they do as they form part of the essential duties of any doctor nowadays. In my proposals I have suggested extra, new performance payments for those who attain the World Health Organisation target of vaccinating nine out of 10 children on their list. I do not believe that that is unrealistic as about 100 out of 190 district health authorities reached 90 per cent. target for diphtheria, tetanus and polio vaccinations in 1987–88. We are not talking about impossible targets, but we shall discuss the details to ensure that they are possible and reasonable for all subjects.

About 2,000 women are still dying needlessly every year of cervical cancer. That is why I have suggested that new rewards should be given to every GP who persuades eight out of 10 of the at-risk women on his list to have the smear test.

All these details can be discussed. Indeed, they have been discussed, and they can be further discussed. My negotiators and I have spent over 100 hours on matters such as rural practice allowances, basic practice allowances, payments for minor surgery and all the other details of the contract. Hon. Members on both sides of the House who have looked into the GPs' contract will, I hope, now study the Red Book and the mass of material which explains to the GP how to work the contract. I hope that they will also study the magazine Medeconomics which appears monthly and which serves no other purpose than to explain to GPs how to get the maximum return out of the contract.

I want to discuss the details yet again so that we can settle the terms of a contract that is up-to-date and rewards the best doctors, because the best doctors are doing this work. We all meet doctors who say, "We are delivering these services" and who will be content so long as the details are reasonable and reflect the realities of practice. We can reach agreement if there is good will, common sense and a commitment on both sides to a better Health Service.

Ms. Marjorie Mowlam (Redcar)

The Minister said in relation to cervical smears that women could choose quality clinical medical treatment. How does a woman, when faced with two doctors who are using different publicity, choose which one offers the best quality clinical treatment? There will be great advertising and excellent pictures, but the Minister must explain how a woman in that situation—indeed, the same difficulty will face pensioners—will be in a position to choose the best quality clinical service.

Mr. Clarke

We are here talking about whether doctors carry out cervical smears and whether they carry out a positive drive to advise people of the benefits and so raise the level. If a woman is particularly interested in services for female patients, she might look at the literature to see, for example, whether what is usually called a well woman clinic is being offered by one practice rather than by another, because that is the type of health promotion session that the new contract would encourage.

Having dealt with the contract, I come to the hospital proposals. The concerns of the BMA are different. I by now have met many doctors. Indeed, I could not make up my mind when I last answered parliamentary questions whether I had met hundreds or thousands. Certainly the number must be well into four figures by now. Judging from the campaign that is being run, most hon. Members have met a lot of GPs. I trust that they have also met many consultants and junior doctors.

I believe—I defy anybody to challenge this—that it is clear from discussions with the hospitals that the great bulk of what we now propose is being accepted by hospital doctors, even though some of them still assert that they are against the White Paper as a whole. Most consultants, in my experience, approve of the whole idea of getting better financial management. That represents a transformation in opinion compared with my time as Minister for Health only four or five years ago.

Few consultants would now argue with the contention that it is ridiculous that the Health Service should be one of the last places to get up to date with modern information technology, to come to grips with the world of the computer, or to have any proper financial management system.

We recently extended what we call the resource management initiative to another 50 hospitals, and the 50 that we named had actually competed for the privilege of being put in the forefront of introducing financial management systems.

The profession is now almost wholly in favour of clinical audit. I have not met a doctor for some time who has been against it. That is almost a total reverse of the situation five or six years ago, when the Royal College of General Practitioners and the Royal College of Surgeons first tentatively began to go into this area. It was invented by the profession and I reassure the profession that it will continue to be professionally led because it is quality control by doctors, of doctors for the benefit of doctors and their patients.

I know few consultants who do not welcome the idea of what is usually described as the concept of money following the patient. My hon. Friend the Member for Mid-Kent has given me a perfect example of how doctors are fed up with the present system which does not tie the resources with where the work is done best and to where the patients are being referred. So the question of money going over administrative boundaries and the ending of the efficiency trap are welcomed by all doctors.

Doctors have reservations and questions; that is sensible. The White Paper is not a blueprint. My hon. and learned Friend the Minister of State says that it is not a tablet of stone. It is not intricately detailed. There is an enormous amount for discussion within it; that is why we have eight working papers for discussion. The detail needs to be worked out with the service. People in the service want to know about planning. There are fears about a comprehensive service and about whether there will be fragmentation. When we debate the White Paper those fears can be answered. District health authorities will continue to have all the money they need. We are under a duty to provide a comprehensive service accessible to all patients. Health authorities will use their money to make sure that they plan where the service is best given to patients.

The profession wants to know about medical teaching and research, an extremely important and complex issue where the old arrangements needed improving anyway. We have to make sure that the training of our doctors and research are not adversely affected by the proposals. The same is true of nurse training. When I encounter consultants in the hospital service I find that they are suspicious to a certain extent of the new system of contracts. They are sometimes suspicious about the self-governing proposals and about the effect of GP practice budgets. They say that we are going too fast. They talk of the need for pilot schemes. They say that when new drugs are introduced they need to experiment.

All that has been picked up by the hon. Member for Livingston. I do not credit him with originality. In the press at the weekend he picked up a theme that has been put to me by the medical profession for the last month, but in a different way. He is interested in running pilots. I assume that he does not want to run pilots of things to which he is fundamentally opposed. Now he has come round to experimenting. As we need legislation before we can set up any of these things, he does not seem to want to rush to experiment because he does not want to legislate for a year or two. It might mean pilot schemes at two or three selected places and a multidisciplinary committee. We would spend years getting an agreed assessment. In the great tradition of that giant service, nothing would happen for a long time.

Consultants are interested in self-governing hospitals and GPs are interested in their own practice budgets. The hon. Member for Livingston is right to have his fears. Many doctors will react to our request for expressions of interest next month. Many of them will move forward with us. They are interested in how we will handle the changes and whether we are going too fast. I believe that we can meet the fears of plunging into the unknown. It is in the nature of our proposals on self-governing hospitals that we are asking who is interested. We shall work with willing volunteers where there is an adequate expression of interest.

There will be GP practice budgets only when GPs have said, "That is a good idea. You have satisfied me on the details. We have negotiated the basis of a contract that I am happy with." They they will go ahead. Before we have the first ones in place by April 1991 we shall have to work out the details. We shall discover much more about how to calculate a budget, about the structure of management needed in self-governing hospitals, and about care services, even after April 1991, depending on where we are. We shall run it on a fairly loose rein at first to get the system bedded in.

The question is, do Labour Members share the Government's aim for a better health service and improved management, and will they commit themselves to proceeding sensibly and purposefully in the right direction, testing things, working out the details, and making sure that it goes smoothly? Or does the Labour party, as some people did at first, just say that it is "agin" it, that the Government are commercialising the service and that it is fundamentally opposed to it?

I will be fair to the hon. Member for Livingston; he has not done it today, but outside the debate has been reduced to a pathetically low level at various times. I have discussed keeping elephants out of the door by opposing privatisation. People have been told that the elderly will be turned away and that hospitals will concentrate on profitable lines, whatever that means. I went through a picket line in Glamorgan when I was late for a train. A chap ran after me and gave me a leaflet. I was told that I had gone past GPs. I do not know who most of them were. They were chanting, "People, not profits," whatever that meant.

The trouble with that level of campaigning is that, as will become clear when we reach the legislation and as we proceed, the BMA does not believe what is being said. It knows that the leaflets contain things that are not true. More importantly, the Labour party does not believe what is being said. It knows that it is not fighting a campaign for privatisation. The snag is that it has no proposals of its own to put forward. At the moment, it is trying to compound confusion for short-term political reasons.

I do not object to political exchanges, whether vigorous or less vigorous, but I strongly object when the Labour party, the hon. Member for Livingston and others doubt the sincere commitment of myself and the Conservative party to a better NHS. I and many of my hon. Friends have worked for years in stints at the Department of Health in order to secure the future of the NHS, which would decline if we adoped a do-nothing option and decided to let it stand still.

The Government have spent more and done more for the NHS than any other Government in the previous two decades. We have presided over the growth of the service, the widespread introduction of new high-tech services and the particularly rapid spread of community-based care and better services for the elderly. We began the introduction of better modern management and we shall continue that.

The Labour party's claims for its commitment are based on the ancient history of two generations ago. Our claims are based on our recent achievements and, above all, on our vision of reforms which will make the NHS better still for future generations of patients and will give us a Health Service which, as a result of the Government's efforts, we shall be proud of in 40 years' time, just as we have been proud of it over the past 40 years.

4.46 pm

Mr. Michael Foot (Blaenau Gwent)

When the Secretary of State said at the end of his speech that what he resented was that anybody should question the allegiance of himself and his party to the National Health Service, I say to him right at the start that if he had been present in 1948, as I was, when the service was introduced, he would have known that the Opposition's suspicions were based on a great foundation.

The Conservative party made a great effort to stop the NHS, on its present comprehensive basis, from ever being introduced. That is why it put down reasoned amendments against Second and Third Readings. I know that the right hon. and learned Gentleman has said that his party was wrong on that occasion—I am happy that he should own up now—but he must not suspect our suspicions when we look back upon that record.

The Secretary of State also referred today—he called it a Freudian slip, but it might be much more of a Freudian landslide—to the British Medical opposition. That is what he is up against, and he must not complain if on some matters the Opposition happen to agree with the British Medical opposition's opposition to his measures.

I hope that this is not too parochial a reference to my constituency, but nothing is resented more in my constituency of Blaenau Gwent, or Ebbw Vale as it was, by the representatives of the medical profession than that the right hon. and learned Gentleman should in some way claim that his quarrels with the British Medical opposition, or the medical professions in their different forms, is in some way comparable to what Aneurin Bevan faced when the service was introduced.

One of the main reasons why doctors, or many sections of the doctors—not all of them by any means—opposed the introduction of the scheme was that they said that it would interfere with their clinical freedom. Large numbers of general practitioners and their leaders in the BMA genuinely believed that right up to the moment when the Health Service was brought into being, as I can confirm. At that moment, the transformation took place and the doctors discovered that they had far more genuine clinical freedom, particularly when dealing with poor people, than ever before. The vast majority of the medical profession welcomed the change as the greatest they had seen in the history of the country. Most of them hold to that same view now.

Therefore, the Secretary of State cannot claim for a moment that his arguments are anything like the same as those that Aneurin Bevan had with the medical profession. At that time it was not easy to get the service comprehensively established, because it had been divided in such different ways. To achieve anything which could properly be termed a National Health Service necessitated detailed consultations with the British Medical Association and other sections.

A few moments ago the Secretary of State spoke as if the medical profession were contained in one body. However, there is a variety of bodies, and if the right hon. and learned Gentleman knew anything about this, he would know that the royal colleges have always taken different approaches. If it had not been for the detailed consultations between Aneurin Bevan and the royal colleges, particularly the leaders of the Royal College of Physicians, there would never have been a National Health Service.

The difference between Aneurin Bevan's Government and this Government is that his did not take orders from the medical profession. Aneurin Bevan always said that supremacy should lie with the House, but he consulted members of the profession. The shape of the National Health Service was powerfully affected by the discussions that he had with the heads of the royal colleges.

The Government have done some terribly foolish things in relation to health. They have done nothing more foolish than slamming the door on the heads of the royal colleges not so many months ago. They did so over the contract but, even worse, they did not consult the colleges about their plans for the future. Why not?

The origin of the troubles that the Government and the country face over the National Health Service, which the Opposition want to protect and for which it has every right to fight, was the Prime Minister's decision to set up a review body—a Cabinet committee—under her chairmanship to investigate the Health Service. No one was stronger than Aneurin Bevan in saying that the service should be reviewed. Almost every Act introduced by the Government in which he served contained a clause stating that the service should be reviewed after five years, or some period, so that the people working in it and the patients dependent on it could take a fresh look at it. He was not dogmatic enough to say that it should stay the same for ever.

Aneurin Bevan would never have agreed to a Cabinet Committee that was presided over by a Prime Minister, even one that favoured the Health Service, which the present one does not. Even if the Prime Minister passionately supported it, it would not be satisfactory for an investigation to be carried out by a Cabinet committee with the Prime Minister able to carry through anything she wanted and to get rid of Cabinet Ministers who did not do as she wanted, almost as easily as if they were health managers.

The Secretary of State is a very clever fellow, although not quite as clever as he sometimes claims. However, I give him full credit for his quality compared to that of many of his comrades and companions in the Cabinet. When he accepted his job, his ambition exceeded his intelligence and he has to live with the consequences. Unfortunately, so do we. Unless we can cut it down, he will suffer to his dying day from the albatross round his neck, which is that he was prepared, in that Cabinet committee, to accept the formal investigation into the most precious of the country's national institutions, accept its terms and recommend them to the country. Even the right hon. and learned Gentleman can hardly stomach some of the terms, such as the special arrangements for BUPA patients, although he defends them.

I suppose that most of the leakages on these subjects come direct from the right hon. and learned Gentleman. The story is that he opposed the proposals right up to the end, but then swallowed his pride. That is the price of keeping his job. He has made his biggest political mistake and, unfortunately, we have to suffer for it.

I am sure that, when he has the chance, my hon. Friend the Member for Livingston (Mr. Cook) will carry out a proper overhaul and investigation of the National Health Service. That must take place, and the intelligent way to do so would be to have consultations before decisions are taken, not afterwards. If that had happened, even with these proposals, if they had not been handed down by the Prime Minister, there might have been some chance of decent consultations. However, nobody knows better than the Secretary of State how narrow the ground is for any possible negotiations. That is an affront to everyone who works in the Health Service, whether representatives of trade unions, about whom the right hon. and learned Gentleman is so rude, or representatives of the general practitioners. The right hon. and learned Gentleman is capable of offending GPs about their medical and monetary habits, when he is in a tight corner in negotiations. The presidents of the royal colleges, who represent some of the greatest traditions in this country, were never once consulted before decisions were made about these major questions on how the service which they did so much to build should operate in the future.

Doctors from my constituency, like many others throughout the country, have been to fake discussions and consultations held by the Secretary of State or by his Ministers, I was affronted by the one that took place on 20 April in Bristol, to which representatives from south Wales went to have discussions with the Secretary of State. After he had made his speech and after a few minutes of discussion, the media were turned out so that other discussions could be held. The Secretary of State did not allow the opportunity for other views to be put to him and many of those who went to the meeting went away affronted by the manner in which matters were discussed and debated, quite apart from their reactions to the proposals.

If the Secretary of State questions what I say, I can give him detailed evidence. I shall not go through every aspect of the objections, but I shall mention those relating to the major matters to which the right hon. and learned Gentleman referred. One of the leading doctors in my constituency went to the consultation meeting. It was the first chance that he and his representatives had had to speak about the proposal, which is now supposed to go through. I shall mention one of his objections from a list of almost equally valid objections: his criticism of the way in which the Government presented their proposals.

When the Secretary of State gets into such a ferocious rhetorical state about the propaganda spread by the BMA, he should he more careful, because he must be spending hundreds of millions of pounds of taxpayers' money on putting his case. The BMA, for probably the first time in history, is using an advertising agent to assist it in putting its case. I dare say the Government will soon introduce a law under which only Government Ministers will be allowed to use advertising agencies to present their case. I dare say that Lord Young, who often co-operated eagerly with the right hon. and learned Gentleman, would be happy to draw up a suitable piece of legislation that could be rushed through to ensure that only the Government have the chance to put their case, and if any other group tried to hit back it would be pilloried and attacked, as the right hon. and learned Gentleman has done so offensively on other occasions.

Doctors in my constituency, and I am sure many others, are asking something that goes to the central principle of the Health Service. The right and learned Gentleman's arguments about the numbers involved in the work in the years ahead will not affect this argument. The doctor said: I think it is morally wrong to claim that the Service will be free at the point of first contact when some GPs will in effect be controlling waiting lists. It would have been more honest for Government to have encouraged these Practices to present private services altogether rather than continue the pretence of the scheme representing NHS principles. Believe me, after the tuition of 30 or 40 years, doctors in my constituency—and, I would say, in most other parts of the country—understand the principles of the NHS very much better than the Prime Minister who presided over the committee that produced these proposals. The right hon. Lady has never understood those principles. Her idea is to kill Socialism, and I am sure that right up to 1979—or 1983, or perhaps 1987—she regarded the NHS as part of Socialism. It would be strange if she did not, because the NHS is the greatest and most obvious Socialist institution in the country and is based on Socialist principles. The Prime Minister cannot kill Socialism without killing off the National Health Service.

Of course, it would be very difficult to kill it off with a single blow or indeed a series of blows, even with such a skilful practitioner as the Secretary of State to do the Prime Minister's dirty work for her. The Government must go about it in a rather different way. I do not respect the good faith of the Secretary of State in these matters, but I know that some Conservative Members, and many doctors who are certainly not Labour party supporters, support the NHS and believe that its principles must be upheld over and above any competing principles about private profit, the market and so forth. That is what I mean by believing in the Health Service.

Many inroads have been made into the NHS as it was first introduced in 1948, and I acknowledge that they have been made by Labour as well as Conservative Governments; but we are now witnessing a much more serious, dangerous and long-term attack on the NHS than we have ever seen before. In case anyone doubts what I say or thinks that I am overstating this aspect of our deep-seated suspicions about the Government's motives, let me quote what was said by the medical correspondent of The Independent a day or two after the publication of the Secretary of State's proposals: In the week since the NHS White Paper was published, the most revealing comment about it has been an aside from David Willetts, formerly the Prime Minister's health care adviser in the Downing Street policy unit and now director of the Centre for Policy Studies, the right-wing think-tank Mrs. Thatcher helped to found. No doubt the Secretary of State is familiar with those bodies: indeed, he may be familiar with David Willetts himself. Mr. Willetts, the closest of the 'outsiders' to the NHS review, said he had asked a senior civil servant what he would do to the NHS if he were the minister. The reply was, 'I'd either leave it entirely alone, because it is too politically dangerous. Or I'd destabilise it, and see what happened.—' That is what the right hon. and learned Gentleman is doing with the backing of the Prime Minister, and that is why we believe that this attack will shape many other aspects of social policy in the years to come.

My hon. Friend the Member for Livingston has led the battle with such skill, knowledge, understanding and hard work that we will accept no insults that may be levelled at him by the Secretary of State. I am sure that the right hon. and learned Gentleman will wish to withdraw the few extra insults that he threw out today. My hon. Friend has led the battle to protect the service with constructive zeal, and we are still determined to protect it. We know that it needs much more money to be made better for the future; but, although that is by far the most important aspect, there are many others.

The improvement of the NHS must be achieved by a Government who believe in the democratic Socialist principles of the service. The Prime Minister does not believe in them, and if the Secretary of State says that he does he will not stay in his job for long. We would find reasons to rejoice at that, and others not to do so.

My hon. Friend has made a generous proposal to the Government. If it were merely a matter of political opportunism—those are the Secretary of State's words, not mine—the best thing for the Labour party would be for the fight to go ahead until we could play it as one of our main cards in the next election. My hon. Friend, on behalf of the Labour party, has proposed that the issue be kicked out until after the next election: that we should have a vote about it. That is a fair offer, and if it is rejected that rejection will expose all the more the malice—the malignity —that the Prime Minister and her aides have brought to this great subject.

5.5 pm

Dame Elaine Kellett-Bowman (Lancaster)

I shall not detain the House for long. I wish to make three points.

I wish first to comment on the disreputable £7 million advertising campaign being run by the British Medical Association. Like many of my hon. Friends, I actually enjoy receiving letters from constituents, but I have been horrified by the number of letters that I have received from elderly patients, many of them in old people's homes, who have been worried stiff by the BMA's untruthful pamphlet. They have been led to believe that they will not obtain the treatment or—if it is near the end of the financial year —the drugs that they need. The BMA knows perfectly well that both those things are untrue.

Even worse, one 84-year-old was informed by his doctor that if the Government's proposals went through he would no longer be able to visit him at home in an isolated rural area. I should dearly like to know the name of his doctor. Despite all that, however, I continue to believe that locally we are very fortunate in our GPs, and that they have merely been misled by the BMA and are supporting what is, after all, their trade union.

I have responded meticulously, point by point, to every point that a doctor has made to me. I assured doctors that this was a consultative document and that I would forward all their letters and comments to the Secretary of State as part of the consultation process, which I have done. I said that I would seek answers to points which were unclear or which worried them, with a view to having them modified —as usually happens during a consultation period—or deleted altogether, as the case might be.

That was until Thursday. On Thursday I received a letter from a local GP. The final paragraph read as follows: Some doctors select the compliant patients by being so unpleasant that the others leave the list, and join the list of a softer doctor. Those are not my words; they are the words of a local GP.

That letter came as a considerable shock to me, because I have always viewed our local doctors—delightful men—through rose-coloured spectacles, and have argued that what the Government were trying to do was bring other areas up to the standard of those in my part of the world.

No doubt the unpleasant doctors mentioned by their colleague are not typical, but even one such doctor is one too many, and shows that reform is necessary for the patients' sake. Fortunately for the excellent reputations of our local hospitals and the vast majority of our local GPs, on the very day that I received that disturbing letter the North-West regional health authority issued a report by its top medical experts showing that the expectation of life in Lancashire and Greater Manchester was two years below the national average—except in Lancaster, where it is above the national average. That rather proves the point that I was making all along to doctors and constituents alike—that the NHS is patchy and uneven. When the BMA and the Royal College of Nursing talk of destroying the comprehensive nature of the NHS, they are talking of a myth. The aim of the Government is to make sure that a comprehensive service, nationally funded, exists everywhere, and that people obtain decent treatment wherever they live.

It is said that things go in threes. On Thursday the BMA held its conference to decide its attitude to the proposals. As one GP representative put it, the BMA attitude is hardening. Really? When did the BMA not oppose change? It opposed it when Lloyd George tried to reform health care in 1911; it opposed the White Paper in 1943; it opposed the introduction of the NHS in 1946–48 until—as the predecessor of the right hon. Gentleman the Member for Blaenau Gwent (Mr. Foot), Aneurin Bevan, put it—its mouth was stuffed with gold; and it opposed the changes in the contract in 1966, changes it is now defending tooth and nail.

I have news for the BMA delegate to whom I have referred: if the BMA attitude is hardening, so is the attitude of myself and my hon. Friends, with every letter that we receive from sick and elderly constituents, people who are frightened, misled and confused by the BMA pamphlets. We do not expect that sort of unprofessional conduct from the delightful and courteous men whom, until now, we have liked and respected. If there be any will to resume the protracted negotiations on conditions of service, all very well. If not, so be it. I advise the Secretary of State to press on with his reforms. The patients need them, and we shall support them.

5.14 pm

Mr. Archy Kirkwood (Roxburgh and Berwickshire)

I believe that the official Opposition's motion left the Labour party wide open to exactly the kind of counter attack launched by the Secretary of State. It is wrong headed at this stage to concentrate simply on the terms of the general practitioners' contract and doctors' opposition. Such a move allows the Government to argue that the doctors are just another special interest group and that they are only concerned about their own wallets. Such an approach diminishes the importance of all the other professional and consumer groups, legion in number, who oppose the Government's proposals.

The range of dissent and the depth of feeling of opposition to the White Paper argue powerfully for the widespread mobilisation of public opinion against these proposals. The motion tabled by the Labour party has potentially minimised the opposition of Conservative Back Benchers and the possibility of getting a response from them to the position in which they find themselves. I get the impression that they are under a lot of pressure from their constituents. Therefore, I believe that an Adjournment motion would have produced a much more instructive and constructive debate.

The Secretary of State announced that a full debate will be held on the White Paper. It would be helpful to know when that might happen. It will be an important debate in Government time, and I look forward to it being held.

The Government's proposals relating to the NHS are ill thought out. No firm long-term commitment has been made to increase funding year by year. I understood the Secretary of State to say that he had won a 5 per cent. real increase at the battle with the Treasury last autumn. If that is correct and if the Secretary of State is saying that, over time, the Health Service can expect that sort of real terms increase in funding under his custodianship, many of the generally held fears will be assuaged. Of course, there is always the question whether Government statements can be trusted.

The very effective speech of the right hon. Member for Blaenau Gwent (Mr. Foot) underscored the fact that part of the problem has really arisen because of a lack of consultation. The Government engaged in an internal review. There was no consultation or empirical research. No evidence was submitted and studied. That situation weakens fundamentally the strength of the case that the Government are trying to argue.

The Secretary of State cannot so readily rubbish the idea of pilot projects. In the autumn, there will be a report on the resources management initiatives that have been in process. Why do we not wait at least until we have the preliminary findings, although even then it may take some further time to establish exactly what has been achieved in those projects? I am aware that another 50 or so are due to commence and they will also take further time to assess. There is no reason for this degree of haste; the pilot projects should first of all be studied carefully, before decisions are made. The time allowed to introduce the plans is totally inadequate, and is a recipe for confusion and disaster. There is no guarantee of resources even to manage the introduction of the reforms—a substantial problem which the service will have to face. In the present situation there is considerable uncertainty and confusion. The response of the Secretary of State is simply to try to bully people into line. That is not a proper or responsible way to behave. The only major effect achieved is to lower morale of staff when they are trying their best to deliver the best service they can.

The proposals in the White Paper are undoubtedly fundamental and far reaching, irrespective of whether one thinks they are right or wrong. Given their importance, the changes should have been introduced much more carefully and thoughtfully. I believe that the debate should really be about the future of primary health care. The Government seem motivated by a desire to create a mechanism that will limit costs. I have a fear, and it is essentially the same fear as that which GPs raised when the NHS was first introduced. They fear now as they did then that limitations on cost will restrict clinical judgment. GPs are right to be afraid, because, given the lack of detail in front of us, that limitation is still a real prospect.

An inevitable result of the present proposals would be doctors spending less time with patients. I cannot see how the Secretary of State can argue otherwise. Less time would be spent on meaningful preventive medicine. I listened carefuly to the Secretary of State's comments about Government targets, statistics and so on. However, meaningful preventive medicine depends on the general practitioner spending sufficient time with individual patients to deal with their requirements. As a result of the Government's proposals, there is certainly a prospect of a fundamental erosion of services provided in rural areas. The Secretary of State has not satisfied the profession that such services would not be eroded.

As a Scottish Member, I realise that some improvements have been made in the Scottish contract. I hope that, as far as possible, those improvements will be made in the English contract, built upon and taken forward. However, in general, doctors are still apprehensive that they are being asked to take a fundamental structural step in an unquantified way in an unknown direction, with the real prospect of damage to their patients as a direct result.

I want to ask some questions that I hope will clear up uncertainties that currently exist in the minds of medical professionals. If the Secretary of State has set up a new organisation known as the British medical opposition, I would certainly like to be a founder member; I will join up this afternoon. Has the Secretary of State considered alternative models to deliver primary care? I refer him to an article published on 15 April in the British Medical Journal by Professor David Morrell, a professor of general practice. He outlines a detailed role for general practice and a contract that would make far more sense. He talks about the need for an increased basic practice allowance. His scheme would also involve annual reports by the GP practices to the family practitioner committee or the area health board, and regular visits by audit committees. I do not have time to go into his proposals in great detail, but general practitioners in my area have told me that it would be a sensible alternative, would lead to the attainment of many of the Government's objectives and would exclude all the objectionable features of the present plans.

It is important that we should hear what the Government have to say about care in the community for the elderly, the mentally handicapped and the mentally ill. What will be the administrative cost of setting up and maintaining the new system? Will the medical audit be adequately funded? The Government studiously avoided making a positive response to the exchanges on that subject in the other place. What will be the career structure for part-time doctors, particularly part-time women doctors? The Government have made no headway on that fundamental question. According to most informed commentators, the basic practice allowance and the group practice allowance are on the way out. That would have a fundemental effect on the career prospects of part-time doctors, particularly part-time women doctors.

The objective is to achieve greater choice for the patient. How will that be possible if a district health authority has a contract with a hospital to provide services and if a general practitioner has not opted to take control of his own budget, and therefore does not have money to send with the patient to that hospital? What will happen if that general practitioner wants to refer a patient to a hospital that has not entered into a contract with the district health authority? Frequently, there are valid reasons for referring the patient to a hospital outwith the district health authority for specialist treatment, or for other reasons. Can the Secretary of State guarantee that such a referral would still be permitted under the new proposals? That question is causing great concern and anxiety to general practitioners and patients in my area and others.

If implemented, the White Paper proposals will change fundamentally the National Health Service. It will be changed almost beyond recognition. The old ideas of consensus and co-operation will be overtaken by competition and cost-cutting, with the result that the standards of care for the elderly and the chronically sick will fall and the administrative and treatment costs for everybody else will rise. The Government should think again.

5.22 pm

Mr. Jonathan Aitken (Thanet, South)

I agree with the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) that the terms of the motion are tactically ill-judged. We have witnessed this afternoon a delightful irony of political history. The House was treated to the spectacle of the Labour party leaping uninhibitedly on the BMA's bandwagon.

The hon. Member for Livingston (Mr. Cook) said that it is not true that doctors always oppose change in the National Health Service. I thought I saw the right hon. Member for Blaenau Gwent (Mr. Foot) respond to that statement with a nervous twitch. It seemed to stir him into doing his best to paper over the cracks of Labour party history. He said that the doctors had responded quite favourably in the end to the Bevan reports and that we should not be surprised that the Labour party agrees with the BMA. However, that is not what the right hon. Gentleman said in his book.

By chance, to amuse myself on bank holiday Monday, I dipped into his majestic biography of Nye Bevan. On page 103, I discovered his description of exactly what was the mood of the doctors as the NHS reforms were introduced—reforms that the BMA opposed as implacably as it defends the status quo today. The right hon. Gentleman said: Much the strongest bent in the medical mind was a non-political conservatism, a revulsion against all change, a habit of intellectual isolation which enabled them to magnify any proposals for reform into a totalitarian nightmare. I find an echo or two of those words in today's BMA campaign and an echo or two in the speech of the hon. Member for Livingston.

Conservative Members do not need to disparage the word "conservatism"—the fact that the medical profession is traditionally a conservative profession. That is natural. General practitioners have much to be proud of in the way that they carry out their duties. Our delicate task in the debate is to try to make a judgment on what parts of the general practitioner's world within the NHS should be preserved and what parts should be altered by the reforms. That is the judgment that we have to make on the White Paper and the supporting documents.

There are plenty of good ideas in the White Paper for both doctors and patients, which I strongly support. The medical audit proposals are excellent. The notion of a peer review is supported by many thoughtful doctors. I believe that the perhaps more controversial proposals on indicative or guideline drug budgets for doctors should be welcomed.

We have heard yet again the BMA's traditional trumpet call sounding the alarm that any such proposals will destroy doctors' clinical freedom to prescribe. Those arguments were shown to be ill-founded at the time of the limited list controversy in 1985. They are even more ill-founded today, in the light of that experience. I recall supporting my right hon. and learned Friend in his previous incarnation as Minister of State. He put up with all kinds of attacks when he introduced the limited list. What was the result when the dust settled? [Interruption.] The hon. Member for Peckham (Ms. Harman) says that he amended it. I hope that all political debates and consultation papers will lead to amendments. The accusations that were levelled against my right hon. and learned Friend were totally unjustified. When the dust had settled, £75 million had been saved from the nation's drug budget and diverted to better patient care. Moreover, the notion that clinical freedom was threatened or would be destroyed proved to be a complete nonsense. It has not been affected at all.

In a world where resources are finite and the demand for medicine is infinite, there can no longer be any absolute prescribing freedoms. We should welcome the guideline drug budgets for doctors as a non-compulsory yardstick of measurement, particularly since the yardstick can be moved after dialogue with the family practitioner committees and after peer review.

Having commended certain parts of the White Paper, may I also express a few misgivings about the sections that deal with the future management of general practice. My real concern is whether the proposals will actually work and whether they are based on the right principles. I must confess that I am a little worried that there may be some fundamental flaws at the heart of the management proposals for general practitioners. Above all, I fear that the White Paper's ideology of free market forces and the untried innovations that flow from that ideology may not satisfactorily be transplanted to the traditional and caring body politic of general practice—at least, not without some hideous practical difficulties.

The first flaw I detect in the White Paper is the impression it gives that all these sweeping management reforms are necessary because general practitioners go about their duties in a way that is inefficient and expensive. If that is Whitehall's view, it is not a view that is widely shared by patients at the grass roots; nor does it seem to be justified by the available statistics. As far as I can discover, Britain's doctors—as gatekeepers of the NHS —operate one of the cheaper and more effective primary health care systems in the Western world. Medical salaries here are pinned down to less than half the levels that exist in some European countries and in the USA. NHS administrative costs are low, at 4.5 per cent. of the total, compared with administrative costs of 21 per cent. of the total in America's competitive, free market medical system.

One part of the Government's reforms that perplexes me concerning their call for greater business efficiency and consumer choice is the starting point of the grievance that doctors are inefficient. Of course there are some bad doctors; there are a few bad apples in any profession. There are some 9 to 5 spirits who seem to have forgotten their vocation. However, on the whole the evidence suggests that there is widespread patient satisfaction with general practitioner services in this country, and I find it curious that a White Paper which is championing consumer demand in medicine should provide no evidence of consumer demand for reforms of general practice.

As I see it, the whole key to the philosophy of this White Paper towards the doctors is summed up in a sentence on page 48: The practices which attract the most custom will attract the most money. That sounds good as a fly-by-night economics textbook sentence published by the university of Chicago business school but, coming down to our own National Health Service, what it means is that the ultimate reward for improved efficiency and improved advertising is that market forces will send successful doctors a longer list of patients from which the doctors can earn higher and higher capitation fees and augment their incomes still further by the performance bonus rule which allows them to retain in their practices 50 per cent. of the savings they make from their budgets.

We should not try to pretend that such proposals are anything other than a very radical reform. After all, they go against the trend of general practitioners trying to keep small lists, as they have been for some years now. It seems to be a decisive shift away from dear old "Dr. Finlay's Casebook," as super-doc comes to the supermarket with these sorts of ideas. Will the reforms work, and if they do, will they damage, as some doctors fear, the fundamental basis of doctor-patient relationships or the established collegiate basis of doctor-to-doctor relationships?

These reforms may work in certain prosperous surburban or metropolitan areas such as parts of the home counties or the city of Westminster, where the residential community consists largely of youngish people of working age, who may well be content with the brusque "Wham barn, thank you, doctor, for getting me back on my feet as quickly as possible" approach, because on the whole that approach to medicine will be quite popular with the age and social group likely to suffer only from short bursts of illness.

However, consider for a moment a completely different kind of community. I take the town of Ramsgate from my own constituency, which is a seaside town with a population of whom 38 per cent. are pensioners and which has the biggest department of social security office in south-east England, with 16,000 people on benefit. It has a particularly high concentration of disabled, disadvantaged, geriatric, chronically sick and mentally handicapped people. In short, doctors there deal with a lot of patients who need time and care. I do not see, in the words of the White Paper, many pluses for elderly and deprived patients in that sort of community, for many of whom the language of consumer choice in general practice might just as well be Mandarin Chinese. They want guidance, not the ability to make yuppy-type consumer choice decisions.

Mr. Sydney Bidwell (Ealing, Southall)

What would the hon. Gentleman say to a constituent who came to see me on Friday to say that, after false diagnosis, his wife needed pretty urgent surgery to the nose after many months of distress? She went to Ealing hospital as a result and was told that she would still have to wait many weeks before the operation could take place, but if he could afford £1,000 it could be carried out next week. What does the White Paper do in this regard?

Mr. Aitken

The hon. Member tries to tempt me into completely different areas from those which are the subject of this debate, and I must resist that temptation other than to express sympathy with his constituent. Whether it is his constituent or my constituent with a problem, I want to emphasise that I am not talking about so-called bad doctors or inefficient practices.

I know a practice in Ramsgate which lives up to and exceeds many of the standards set by the Government in the working papers. Its child immunisation rates are in excess of the Government's target of 90 per cent.; its drug bill is 23 per cent. below the average for the area; it operates minor surgery sessions; it holds preventive medicine clinics; it is computerised, with modern capability and enjoys a good professional and popular reputation. It is just the sort of practice which should benefit from the White Paper proposals, and yet the doctors in that practice regard the Government's management and budgetary ideas and target payment schemes in particular with feelings close to horror. Why do they have those very strong feelings? The answer is that they believe—and I think they are right, with 12 per cent. of their patients over 75 and another 33 per cent. over 65 —that they are serving the kind of community which can best be looked after by the gentler culture of traditional general practice, with all its occasional necessary time-wasting delays and pauses for counselling and sympathy which a caring service involves, rather than the harsher disciplines of competitive, doctor—versus—doctor consumer choice, free market medicine portrayed in the White Paper.

I do not want to fall into the trap which the Labour party has fallen into of knocking everything in the White Paper on the curious principle that any stigma will do to beat a dogma, but there should be more flexibility in some of the Government's proposals. I could not find much indication of that vital ingredient in the White Paper, but I was glad to hear in some of the things my right hon. and learned Friend was saying today, and indeed in the tone of some of the recent press statements and working papers, that a gentler and more flexible note may now be injected into some of these proposals as they affect doctors.

Can I follow the point made by the hon. Member for Ealing, Southall (Mr. Bidwell) in supporting his call to the Minister to pay some attention to that profound article by Professor David Morell in a recent edition of the British Medical Journal? His point, as I understood it, was that the Government could get everything they wanted, but the foundation stone for the new contract should not be so much free market forces as the ideal that a medical practice serves the community in which it is based and that the standard of service by doctors to a community could be defined, graded and rewarded not by competitive forces within that community but by an annual audit carried out under the supervision of the area family practitioner committee. There was a great deal of merit in that proposal.

Finally, whether we are talking about Professor Morell's ideas or the Government's more radical proposals, when tackling this subject of reforming general practice a little humility and caution is essential. We are getting into deep and uncharted waters. I was sorry to hear the Secretary of State sound a little disparaging as he brushed aside any suggestion that pilot schemes might be workable. It is always bad news when the Labour party has a good idea, but the pilot scheme has something to commend it, because rural, coastal, inner city, suburban and metropolitan areas all have their different problems, and a different programme of pilot schemes in each one to see how some of these ideas work would be sensible.

The decent, diligent family doctor is part of the culture of Britain, part of the fabric of our society, and on the whole general practitioners have served their communities well. They rightly enjoy a far higher level of popularity and respect than a great many other professionals including, I might say, politicians. Maybe some general practitioners do need a bit of a shake-up and many of them would accept the best of the Government's new ideas and agree that the White Paper does give a useful nudge towards some welcome changes, but let us proceed by evolution rather than by revolution and let us have more time, collaboration and path-finding by pilot schemes, because that is the way of accomplishing what the Secretary of State and all his supporters wish to achieve.

5.38 pm

Mr. Ron Leighton (Newham, North-East)

The Secretary of State has had the unique distinction of uniting the whole of the medical world including all the royal colleges, against himself. I see today that he also has the opposition of the community health councils, who found the issuing of his White Paper 'objectionable', the proposals 'drastic' and the time scale 'unacceptably hasty'. and are asking him to suspend implementation of these 'undesirable' and 'impractical' plans. Today, we are discussing the views of the doctors. In preparation for the debate I conducted a survey of all the doctors in my constituency. They voted 47 against the Secretary of State's proposals and only three in favour. I asked them for any further comments and I received a huge sheaf of impassioned correspondence which I should be only too pleased to allow the Secretary of State to inspect.

I should like to read a small selection of the comments that I received, to which I hope the Secretary of State will pay attention. Dr. Spalding wrote: I am disturbed by the proposals of the Government's White Paper on the National Health Service. I see them as doing great harm to general practice. I have been in practice in Manor Park for 25 years and retire in one week and so I have no vested interest either way. The White Paper is pervaded by a materialistic attitude to medicine. Money matters but it should not be the only ruler. Interestingly, this attitude is revealed in the White Paper by the use of the word 'Consumer', where Patient is meant … I am afraid that if its ideas are enacted, the patient will indeed become merely a consumer. Dr. Patel said: No, the new proposals won't help the NHS, they will destroy it. Please ask the Government whether the advisers on the new proposals are full-time NHS doctors or economists? The new proposals will destroy the doctor and patient relationship. There would be a two tier fragmented Health Service. Dr. Phillips said: Medicine is not a business and should never be run entirely on that basis. In general practice it would not improve patient care. Extra administration would be necessary—there is already too much. If the Government expects us to be capable of running the practice on a financial level, and negotiate with hospitals, etc. we should be considered capable of running the internal affairs of our practices without outside pressure and interference. Dr. Kapur said: the opting out of hospitals, the buying of hospital facilities by Family Practitioner Committees, the restrictions on the GPs' budget and referral rights; the increased (60 per cent.) payment on number of patients—all these factors plus many others will lead to a deterioration of morale, and to two levels of NHS care. Dr. Graham wrote: In my opinion the new contract introduces increased bureaucracy causing a greater distance between doctors and patients and distrust. As a course organiser I am alarmed that the Government are demanding 20 hours in surgery per week as I spend two or more sessions a week in Newham General Hospital teaching post-graduates. When I see a patient who looks ill I cannot tell whether he has influenza needing rest, food poisoning or acute leukaemia where a bone marrow transplant costs £220,000. It is only detailed hospital tests that will eventually uncover the truth, by which time the patient is out of my control. He would not want a GP coming to Hospital behind his back to consult with the specialist and possibly saying, 'Our practice cannot afford this treatment in future this year'.". Dr. David Keable-Elliot said: The Government's proposed health service changes will seriously damage patient care and risk trust between doctor and patient. For the first time, general practitioner services are to be cash limited. This means a possible rationing of the care we provide each year. We are to be offered financial incentives to save on the cost of patient care. … We are to be offered rewards not to treat patients, or to delay their care whether this be arranging hospital tests, giving treatment or referring patients to a specialist for a possible operation. We are to be encouraged to arrange for patients to go to the cheapest hospital, perhaps not the best, the nearest or the one with the shortest waiting list. The Government want GPs to become 'rationers' of health care and thus take the blame for chronic underfunding of the NHS. Once that happens, our concern is that we will be blamed for the service's failures and that will then be used as an excuse to force further changes which will finally end the health service as we know it. We are not prepared to risk the trust and confidence our patients have in us. How long will that trust last when they know we have an incentive not to act in their best interest? Dr. Mahendran wrote: Budget or cost cutting on an open ended comprehensive service such as the NHS is unacceptable. An unlimited number of patients under a doctor will mean no time for patients who deserve more time and attention. Chronically ill, disabled and patients requiring multiple therapy will lose out from this White Paper. If Regional Hospitals opt out the patients will have to travel to distant hospitals to obtain basic specialist attention or hospitalised care. This cannot mean that patients have greater choice. Even if Doctors' surgeries remain prudent and minimise costs, what guarantee is there that the money allocated for the subsesquent years will match the needs and inflationary increases? He adds the postscript: In the entire discussion Kenneth Clarke sounds as if the NHS is a wasteful and inefficient service. Does he not realise that throughout the world there is no parallel to the effective, comprehensive health service provided by the NHS taking into account the total cost incurred? The hon. Member for Thanet, South (Mr. Aitken) also raised that point.

Dr. Dubai said: As budget holders we would be asked to offer our patients treatment influenced more by the cost than the needs of the patient. I have two patients with kidney transplants and a third on a waiting list for a kidney transplant. Each time I write medicine for these patients, as recommended by the hospital to stop transplant rejection it costs over £100. I also have several elderly patients with multiple diseases and disabilities which demand a lot of time, energy and social support. If I am to be a budget holder I would have to think seriously about keeping these patients on my list as I would not have the time or money to look after these patients—even if I tried hard. I would have to refer the patient to the cheapest hospital and look for the cheapest drug to treat them—the so-called 'shop around'. I do not believe that a patient who has paid his national Insurance and his 'dues' should be offered a second class treatment. If the Government cannot afford the National Health Service they should tell the people and patients, rather than hide behind the doctors and get their objectives done by forcing the doctors to do that for them. He goes on to praise group practice and says that he had thought that the Government favoured it. He adds: By abolishing Group Practice allowance there will be a disincentive to form group practices with the resultant fall in the standard of patient care. Dr. Bapna wanted me to tell the Government that Doctors are not running a shop, they are doing what is best for their patients. Dr. Patel asked: How can a doctor give more time and do all the preventative work by increasing the size of the list? I hope that the Secretary of State is paying close attention to the views of doctors in my constituency. Dr. Lazarus said: Having considered all aspects, I feel my time spent in budgetary and choosing cheap alternatives and unnecessary form filling would be better spent giving my patients a service I already provide. Dr. Desai said: The new contract is likely to cause deterioration in the service as doctors will not have time for promotive and preventative work if they have to look after more patients. In inner cities the situation is likely to worsen. The proposed payment structure for preventative work and immunisations etc., will make doctors despondent and lose interest in such work. The targets stated are not achievable as they depend on the patients. Dr. Watt said: The immunisation and cervical smear targets are unreasonable. GPs cannot be a paternalistic police force forcing people to have what is good for them. Dr. Christopher Derret said: Increased capitation fees are not an incentive to doctors to spend less time with each patient. Many patients say they already think their doctor gives too little time for each consultation. Quantity not quality is to be paid for. In the inner cities morbidity is higher and patient consultation rate can be almost double that in some prosperous areas. The hon. Member for Thanet, South also mentioned that point. Dr. Derret went on: There is a widespread fear that the Government has a hidden agenda for the privatisation of Health Care. Dr. Cramsie said—

Mr. Aitken

On a point of order, Madam Deputy Speaker. Is it in order for an hon. Member to read out verbatim quotes from doctors' letters with no break when many hon. Members on both sides of the House have speeches which they have thought about carefully and wish to deliver?

Madam Deputy Speaker (Miss Betty Boothroyd)

It is for hon. Members to deploy their arguments as they wish, but I remind the House that many hon. Members wish to take part in the debate and I appeal for very short speeches.

Mr. Leighton

I take your point, Madam Deputy Speaker, and I take the point made by the hon. Member for Thanet, South, but we are debating the views of the doctors. I am giving the views of rank and file doctors working in my constituency. Those are the views they have given me, which they have asked me to represent in Parliament. I shall compromise and read out two more letters. Perhaps the House will then have got the message from their remarks.

Dr. Rachman says: The plan to change the BPA to a per capita allowance will discourage existing practices from taking on new partners —there will be no incentive to. Instead I believe we will all be encouraged to employ assistants—these are often women and have no prospects of promotion or extension of their role. This is a retrograde move which seriously affects the position of all new young doctors seeking partnerships. Dr. Haas says: I am very concerned that patients will find it hard to develop trust in their doctors as they will no longer see us as their advocates but as agents of cost control. Most of all, the health of those able to shout least loud, the old and physically handicapped will suffer. That is an accurate reflection of doctors' views in my constituency. I would be delighted to give the Secretary of State the pile of correspondence so that he can read it. He should not laugh at the doctors' views or mock them. The doctors work in the depressed and deprived inner city. They have many problems. They considered the White Paper, then contacted me and asked me to put their views in the House.

How can the Secretary of State implement the proposals against what even he calls the "British medical opposition"? If the doctors do not become budget holders and if the hospitals do not opt out, what is left of the proposals? The Secretary of State should listen carefully and respectfully to the views of doctors. He should take his White Paper away and launch a genuine consultation. He should proceed by agreement to achieve a strong, free and adequately funded NHS.

5.51 pm

Mr. Jerry Hayes (Harlow)

It was fascinating, to listen to the hon. Member for Newham, North-East (Mr. Leighton). Although it may destroy his political career, I must say that I rather like him. He held himself spellbound by some of the most awful codswallop. What have the doctors been reading? They must have been reading letters from the hon. Gentleman and the British Medical Association. If they want to hear what the Government are doing through the White Paper I would be only too delighted—and I am sure that many of my hon. Friends would be delighted—to speak to the doctors in Newham, North-East. I lay that down as a friendly challenge.

Mr. Leighton

The hon. Gentleman would have to be rather careful. If he spoke to the doctors like that, several of them in their white coats might think that it was a section 42 job and take him away.

Mr. Hayes

I concede that one on points.

It was fascinating to listen to the right hon. Member for Blaenau Gwent (Mr. Foot). It is always a joy to listen to such eloquence. Although I thought about what he said carefully, in the words of F. E. Smith, I was none the wiser or better informed. There was a lot of chat about destabilisation and under-resourcing. It suddenly dawned on me that this speech was coming from a member of a Labour Cabinet which cut capital expenditure on hospital building by 30 per cent., which for the first time in the history of the National Health Service agreed to cut the overall budget of the Health Service in real terms and which agreed to spend more on defence than on the Health Service—the opposite to what is happening now.

I want to draw to the attention of the House what was probably the most telling remark in the debate so far. It was made by the hon. Member for Livingston (Mr. Cook). He said that there would be a breach of the trust between doctor and patient and he asked how a patient would be able to look a doctor in the eye and trust him. The hon. Gentleman is right, especially when one considers the doctors who put skulls and crossbones up in their surgeries, the doctors who have been warning the most vulnerable members of society, such as the elderly, that they will not be welcome at their surgeries and the doctors who, at the instigation of the BMA, have put at the bottom of their prescriptions, "Voting Conservative will damage your health." That is where there has been a breach of trust. It has been a breach of trust by a small minority of general practitioners and by the overwhelming majority of the BMA.

I raised a point with the hon. Member for Livingston earlier. He was giving a long litany of the opposition from the medical bodies, but he did not mention the National Association of Health Authorities in England and Wales. He stood there as if polyunsaturated margarine would not melt in his mouth and said that the association was the stooge of the Government. Yet the members of that association are the people who run the Health Service. I and many of my hon. Friends believe that their views are important. With the leave of the House, I shall quote the association's conclusions, warts and all, which is what consultation is all about. The association said: Overall, the Association welcomes many of the proposals in the White Paper. These include the more effective use of resources, greater responsiveness to the needs of the general public, clinical audit, greater delegation to the operational level, more involvement of clinicians in management and incentives for providing better services. The Association is also supportive of the separation of funding and provision of services. It has to be recognised, however, that whilst many of these proposals are welcome, there are also a number of risks. The principal risk is that in the more diffuse NHS that is likely to emerge in the post White paper situation, it may be more difficult for the Service to guarantee comprehensive services to the population as a whole. It is therefore essential that RHAs, FPCs and DHAs are given the ability and authority to ensure that services are accessible, integrated, of a high quality and well funded. If these conditions are met, the NHS can look forward to the future with confidence. That is constructive criticism such as my right hon. and learned Friend welcomes.

Mrs. Alice Mahon (Halifax)

Can the hon. Gentleman tell us how many letters he has received from GPs and consultants supporting the Government's proposals? Like my hon. Friend the Member for Newham, North-East (Mr. Leighton), who was criticised for doing so, I could read out a file of letters from doctors who oppose the Government. How many letters has the hon. Gentleman received in support?

Mr. Hayes

The hon. Lady has raised a valid point. I have received many letters from general practitioners who are wholly opposed to the White Paper. But when I go to see them and talk to them about it, they realise that the proposals are working for their patients. The overwhelming majority of general practitioners care deeply about their patients and do not like to be conned by people making cynical political capital out of other people's misfortune, as is happening now. The time must come when, in the words of my hon. Friend the Member for Thanet, South (Mr. Aitken), the dust must be allowed to settle, the megaphone diplomacy must stop and we must get round the table with those who care about the Health Service—the GPs, the consultants, the administrators and the nurses. There is much in the proposals for all of them, as they will appreciate soon. In the past—and I see my right hon. and learned Friend the Chief Whip sitting here —I have been highly critical of Government policy on the Health Service—[HON. MEMBERS: "No."] Yes. That may come as a shock to some of my hon. Friends. Some of us have voted against the Government, but when they get it right, we should darn well support them.

Dame Jill Knight

My hon. Friend spoke about letters he had received from doctors. Will he take the point that those doctors have been grossly misled and misinformed by their own leaders about the true contents of the review?

Mr. Hayes

Of course, many of us on the Select Committee raised that issue with the people who run the BMA, and they have said, "This is what we feel is in the White Paper," or, "This is what we think might be in the White Paper." However, when confronted with the facts and the reality, they are speechless—[Interruption.] Let us be constructive. This is a time when there should be sensible negotiations.

Going back to something else that my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) said, this is not the first time such things have happened because all of us can remember notices going up in local surgeries in 1985 about the limited list. We all received letters from doctors, consultants and even from elderly patients who said, "My health will deteriorate if this wicked proposal goes through." That proposal was put forward by the then Minister of State, my right hon. and learned Friend who is now the Secretary of State for Health. There was sensible negotiation on that, the NHS saved £75 million and patients are receiving a good standard of health care. If one speaks to a GP now and says, "Hang on, a few years ago I saw a poster in your surgery about limited lists," that GP will probably say, "Oh well, we agreed with it really." I suspect that when GPs hear the truth now, the same thing will happen.

However, there are a few things that I should like my right hon. and learned Friend to take into account—[HON. MEMBERS: "Ah."] This is not a criticism. It is about negotiation and consultation. I want to put to my right hon. and learned Friend some of the points that many doctors have put to me and to some of my hon. Friends. I know that my right hon. and learned Friend has said on television and on radio that there will be compromise and negotiation. I ask him to look carefully at the rural practice allowance, which is concerning many doctors. I ask him to look also at the 20-hours provision because it is absolutely right that there should be a division between part-timers and full-timers and many doctors are concerned that the Secretary of State means 20 hours in the surgery, which might cause problems. I am sure that my right hon. and learned Friend will look again at such things and at the targets for immunisation which in many areas, especially in highly ethnically populated areas, might cause some difficulty. Perhaps it will be worth considering some form of exemption for doctors who have done their very best to get people in for cervical smears and immunisation but whose patients do not turn up. I do not see why the doctors should be penalised.

The Health Service is really about people getting their operations. One can wax lyrical about more money and about more doctors and nurses, but what people really care about is getting into hospital for their operation. Once they are in hospital, they like the nurses and the doctors —they do not much like the food—and they are satisfied with the service. The main thing is to get the patients into hospital.

The crucial thing about this whole review—my right hon. and learned Friend said this at the beginning of his speech—is that the efficiency trap will be abolished. We have a ridiculous state of affairs at the moment. We are paying hospitals to close beds for economic reasons. More patients are being treated, more operations are being performed—this is happening every day—but approximately 20 per cent. of National Health Service beds are being closed. That will cease if the money travels with the patient because it will then be in the interests of hospitals to keep beds open.

I turn briefly to the private sector. There will be shock and gasps of horror from Opposition Members who will ask how one dares to mention the private sector. The private sector is working at about 45 per cent. capacity. Let us examine what is happening in, dare I say it, South Glamorgan where the South Glamorgan health authority has done a deal with an excellent private hospital in Southampton called Chalybeate. The South Glamorgan health authority has contracted all its open heart surgery to that private hospital. The families of the patients are looked after. They are transported to Southampton and put up in hotels. The operations are carried out speedily and efficiently. There is absolutely no cost to the patient. What is more, because of surplus capacity the South Glamorgan health authority is saving money. If ever there was an example of co-operation between the private and public sectors, that is it. That is what we are aiming for in the White Paper because what is happening in South Glamorgan should be happening all over the country and we should have the opportunity to let it happen.

The last point that I wish to raise with my right hon. and learned Friend—

Mr. David Hinchliffe (Wakefield)

rose—

Mr. Hayes

No, on another occasion. I shall not give way because other hon. Members wish to speak in the debate.

I should like to say a few brief words about the Treasury. It is important to mention the Treasury because in the past the Treasury has been able to play all sorts of people off against each other. The Select Committee may say, "£2 billion is needed for the Health Service", the nurses can say, "£X billion" and the doctors, "£Y billion", but no one really knows how much the Health Service really needs because no one knows the cost of an operation or a treatment.

Mr. Battle

What about tax cuts on private health?

Mr. Hayes

The hon. Gentleman refers to tax cuts, but they are totally irrelevant to what we are talking about.

How can one plan for the future unless one knows how much operations and treatment cost? When information technology comes in and when doctors know the cost of an operation, persuasive and almost unanswerable arguments will be put to the Treasury about putting more money into the Health Service. In the past no one has known where the money has been going, but at least we will now be able to know that.

Before I sit down, I should like to say a few brief words about the existing system because in the meantime we have a problem, especially in areas with large waiting lists. My own West Essex health authority is in the top 22. My right hon. and learned Friend has helpfully given us waiting list initiative money and, although we have also been given £800,000 in growth money, we have suddenly been told that the North East Thames regional health authority, which has loaned us £1.5 million to be paid back over three years, is going back on its agreement and wants to take that £800,000 growth money. I ask my right hon. and learned Friend to look carefully at that instance of gross mismanagement, which must be totally contrary to his wishes and those of his health team. Growth money must be for growth and must be specifically earmarked.

All in all, there may be difficulties with my right hon. and learned Friend's White Paper and with the working document, but I advise him to listen to the views of the general practitioners and of the Health Service professionals because I further advise him that when they hear what the White Paper is trying to do and that it will work for patients, they will support it.

6.6 pm

Mr. Andrew Welsh (Angus, East)

I shall be as brief as possible, simply because I wish to let as many other hon. Members as possible speak in the debate. I shall speak faster than my normally fast pace because I want to put on the record some of the comments that have been put to me by local doctors; after all, this is their debate.

One depressing development, both in the debate and before we reached this stage, has been the vitriolic language of the Government and their supporters and the abuse that they have hurled at general practitioners because of their opposition to the National Health Service proposals. In choosing to react with the language of confrontation and abuse, the Secretary of State is making a big mistake and is completely misunderstanding the mood and reasoned arguments of the profession, which will be faced with implementing the changes if they are passed by the House.

General practitioners are opposed to these provisions not for the sake of opposition, but because they genuinely feel that patient care and the National Health Service will be the losers if the proposals are not amended drastically. I have received the highest ever mailing in my constituency from individuals and groups opposed to the Government's proposals. In the words of Angus district health authority, its members are agreed that The proposals in the White Paper are so far reaching and so unwarranted that the Council should take immediate action in an effort to enlist the help and support of every inhabitant in Angus in fighting against implementation of these proposals". Let the Government be in no doubt about the strength of opposition to these White Paper proposals. I have never heard doctors so united, so angry and so opposed to any set of measures as they are to these Government proposals. I am sure that the situation in my constituency is no different from that in many others.

The doctors' basic argument is not about money. It is based purely on the relationship between doctor and patient and is about their ability to provide the best quality of service as professionals and at reasonable cost to the taxpayer. Doctors have told me that there are fundamental and dangerous trends in the Government's proposals that will inevitably strike at the heart of the National Health Service.

Unamended, the proposals will mean that cost rather than care will become the criterion for health provision. Medical professionals will become more like accountants, bargaining over prices and debt collection. Inevitably, it will be in the interests of health boards and GP budget holders to look for the cheapest service in order to direct cash to other areas. Inevitably, under these proposals, there will be an inbuilt bias towards offering only the most convenient and profitable services. The Minister should make that clear to the general public, because in every survey the public have made it clear to the Government that people's preference is for the maximum service delivered as close to their own homes as possible.

That will simply not happen under the Government's proposals. Indeed, the opposite will occur. The accent will be on delivery of uncomplicated care for the young and generally fit adults, not on complex, unprofitable services. That will inevitably lead to poorer facilities and opportunities for patients, particularly the elderly or chronically sick. I always thought that those were the people for whom the National Health Service was designed to cater, but the proposals will take us in the opposite direction.

Scarce resources will mean that medical treatment is placed to one side while doctors are placed in a new bureaucracy, and it will mean the advertising which this system will, by definition, spawn. There will be fragmentation—I find this the least forgivable thing that the Government are introducing—of the National Health Service into a two-tier hospital system, thus ending the national, comprehensive system of care that we have so far enjoyed.

My local doctors want to make it very clear to the Government that they see dangers in the proposals—dangers that budgets will dictate treatment, and that there will be a financial inducement not to treat. For example, regarding tests and referrals, doctors will be given an incentive to use only the cheapest hospitals, and there will be a break in the close relationship between GPs and locally based consultants. The GPs will be drawn towards refusing new patients who require long-term, expensive treatment, putting at risk the worst off in deprived areas, the old and the disabled. Because of budgetary restraints, general practitioners may well not accept patients who need expensive drugs.

Mr. Kenneth Hind (Lancashire, West)

rose—

Mr. Welsh

If the hon. Member does not mind, I will not give way. He may get a chance to speak later.

Mr. Hind

But the BMA—

Mr. Welsh

This is not the BMA; these are my local doctors. It is the doctors who are the profesionals and who have to deal with this and they have a right to be heard in the House.

There is a fear that doctors will increase the number of young, generally fit adults on their lists, and be forced to do so by their competitors. The very thing that the Government are introducing—the force of competition —will lead to doctors taking a path that they would not normally take, instead of giving treatment to all their patients as they need and deserve. That is inevitable and inbuilt in the arrangements.

I want to use the words of the general practitioners to describe their concern, because they will have the reality on their hands if the Government push these measures through. One doctor says: The introduction of practice budgets and indicative drug budgets is seen as a cost-cutting exercise which serves to put financial pressures on the GP and undoubtedly will lead to a deterioration in the doctor-patient relationship. All doctors are aware that economies can be made in drug prescribing and the profession should be supported in their attempts to diminish costs in such a way that it will not adversely affect patient care, rather than have radical, ill-conceived methods imposed on it. The increase in remuneration from capitation fees will lead to a rise in list sizes rather than the reduction we have seen in recent years. This means less time per patient, a decline in the quality of care and ultimately a decrease in the number of GPs. I put again to the Minister the point regarding women general practitioners. Women have a right to expect that the Minister will have regard to their problems and address them. What is their future under the Government's proposals? Can he guarantee that women doctors will not be adversely treated and will be allowed to carry on making their very important contribution to the medical profession? I hope that the Minister will answer that point.

My local doctors have made detailed, reasoned criticisms of the Government's proposals on budgeting, capitation fees, effects on partnerships and women doctors and drug budgeting. Only time prevents me from analysing them. No doubt they will be raised as the debate continues and as the Government move towards legislation.

I want to put one more point to the Government. One doctor says: my colleagues and I do not see the new proposals as working for patients but rather as working against patients. The new charter will provide less time and less choice for patients and will engender within the profession a mentality more akin to achieving personal wealth rather than patients' health. The knock-on effects will be to accelerate the rate of litigation in this country and a litigation strewn profession is ultimately damaging for patients and more expensive. I must condemn … the Secretary for Health for attempting to bluster and hustle the profession on this matter and I must further condemn him for throwing up a smoke screen over the real issues. It is particularly noticeable that, when asked pertinent questions, he merely diverts the discussion by blaming us for 'feeling for our wallets'. It is the Secretary of State who is feeling for the NHS wallet and he is prepared to see patient care suffer in the execution of this. I have tried to state how my doctors feel, because this debate is about them. My plea is quite simply for the Government to think again. If they insist on these changes, they should introduce them gradually on an experimental basis to see whether they work. If there are all these great benefits to be gained from such experiments, let them be tried and tested and let everybody see them. If this scheme is simply imposed on the medical profession we may well find that the loser will be the nation, because our National Health Service will suffer a massive trauma and its essence will be destroyed if the Government go ahead unhindered. My message is clear and my plea is, quite simply, that the Government think again.

6.16 pm

Sir Michael McNair-Wilson (Newbury)

If I really believed all the dire warnings that we have heard from all parts of the House, I should be the most frightened man in the House tonight because I am numbered among the chronically sick and am on extremely expensive medication. As it is, however, I believe what my right hon. and learned Friend has said, I believe in his White Paper and he has my support. The White Paper is a most far-reaching document that will undoubtedly set the course for the Health Service in the future.

In the 40 years since its inception the National Health Service has transformed the general practitioner from a family doctor who had both to provide for his patients and his community's care and win for himself an income into a Government servant who no longer has to consider the budget he spends. That is a very far cry indeed from what existed before the NHS was set up.

Now, as we know, when a young doctor wants to enter general practice he can get a start only if there is a vacancy in a group practice or if that group practice decides to take on an additional partner. At least, thanks to the White Paper, more vacancies should occur when doctors have to retire at 65.

Before the NHS existed doctors were practising in a competitive world. In the world before the NHS any doctor who chose to go into practice could put up his plate and see what patients he could pick up. My father, who practised in Argyllshire and in Northumberland, told me that in those days when one got a call late at night one did not hesitate to go, because if one did not another doctor got the patient. That was a competitive edge that does not exist any more.

In the past 40 years of the NHS the balance has changed so that the modern GP, while he is no doubt just as dedicated as his predecessor and a great deal more effective as a provider of cures for diseases which were once incurable, has not had to consider or take responsibility for the financial consequences of his action. He has become a different type of practitioner. His salary is not won in competition with his fellows. He is a state servant answerable to the family practitioner service, which is currently funded by the Department of Health on an open-ended contract to the tune of £4.2 billion a year—a threefold increase since 1978–79.

To change that and to impose budgetary limits is bound to be seen as an assault on a situation that suits GPs very well. Suddenly they are being asked to relearn those financial skills that their predecessors took for granted. It would be surprising if they did not protest, especially as some of them may be affected by the changes in a way that may reduce their incomes.

I want now to refer to a question that I asked my hon. and learned Friend the Minister of State during Question Time last week concerning rural practices. I was not talking about a rural practice in a sparsely populated area that, according to the White Paper, is to receive special help, but one which is to some extent restricted by the ward limitations in the White Paper. A country practice, such as many in my constituency, cannot significantly increase its list size however hard its doctors work. Even if it could physically cope with an increased patient load, there are no other patients for that practice to treat. I do not see how it can have the basic practice allowance reduced from 60 to 40 per cent. and be expected to make up the difference out of capitation if the patients are not there.

By the same token, such a practice is to lose the rural practice allowance. My right hon. and learned Friend will know that that allowance really relates to the mileage that the doctor does in his constituency. It is the sort of thing that each one of us, as Members of Parliament, accepts as part of our constituency expenses. If a rural practitioner sees his basic practice allowance reduced, and is required to make up the difference from a capitation that he cannot achieve, and he loses his rural practice allowance, how can he possibly feel other than that his remuneration is being reduced? Although I heard my right hon. and learned Friend give the average figure for GPs' salaries after the White Paper, nevertheless it is an average figure. I would be grateful if in that connection he would look at the situation of rural practitioners.

The downward pressure on drug budgets, which will have the greatest effect on the pharmaceutical industry and make it look at its pricing in a way it has never done before, may make isolated dispensaries in country areas less viable. Again, the rural practitioner could find himself at a disadvantage. As ancillary and attached staff are probably more important to country practices, cost-limiting that section of the allowance may endanger such services as the mini-buses that many practices run to take their patients to and from surgery.

Then there is the position of women GPs referred to by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood). Many women GPs are part-timers, because they are married. They are concerned that the new proposals will militate against them and practices will prefer a full-time male doctor to, for sake of argument, two part-time women assistants. I understand that more than 50 per cent. of doctors training for general practice are women. As matters now stand, there is a financial advantage to be gained by a group practice in taking on women as part-timers, but that advantage will disappear if the White Paper proposals go through as they are at present. I believe that those proposals must be reconsidered. I do not believe that there should be financial disadvantages that could militate against women remaining as part-time GPs. They are popular, excellent and a valuable asset to the service.

The question of screening, and especially the surveillance of elderly patients, is set out on page 30, paragraph II of the new contract. A doctor from a practice in my constituency, which has 500 patients of 75 years and over, told me that surveillance would cost that practice 500 man hours per year, yet he doubted the value of that exercise because of the age of the patients. That point was supported by a doctor in a BBC medical programme. In that doctor's view, screening can produce psychological distress without achieving anything worthwhile. He said that, unless definite and provable benefits can be demonstrated from such screening of the elderly, the programme will simply be a waste of money and doctors' time.

The White Paper rightly places emphasis on preventive medicine, vaccinations, immunisation and cervical smears. It sets a very high target for GPs to reach before they receive payment for that work, unlike the present situation where they are paid for each treatment. I question whether the target for cervical smears is realistic. I shall cite the figures given to me by one doctor for his practice. Of the women he tested, 10 per cent. had had a hysterectomy and 8 per cent. refused a smear. In his practice, the annual turnover of women patients was 20 per cent. Accepting those figures, he claimed that a figure of 82 per cent. was achieveable if one included women who had had hysterectomies, or 71 per cent. if, and reasonably, one did not. One might honestly question the value of a cervical smear on a woman who has had a hysterectomy. If he is right—and I know how dangerous it is to generalise from the particular—is 80 per cent. the right target for cervical smears or is that a target beyond the reach of the average practice?

One of the points that has been raised with me in so many of the letters that I, too, have received about the White Paper concerns the status of the chronically sick —someone like myself who requires expensive medical treatment to stay alive. From my reading of the White Paper and the working documents, I believe that I am right in believing that the chronically sick have an inalienable right to be on a GP's list, to be treated in hospital and to receive whatever medication is laid down for them. What is more, no GP will be put at a financial disadvantage by having such a patient on his or her list, nor will his drug budget be considered to be overspent because that patient requires very expensive drugs, which takes the GP over his or her stated target. I believe that to be the case, but I would be grateful if my right hon. and learned Friend could reinforce that point in his reply. By the same token, can my right hon. and learned Friend state categorically that, whether a hospital chooses to be self-governing or not, it will be required to provide certain essential core services to its local community?

During my time in hospital and having talked over a number of years to those who run hospitals, I have been told again and again how much they wished they had control of their budgets and were allowed to develop the assets of their hospitals to maximise resources. I remember a consultant at the Battle hospital in Reading telling me that, if he had his way, he would build a 10-bedded private unit in the grounds of the hospital because of the funds that that would generate for the hospital overall. He was not interested in the out-of-date, political point-scoring about a two-tier system. He was interested in getting the maximum resources for a large general hospital. When I asked him why he did not do so, he said that it was because the regional health authority would consider that the additional funds were its and that the Battle hospital might not benefit at all. Therefore, nothing was done.

The White Paper encourages me to think that in future hospitals—especially those that are self-governing—will be able to make the best use of their assets knowing that by doing so they can improve their cash flows and their services. I welcome such a proposal.

6.27 pm

Mr. Bill Michie (Sheffield, Heeley)

I am happy and grateful to speak in this short debate. I have been instructed that I have no more than five minutes in which to do it. It is obviously an important debate and many Opposition Members have talked about what is, perhaps, the first love of anyone in the Labour party—the National Health Service. My hon. Friend the Member for Livingston (Mr. Cook) was right when he said that many doctors, and indeed many patients, feel that they have been deceived by the Government. Nobody at the last election realised what was in the mind of the Government. It was obvious that the Government were not prepared to put that in their manifesto to the people.

Doctors and patients know very well that, if one increases the number of patients, one cannot increase the number of hours in a day, so there must be less time per patient. That strikes me as simple arithmetic. We know that in future the prosperous surgeries will be in areas where people are generally prosperous. In areas such as Sheffield, which I represent—the inner cities, the poor areas and certainly some of the rural areas—practices will have certain difficulties that will not be resolved by the White Paper.

The Secretary of State has got angry about this issue and has hit out at the Labour party for exploiting the situation for political purposes. The only reason why the Secretary of State has attacked politicians, patients and doctors is that he must defend thin ground and he finds it difficult to do so. Instead of attempting to explain the Government's case, he has gone on the attack.

The Secretary of State has said that doctors' opposition to the proposals is based on different motives from the Labour party's opposition. From my discussions with doctors, I believe that their motives are similar to mine —they are worried about the future state of the Health Service rather than their wages or anything else. The right hon. and learned Gentleman has said that, as a result of the proposals, GPs' pay will rise substantially, but their main concern is not pay, but patient care and what will happen to their surgeries. If the scheme is so good, why are so many doctors against it? Where are all the doctors who are in favour?

Mrs. Mahon

Does my hon. Friend share my disgust at the hon. Member for Harlow (Mr. Hayes), who could not produce a single letter from a GP in support of the proposals? I found it contemptible when he said that, when he had gone along to talk to doctors, they had changed their minds. He must think that we are all daft and that GPs are thick, which is insulting.

Mr. Michie

My hon. Friend took the words out of my mouth. There is no doubt that doctors are concerned about their patients rather than their own skins. Doctors know that they will spend more time checking the accounts than checking their patients, more time looking for the cheap hospital instead of looking at each patient and deciding how to treat that person.

In my constituency, a meeting of the regional branch of the BMA attracted 200 doctors, which was almost a record; doctors do not always turn up at those meetings, as they are such busy people. Those doctors watched the video that has been produced by the Government—they have spent millions on that propaganda. Those doctors were so impressed by that video that they voted, almost unanimously, against the White Paper. The video is a waste of taxpayers' money. Those doctors were horrified by it. It is supposed to be subtle stuff, but the doctors understood it and they voted on a motion tantamount to resignation.

Local doctors are not thick; they understand the situation. They are not greedy; all they want is to be assured that everything will be all right for their patients.

Mr. Allen McKay

Does my hon. Friend agree that the argument that the doctors have been brainwashed by the BMA is a slur on doctors who have been in practice all their lives, often following their fathers and grandfathers? Such an argument implies that they cannot think for themselves.

Mr. Michie

My hon. Friend is correct. The only person who has been indoctrinated is the Secretary of State. He was not keen when he started off, but now he is convinced that his proposals will work. He has tried to reverse the argument by maintaining that doctors have been brainwashed.

Doctors are keen and dedicated. I have had my disagreements, political or otherwise, with my local doctors. On this occasion, however, we are not arguing about politics; that is why I was so annoyed with the Secretary of State when he tried to make it a political issue. He tried to argue about what the Labour party would say rather than what doctors and others have said about the proposals.

I know that the Secretary of State has received a letter from one doctor in my constituency. At the end of that letter, the doctor says that the Secretary of State should resign, or change his mind; otherwise, he will resign. That doctor has not been indoctrinated in any way. He is a strong practising Christian in the community and he feels so strongly about the White Paper that he believes that the Secretary of State should give up his job or he will give up his.

When the Government decide to give us time for a major debate on the White Paper, I hope that they will think again. If they really believe that the White Paper is a marvellous idea, they should follow the advice in the Opposition motion—they should delay the changes for the time being and put them to the people at the next general election. If they do that, the Labour party will be home and dry.

6.34 pm

Mr. Douglas French (Gloucester)

My remarks are based on extensive consultation with many doctors who are practising in Gloucester and the Gloucestershire district, who are a highly professional and effective group of practitioners. The Gloucestershire district has one of the best patient-doctor ratios in the country and it has one of the lowest FPC average prescription costs. It also carries out a high percentage of cervical smears in comparison with other districts.

I hope that the Secretary of State will be able to confirm that, as a result of his proposals, such an area will not witness a relative outflow of funds. There may be other areas that need funds, but if the declared aim of the proposals is to bring the worst up to the standards of the best, that cannot be done unless the best retain all the funding that they already receive.

I acknowledge what my right hon. and learned Friend has said on other occasions: that the proposed new system will not force—I emphasise that word—doctors to take on more patients, and that their overriding aim will be to please patients so as to retain them. For many years, list sizes in the Gloucestershire district have been gradually reducing. They are now down to below 1,800, compared with the national average of 1,969. That does not mean that doctors are having an easy time, but it is one of the reasons for the district's good patient care figures. I believe that that evidence proves that there is a relationship between shorter lists and good patient care.

One of my chief anxieties is that there is an incentive within the new system to build up lists. I know that the new system can be presented in different ways, but I believe that that incentive exists. The doctor can make up his income from other services, but an increased list appears to be one way in which to do so. That would come about not because increased income is of paramount importance, but because increased income happens to be one result of larger lists. Therefore, the proposed system pulls in an opposite direction from shorter lists which, historically, have achieved good results in the Gloucestershire district. It is true that the reduced list may provide the lazy doctor with an easy life, but it also provides the hard-working, diligent doctor with the best possible opportunity to give his patients the best attention.

I have two comments to make about the capitation proposals. First, my hon. Friend the Member for Newbury (Sir M. McNair-Wilson) has already referred to the likely effect on the enlistment of women doctors who perform an important role, often in a part-time capacity. The White Paper makes reference to incentives for female doctors, but paragraph 47a of the new contract is far from clear on this matter. I want to be assured that the new arrangements will not mean women doctors failing to be offered appointments that might otherwise have been open to them. Secondly, there may be pressure against taking on new doctors who do not bring personal lists to a practice. When some doctors reach retirement, their posts may not be filled automatically by new doctors.

Although I have reservations about the greater emphasis on capitation as proposed in the new system, I support the emphasis on new services and the incentives to provide comprehensive services to the patient covering prevention and treatment. The emphasis on health promotion, disease prevention, screening and check-ups is welcome. I hope that the value put on services such as minor operations will be realistic and cover the initial outlay not only for the instruments that may be required, but for the costs of consumables. That figure should be based on a proper costing rather than on a subjective judgment about what figure may or may not be sufficient encouragement for a doctor to undertake an operation.

On other occasions, my right hon. and learned Friend has said that the targets that he has set for immunisation and cervical smear tests may be subject to some modification. In Gloucestershire, the number of women having cervical smears is greater than in any other district, but in some cases an 80 per cent. target would be unrealistic. In a practice in Gloucester city, 19 per cent. of the female patients aged between 35 and 65 have had a hysterectomy, 5 per cent. decided against the test, 6 per cent. failed to respond to letters and 14 per cent. are over the age of 70. It is hardly appropriate to apply such a percentage in that type of practice.

There has been much talk about doctors being available for consultation in the surgery for 20 hours a week. I find the opposition to that requirement less persuasive than the other points that have been made to me. There may be individual cases where it would cause hardship, but it seems illogical to be saying, on the one hand, that more time is needed with individual patients and, on the other, that 20 hours in the surgery is too much.

I believe that many of the proposals will enhance choice, competition, accountability and responsibility, and all those are to be welcomed. But the reservations I have mentioned will, I hope, be addressed by the Secretary of State before he reaches any final conclusions on the package to be adopted.

6.41 pm

Ms. Harriet Harman (Peckham)

It is clear from the debate this afternoon that the Government have lost the argument—[Interruption.] Conservative Members who have just drifted into the Chamber may care to know that only one Government Back Bencher, the hon. Member for Lancaster (Dame E. Kellett-Bowman), unreservedly supported the Government's plans—[Interruption.] The day the Government pray in aid the hon. Member for Harlow (Mr. Hayes) is the day when they are really facing hard times selling their proposals.

It is clear that the concerns of the Government are completely different from the concerns of everybody else. The Government are talking about accounting, costing and pricing. Everyone else is talking about people, health and wellbeing. The Government are concerned about a healthy bank balance. Everyone else is concerned about a healthy patient.

The Government think that the major battle for the next century is to make the NHS cheaper. All their plans go towards achieving that. We and everyone else believe that the major battle is to make the NHS better and to move on to conquer the major killer diseases such as cancer and heart disease. The Tories simply do not understand. They think that doctors are interested only in money, because that is all that interests them.

The Government do not understand that they cannot bully and bribe their way out of this. By accusing the doctors, first, of stupidity—by saying, "They do not understand our plans"—and, secondly, of greediness, they have simply hardened the attitude of doctors and astounded the public. The Tories do not understand that they are up against a profound NHS culture which affects Tory voting doctors in the shires as much as it affects working class communities in inner cities. The Government will discover that on Thursday in the Vale of Glamorgan. They are badly out of touch with the popular pulse.

The Secretary of State cannot have it both ways. In his amendment to our motion he welcomes the widespread medical support for the objectives of the White Paper". In his speech, however, he did little more than berate what he was pleased to describe as "the British Medical opposition."

Conservative Members cannot say that the doctors do not understand and that they are being led by the nose by their leaders. The BMA's general medical services committee sent to every GP reprints of every working paper as well as the general medical services committee's comments. The thoroughness with which the doctors went about their consultations stands in marked contrast with the total failure of the Government to carry out any consultations. Having failed to consult anyone, as my right hon. Friend the Member for Blaenau Gwent (Mr. Foot) pointed out, they went on to spend over £1¼ million of taxpayers' money trying to persuade us that it is a good idea.

The Government must accept that it is not because doctors do not understand the plans that they are against them. They are against them because they understand them and do not like the way they will work. That must be clear to all Conservative Members when they read the letters that are swamping their postbags from local GPs.

Mr. Hind

The hon. Lady claims that by reading letters from GPs we become aware of their views. That is so, but most of the letters I have received show that the GPs in question have not read the detailed working papers properly —[Interruption.]—and that some of them are listening to the sort of propaganda that the hon. Lady has been sending to weekly newspapers such as I have in my constituency suggesting that, in some way, my local hospital will be opted out. She and many of her colleagues are responsible for the disinformation that is currently being disseminated.

Ms. Harman

I challenge the hon. Gentleman to send me copies of letters he has received from GPs whom he claims have not read the working papers and do not understand what is proposed in the White Paper. We shall then be able to see whether what he says is simply bluff and bluster.

The message from every independent medical organisation is twofold—that the plans will harm patients and that the timetable for their implementation is wildly unrealistic. Even the American professor who is credited with thinking up some of these proposals cannot understand why they are not being preceded by pilot schemes and believes that the Government are attempting to implement them with amazing speed.

Five out of six of the consultant teams who have pioneered the resource management initiative have rejected the timetable for opt-out because they say that they—the front line, the six leaders—will not be ready, and the sixth is Guy's hospital, where profound concern exists because of the feeling that they are being steamrollered into opt-out.

The pressure on hospital consultants to support opting out has been shameful. It has been a disgraceful combination of bribery and blackmail along the lines of, "If you are good boys and girls and among the first to opt out, we will see you all right, but if you do not, we will leave you to sink under your budget deficits." That is disgraceful and senior consultants are up in arms about being subjected to that sort of treatment.

The working paper on capital charges sets out the small print about which the BMA has warned consultants—the small print that the Government opt-out salesmen never mention. The Secretary of State talks a great deal about medical audit, but there is only a thin working paper on that saying, basically, "The chaps have thought up medical audit. It is clearly a good idea for the chaps to get on with it." There is little substance in that working paper. The fattest working paper is about capital charges—the "more work for accountants" paper—and it is clear that the Government have really thought about that, though the opt-out salesmen never mention it.

When the Secretary of State decides that a hospital will opt out—and the decision will be his and not that of the hospital—the hospital will take with it into independence all of its debts for its land, buildings and equipment, on which it will have to pay full rates of interest.

St. Thomas's, across the river, estimates that this will mean it having to pay the Treasury about £40 million a year extra. Guy's, a mile or so down the river, will have to pay an extra £27 million a year. This is pressure for the greatest asset-strip of all time. London hospitals in particular, because land values are so high, will simply close down, sell up and move out, leaving the sites of our great London hospitals—[Interruption] I challenge the Secretary of State to deny that, if it is not the case. The sites of our great London hospitals will be snapped up for offices or luxury riverside apartments.

Department of Health officials have already said that two fifths of hospital sites will be sold in this great asset-strip. Conservative Members should read the information that the Department has disseminated. The effect of the capital charges is that opting out for many is likely to spell financial suicide rather than financial freedom.

The Government have said that their plans will increase choice. In fact, choice will be reduced. What choice will there be for the patient of a GP budget-holder? The patient will have no choice of hospital for tests or treatment because the decision will have been made at the start of the year by the GP negotiating contracts for bulk buys of certain operations and treatments. Those negotiations will take place at the beginning of the year, probably long before the patient has got ill, let alone walked into the surgery. There will be no choice for the patient of a GP budget-holder.

There will be even less choice for the patient of a GP who is not a budget-holder. The decision on where that patient will go if in need of hospital tests or treatment will not rest with the GP but will be made at the start of the year by health authority managers who never see the patient. They will make a decision based on cost. They will get the cheapest buy. There is no requirement for them to get the approval of local GPs before contracts are placed. Managers who are not recruited or trained to know anything about clinical standards will make decisions on the basis of cost for patients whom they never see.

That is the absolute opposite of the Prime Minister's wish for treatment at the time of her choice, in the hospital of her choice. Under the NHS as she plans it, the patient will get the hospital of a manager's choice, at the place of the manager's choice and at the cheapest cost. No doubt the Government hope that that will join waiting lists as another powerful incentive for patients to go private and will drive patients out of the NHS.

Despite what the hon. Member for Newbury (Sir M. McNair-Wilson) asked the Secretary of State about, there will be less choice for patients who are elderly or who have long-term illnesses because, as the Royal College of Nursing so aptly described it, for the first time every patient will have a price tag on his head and for the first time doctors will have a financial disincentive to take on to their lists patients who will be expensive in requiring drugs or hospital treatment.

The right to choose a GP is not matched anywhere in the White Paper or in the working papers by a right to be accepted by that GP. The GP could say that his list was full. How will the Government police that? GPs will not refuse to take on more patients because they are lazy or heartless but because, with cash limits, they will have to balance the resources available for existing patients against the demands of future patients.

The greatest cheek is for the Government to offer us a choice that we already have—the chance of travelling hundreds of miles away from home to get treatment. We already have the possibility of travelling across boundaries, but people do not often do that because no one in his right mind wants to travel hundreds of miles to get treatment. What happens if there is a problem and the patient is stranded at the hospital? What happens if there is a need for post-operative care and the patient is unable to go back easily to that hospital?

The Government do not understand those arguments because they are about the patient and not about cost. The Government think only of the cost and never of the patient. GPs have seen what fierce spending limits have done to patients waiting for hospital treatment. They do not relish cash limits on GP services. Despite the fact that only last week the Secretary of State was still asserting that there will not be cash limits, it is clear from the working papers, and clear already from the Health and Medicines Act 1988, that cash limits on GP services are planned.

The White Paper says that GP budgets will not be underwritten for what are described as too high referral rates. The Government have no idea what a too high or a too low referral rate is. What is needed is not an average referral rate but appropriate referral decisions. The Government do not see that because they are considering not the quality of decisions but only the cost. The same is true of prescribing patterns. The Government are using the blunt instrument of cash limits when they should be using the instrument of training and education.

The Government have said that they have no plans to allow topping-up by patients of GP practice budgets but, if the proposals go ahead, that is inevitable. Even if we do not have the scenario of an individual patient handing over a bundle of notes to back up his demand to go to a particular hospital, we shall see groups of patients getting together for voluntary fund-raising for their own practice to get equipment for a new play area or new reception facilities. In the better-off areas that will free more money for hospital referrals.

The health divide that has already been referred to by my hon. Friend the Member for Sheffield, Heeley (Mr. Michie) will widen. The patients who need most health care will probably get inferior care and the well-off surgeries will depend on their communities to put their hands in their pockets to finance them in the face of cash limiting. That is how communities have responded when hospitals have been cash-limited. We have already seen that skew the service on the basis of hospitals providing what they think they can get money for rather than what they know the community needs.

The Secretary of State is beginning to look as though he is in as bad shape as his predecessor. He cannot blunder on with his plans because of the weight of public and professional opinion that is so heavily against him. If he falls forward, the doctors, assisted by the public, will get him; if he falls backward, the Prime Minister will get him. Conservative Members should listen to their constituents and to the doctors rather than deride them. Hon. Members have a chance to tell the Government this evening that they cannot press on with their plans before the next general election. They have no mandate to destroy the Health Service. I hope that Conservative Members will join us in voting for the motion.

6.54 pm

Mr. Kenneth Clarke

With the leave of the House, I assure hon. Members that I shall speak briefly so that I shall not intrude into the time for the debate on education; that means that I shall not follow the hon. Member for Peckham (Ms. Harman) into the things that she said about the hospital service. I shall reserve my reply for the full debate on the White Paper.

As I am short of time, let me take it at face value that the hon. Lady is interested in producing a better National Health Service. When we debate the proposals for self-governing hospitals and when she sees the expressions of interest that come forward, we will be able to debate the subject more seriously. Those expressions of interest will be taken for what they are described as—expressions of interest with a great deal of detail left to be considered by all in the hospitals concerned or by anyone who wants to commit himself to the proposals. People will want to know, for example, exactly what capital charges will mean for their hospital and for every other hospital in which the system is being introduced. I reassure the hon. Lady that nonsense about all our great hospitals in London being sold for office blocks is wide of the mark.

Ms. Harman

Two fifths.

Mr. Clarke

Even the suggestion that two fifths of hospitals in London will be sold to property developers for office blocks is very wide of the mark. When we get to the sensible discussions, I hope that that childish parody of our proposals is abandoned and that we can talk about how hospitals which have management in their own hands can contribute to the care of patients.

Most of the debate has been about general practitioners. There was a great deal of letter-reading on all sides. I shall not go as far as the hon. Member for Newham, North-East (Mr. Leighton) who read into the record more of his constituents' letters in 10 minutes than I have ever heard any hon. Member do before. As we were challenged to produce letters, I cannot resist producing just one from a professor in the department of general practice and primary care in a great London teaching hospital not far from the hon. Gentleman's constituency. I shall quote just two paragraphs: I am in constant contact with several hundred practices scattered over the United Kingdom and it appears that there is a consensus which is not reflected in public statements, and which is positive. The general feeling is one that the reorganisation is long overdue and that the efficiency of the Health Service has to be materially improved. There is also a considerable welcome for the beginnings of integration of general practice with secondary care. I too have a sheaf of letters. I could go on quoting consultants and GPs from all over the country.

My hon. Friends keep producing the views of their doctors. We are taking note of those and other views. I was asked by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) and by my hon. Friend the Member for Thanet, South (Mr. Aitken) whether we have over the years considered other possibilities. It is not true that the idea of improving the contract for general practice is an overnight thought that occurred during the Prime Minister's review. Discussions go back five or six years. The hon. Member and my hon. Friend quoted other views and asked whether we had considered other options.

I have not read the recent letter of Professor Morell, but it sounds as though he was commending the idea of a good practice allowance as a feature of a contract based on medical audit. We were discussing that five or six years ago. I remember it well. It was rejected because of medical opposition, which was organised and very strong. Because it was thought that the whole idea of clinical audit and peer review would be jeopardised if linked to payment, we turned away from that and considered other methods of evolving an acceptable contract that reflected the aims to which the Government remain committed—rewarding those doctors who work hardest and best, setting new standards for the introduction of services, particularly in health promotion and disease prevention, and setting new targets for services such as immunisation, screening and so on.

My hon. Friend the Member for Lancaster (Dame E. Kellett-Bowman) pressed all the points made by her general practitioners upon me without reading them into Hansard, as the hon. Member for Newham, North-East did. Contrary to what was said, she and my hon. Friends the Members for Harlow (Mr. Hayes), for Newbury (Sir M. McNair-Wilson) and for Gloucester (Mr. French) seemed to support the principles behind the White Paper. They wished to take up particular points that general practitioners had put to them about the present state of the contract discussions.

I would welcome a resumption of those discussions. They had been going on for a long time and were broken off at the behest of the negotiators while the conference was held last week. That conference lifted the threat of resignations and began to talk of discussions again and how those discussions should be renewed. I have made it clear throughout that, as long as we reach a conclusion soon at the end of a six-year process, I am prepared to seek to reach agreement on a form of contract with doctors, so long as they demonstrate to me that their negotiators share the aims that I have just enunciated.

Mr. Michael Morris (Northampton, South)

As my right hon. and learned Friend is prepared to put forward proposals with my right hon. and learned Friend the Secretary of State for Scotland, which seem broadly to meet general practitioners' requirements, now that the conference is over, is it his intention to meet the English general practitioners and to anglicise those proposals?

Mr. Clarke

I do not want to take the discussions much further on the Floor of the House. The Scottish contract, the so-called tartan contract, was put forward by my right hon. and learned Friend the Secretary of State for Scotland to represent particularly Scottish problems a few weeks after I had put forward my English proposals. We both took account of the views put to us in producing the Scottish contract. I shall be interested to hear whether general practitioners in Northampton and elsewhere will be interested in accepting what the Scots have so far on offer. I shall be interested to hear whether Scottish general practitioners are content with the tartan contract. No doubt the hon. Member for Angus, East (Mr. Welsh) knows.

Various matters have been raised about which I cannot go into detail here. My hon. Friends the Members for Harlow and for Newbury asked about rural practice. I am perfectly content to continue to discuss the rather curious disagreement between us on rural practice. My negotiators and the BMA negotiators are determined that there must be some special arrangements for rural practice. In discussions so far we have both been convinced that our respective suggestions are better and fairer for those who live in rural areas and scattered districts, but, as we are both agreed that special arrangements have to be made for rural areas, it must be possible to reach agreement.

A similar situation applies to deprived inner-city areas. I have been proposing extra capitation for those who practise in deprived areas because, again, general practitioners there cannot build up their lists. There has been no pressure in our contract proposals on any general practitioner with average or near-average lists to raise his list size, which is a fear that has been voiced. Other fears can also be met in discussion.

I was asked about the position of women practitioners by my hon. Friends the Members for Newbury and for Gloucester and by Opposition Members. The nature of general practice will change in many ways. One is that many more practitioners will be women. More than half the students in our medical schools now are women and we must accept that equal opportunities must be presented to all women who go into general practice, including those who will have family responsibilities at some time or another. The contract proposals are friendly to women seeking to enter general practice.

The notion of job sharing is floated in my proposals, as is the idea of part-time women being full principals in a practice. Therefore, the differences between me and my negotiators on the one hand and some women general practitioners on the other are not differences of aim; they are based on what I regard as an unusual interpretation of some of the changes that we are making to basic practice allowance. I am prepared to talk through a contract which in the end will encourage more women to go into practice and accept a desirable change in the contract.

I mention those matters not to trail any further what we might discuss, but to make it clear that discussions were broken off only because the BMA asked for that. The BMA carried out a leaflet campaign and held its conference, and, as far as I am concerned, discussions can now be resumed. My proposals were evolved after 12 months of detailed discussions, but they were plainly open to further discussions. That is the way that we should proceed. If both sides show common sense and are genuinely committed to a better NHS, raising standards of general practice and improving service to the patient, it should be possible to reach agreement. The remuneration of individual general practitioners should not be the great stumbling block to progress. Other reforms should not be regarded as sanctions where consent can be withheld unless a proper deal on the contract is arrived at.

The contract should now be resolved by sensible discussion, and further examination of the White Paper will reveal what my hon. Friends have all said has been revealed in sensible discussions with small groups of doctors throughout Britain—that, on balance, almost all agree that it is beneficial. When details are explained, most general practitioners will agree that. As we proceed with the implementation, it will be seen that this is just the next step in the Government's commitment to a better NHS, a free NHS financed out of taxation, and one that keeps up with the times to deliver the best of modern medical practice to patients who will he proud of it in the future.

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

The House divided: Ayes 181, Noes 279.

Division No. 182]	[7.05 pm
AYES
Abbott, Ms Diane	Bray, Dr Jeremy
Alton, David	Brown, Gordon (D'mline E)
Anderson, Donald	Brown, Nicholas (Newcastle E)
Archer, Rt Hon Peter	Brown, Ron (Edinburgh Leith)
Armstrong, Hilary	Bruce, Malcolm (Gordon)
Ashley, Rt Hon Jack	Buchan, Norman
Ashton, Joe	Buckley, George J.
Banks, Tony (Newham NW)	Caborn, Richard
Barnes, Harry (Derbyshire NE)	Campbell, Menzies (Fife NE)
Barnes, Mrs Rosie (Greenwich)	Campbell-Savours, D. N.
Barron, Kevin	Cartwright, John
Battle, John	Clarke, Tom (Monklands W)
Beckett, Margaret	Clay, Bob
Beggs, Roy	Cohen, Harry
Bell, Stuart	Coleman, Donald
Benn, Rt Hon Tony	Cook, Frank (Stockton N)
Bermingham, Gerald	Cook, Robin (Livingston)
Bidwell, Sydney	Corbett, Robin
Blunkett, David	Corbyn, Jeremy

Cousins, Jim	McWilliam, John
Crowther, Stan	Madden, Max
Cryer, Bob	Mahon, Mrs Alice
Cummings, John	Marek, Dr John
Cunliffe, Lawrence	Marshall, Jim (Leicester S)
Dalyell, Tam	Martin, Michael J. (Springburn)
Darling, Alistair	Martlew, Eric
Davies, Rt Hon Denzil (Llanelli)	Meacher, Michael
Davis, Terry (B'ham Hodge H'I)	Michie, Bill (Sheffield Heeley)
Dixon, Don	Michie, Mrs Ray (Arg'l & Bute)
Dobson, Frank	Mitchell, Austin (G't Grimsby)
Doran, Frank	Morley, Elliott
Douglas, Dick	Morris, Rt Hon A. (W'shawe)
Dunnachie, Jimmy	Morris, Rt Hon J. (Aberavon)
Eadie, Alexander	Mowlam, Marjorie
Eastham, Ken	Mullin, Chris
Evans, John (St Helens N)	Murphy, Paul
Ewing, Mrs Margaret (Moray)	Nellist, Dave
Fatchett, Derek	Oakes, Rt Hon Gordon
Faulds, Andrew	O'Brien, William
Fearn, Ronald	Orme, Rt Hon Stanley
Field, Frank (Birkenhead)	Patchett, Terry
Fields, Terry (L'pool B G'n)	Pendry, Tom
Fisher, Mark	Pike, Peter L.
Flannery, Martin	Powell, Ray (Ogmore)
Foot, Rt Hon Michael	Prescott, John
Foster, Derek	Primarolo, Dawn
Fraser, John	Quin, Ms Joyce
Fyfe, Maria	Radice, Giles
Galbraith, Sam	Randall, Stuart
Galloway, George	Rees, Rt Hon Merlyn
Garrett, John (Norwich South)	Richardson, Jo
Garrett, Ted (Wallsend)	Roberts, Allan (Bootle)
Godman, Dr Norman A.	Robertson, George
Gordon, Mildred	Robinson, Geoffrey
Gould, Bryan	Rogers, Allan
Griffiths, Nigel (Edinburgh S)	Ross, Ernie (Dundee W)
Griffiths, Win (Bridgend)	Ruddock, Joan
Grocott, Bruce	Sedgemore, Brian
Hardy, Peter	Sheerman, Barry
Harman, Ms Harriet	Sheldon, Rt Hon Robert
Hattersley, Rt Hon Roy	Shore, Rt Hon Peter
Hinchliffe, David	Short, Clare
Hogg, N. (C'nauld & Kilsyth)	Sillars, Jim
Holland, Stuart	Skinner, Dennis
Home Robertson, John	Smith, Andrew (Oxford E)
Howarth, George (Knowsley N)	Smith, Rt Hon J. (Monk'ds E)
Howells, Dr. Kim (Pontypridd)	Soley, Clive
Hughes, John (Coventry NE)	Spearing, Nigel
Hughes, Robert (Aberdeen N)	Steinberg, Gerry
Hughes, Simon (Southwark)	Stott, Roger
Ingram, Adam	Strang, Gavin
Janner, Greville	Straw, Jack
Jones, Ieuan (Ynys Môn)	Taylor, Mrs Ann (Dewsbury)
Jones, Martyn (Clwyd S W)	Taylor, Matthew (Truro)
Kinnock, Rt Hon Neil	Thompson, Jack (Wansbeck)
Kirkwood, Archy	Turner, Dennis
Lambie, David	Vaz, Keith
Lamond, James	Wall, Pat
Leighton, Ron	Wallace, James
Lestor, Joan (Eccles)	Warden, Gareth (Gower)
Lewis, Terry	Wareing, Robert N.
Litherland, Robert	Welsh, Andrew (Angus E)
Livsey, Richard	Wigley, Dafydd
Lloyd, Tony (Stretford)	Williams, Rt Hon Alan
McAllion, John	Wilson, Brian
McAvoy, Thomas	Winnick, David
Macdonald, Calum A.	Worthington, Tony
McFall, John	Wray, Jimmy
McKay, Allen (Barnsley West)
McKelvey, William	Tellers for the Ayes:
McLeish, Henry	Mr. Frank Haynes and
Maclennan, Robert	Mrs. Llin Golding.
McNamara, Kevin
NOES
Aitken, Jonathan	Amos, Alan
Alexander, Richard	Arbuthnot, James
Allason, Rupert	Arnold, Jacques (Gravesham)
Amess, David	Ashby, David

Atkins, Robert	French, Douglas
Baker, Rt Hon K. (Mole Valley)	Gale, Roger
Baker, Nicholas (Dorset N)	Gardiner, George
Baldry, Tony	Garel-Jones, Tristan
Banks, Robert (Harrogate)	Gill, Christopher
Beaumont-Dark, Anthony	Gilmour, Rt Hon Sir Ian
Bellingham, Henry	Glyn, Dr Alan
Bendall, Vivian	Goodhart, Sir Philip
Bennett, Nicholas (Pembroke)	Goodson-Wickes, Dr Charles
Benyon, W.	Gorman, Mrs Teresa
Blackburn, Dr John G.	Gow, Ian
Blaker, Rt Hon Sir Peter	Grant, Sir Anthony (CambsSW)
Body, Sir Richard	Green way, Harry (Ealing N)
Bonsor, Sir Nicholas	Greenway, John (Ryedale)
Boscawen, Hon Robert	Gregory, Conal
Boswell, Tim	Griffiths, Peter (Portsmouth N)
Bottomley, Mrs Virginia	Grist, Ian
Bowden, A (Brighton K'pto'n)	Ground, Patrick
Bowden, Gerald (Dulwich)	Grylls, Michael
Bowis, John	Gummer, Rt Hon John Selwyn
Boyson, Rt Hon Dr Sir Rhodes	Hague, William
Brandon-Bravo, Martin	Hamilton, Hon Archie (Epsom)
Brazier, Julian	Hamilton, Neil (Tatton)
Bright, Graham	Hanley, Jeremy
Brown, Michael (Brigg & Cl't's)	Hannam, John
Browne, John (Winchester)	Harris, David
Bruce, Ian (Dorset South)	Haselhurst, Alan
Buchanan-Smith, Rt Hon Alick	Hawkins, Christopher
Buck, Sir Antony	Hayes, Jerry
Budgen, Nicholas	Hayward, Robert
Burns, Simon	Heseltine, Rt Hon Michael
Burt, Alistair	Hicks, Mrs Maureen (Wolv' NE)
Butler, Chris	Higgins, Rt Hon Terence L.
Butterfill, John	Hill, James
Carlisle, John, (Luton N)	Hind, Kenneth
Carlisle, Kenneth (Lincoln)	Holt, Richard
Carrington, Matthew	Howarth, Alan (Strat'd-on-A)
Carttiss, Michael	Howarth, G. (Cannock & B'wd)
Cash, William	Howe, Rt Hon Sir Geoffrey
Channon, Rt Hon Paul	Hughes, Robert G. (Harrow W)
Chapman, Sydney	Hunt, David (Wirral W)
Chope, Christopher	Irvine, Michael
Clark, Hon Alan (Plym'th S'n)	Irving, Charles
Clark, Dr Michael (Rochford)	Jack, Michael
Clarke, Rt Hon K. (Rushcliffe)	Janman, Tim
Colvin, Michael	Jessel, Toby
Conway, Derek	Johnson Smith, Sir Geoffrey
Coombs, Anthony (Wyre F'rest)	Jones, Robert B (Herts W)
Coombs, Simon (Swindon)	Jopling, Rt Hon Michael
Cope, Rt Hon John	Kellett-Bowman, Dame Elaine
Couchman, James	Kirkhope, Timothy
Cran, James	Knapman, Roger
Critchley, Julian	Knight, Greg (Derby North)
Currie, Mrs Edwina	Knight, Dame Jill (Edgbaston)
Curry, David	Knowles, Michael
Davies, Q. (Stamf'd & Spald'g)	Knox, David
Davis, David (Boothferry)	Lamont, Rt Hon Norman
Devlin, Tim	Lang, Ian
Dickens, Geoffrey	Latham, Michael
Dorrell, Stephen	Lawrence, Ivan
Douglas-Hamilton, Lord James	Lawson, Rt Hon Nigel
Dover, Den	Lee, John (Pendle)
Dunn, Bob	Lennox-Boyd, Hon Mark
Durant, Tony	Lester, Jim (Broxtowe)
Dykes, Hugh	Lightbown, David
Eggar, Tim	Lilley, Peter
Evennett, David	Lloyd, Peter (Fareham)
Fallon, Michael	Lord, Michael
Favell, Tony	Luce, Rt Hon Richard
Fenner, Dame Peggy	Lyell, Sir Nicholas
Field, Barry (Isle of Wight)	McCrindle, Robert
Fishburn, John Dudley	Macfarlane, Sir Neil
Fookes, Dame Janet	MacGregor, Rt Hon John
Forman, Nigel	MacKay, Andrew (E Berkshire)
Forsyth, Michael (Stirling)	Maclean, David
Forth, Eric	McLoughlin, Patrick
Fowler, Rt Hon Norman	McNair-Wilson, Sir Michael
Fox, Sir Marcus	McNair-Wilson, P. (New Forest)
Freeman, Roger	Major, Rt Hon John

Malins, Humfrey	Sims, Roger
Mans, Keith	Skeet, Sir Trevor
Marlow, Tony	Smith, Tim (Beaconsfield)
Marshall, Michael (Arundel)	Soames, Hon Nicholas
Martin, David (Portsmouth S)	Speller, Tony
Mates, Michael	Spicer, Sir Jim (Dorset W)
Maude, Hon Francis	Spicer, Michael (S Worcs)
Mayhew, Rt Hon Sir Patrick	Squire, Robin
Mellor, David	Stanbrook, Ivor
Meyer, Sir Anthony	Stanley, Rt Hon Sir John
Miller, Sir Hal	Steen, Anthony
Mills, Iain	Stern, Michael
Miscampbell, Norman	Stevens, Lewis
Mitchell, Andrew (Gedling)	Stewart, Allan (Eastwood)
Mitchell, Sir David	Stewart, Andy (Sherwood)
Moate, Roger	Stokes, Sir John
Monro, Sir Hector	Stradling Thomas, Sir John
Montgomery, Sir Fergus	Sumberg, David
Moore, Rt Hon John	Summerson, Hugo
Morrison, Sir Charles	Taylor, Ian (Esher)
Morrison, Rt Hon P (Chester)	Taylor, Teddy (S'end E)
Moynihan, Hon Colin	Tebbit, Rt Hon Norman
Neale, Gerrard	Temple-Morris, Peter
Nelson, Anthony	Thompson, D. (Calder Valley)
Neubert, Michael	Thompson, Patrick (Norwich N)
Nicholson, David (Taunton)	Thorne, Neil
Onslow, Rt Hon Cranley	Thornton, Malcolm
Oppenheim, Phillip	Thurnham, Peter
Page, Richard	Townend, John (Bridlington)
Paice, James	Townsend, Cyril D. (B'heath)
Patnick, Irvine	Tracey, Richard
Patten, John (Oxford W)	Trippier, David
Pawsey, James	Twinn, Dr Ian
Peacock, Mrs Elizabeth	Vaughan, Sir Gerard
Porter, Barry (Wirral S)	Viggers, Peter
Porter, David (Waveney)	Waddington, Rt Hon David
Portillo, Michael	Waldegrave, Hon William
Powell, William (Corby)	Walden, George
Price, Sir David	Walker, Bill (T'side North)
Raison, Rt Hon Timothy	Waller, Gary
Rathbone, Tim	Walters, Sir Dennis
Redwood, John	Ward, John
Renton, Tim	Wardle, Charles (Bexhill)
Rhodes James, Robert	Warren, Kenneth
Riddick, Graham	Wells, Bowen
Ridsdale, Sir Julian	Whitney, Ray
Roberts, Wyn (Conwy)	Widdecombe, Ann
Rossi, Sir Hugh	Wiggin, Jerry
Rowe, Andrew	Wilshire, David
Rumbold, Mrs Angela	Winterton, Mrs Ann
Ryder, Richard	Wolfson, Mark
Sackville, Hon Tom	Wood, Timothy
Sayeed, Jonathan	Woodcock, Mike
Shaw, David (Dover)	Young, Sir George (Acton)
Shaw, Sir Giles (Pudsey)
Shaw, Sir Michael (Scarb')	Tellers for the Moes:
Shephard, Mrs G. (Norfolk SW)	Mr. John M. Taylor and
Shepherd, Richard (Aldridge)	Mr. David Heathcoat-Amory
Shersby, Michael

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. Deputy Speaker forthwith declared the main Question, as amended, to be agreed to.

Resolved, That this House welcomes the widespread medical support for the objectives of the White Paper "Working for Patients" and believes that the proposals in that White Paper will enable the health service and individual doctors to respond better to the needs and wishes of patients, extend patient choice, delegate responsibility to where the services are provided and secure the best value for money; affirms its support for the basic principles of the National Health Service which will be strengthened by the early implementation of the White Paper proposals; and looks forward to the constructive contributions from medical organisations to achieve that.