HC Deb 11 May 1989 vol 152 cc1013-100

[Relevant documents: Fifth Report from the Social Services Committee of Session 1987–88 on the Future of the National Health Service (HC 613) and the Government Response thereto (Cm. 599).]

Mr. Speaker

I have selected the amendment in the name of the Leader of the Opposition.

In view of the number of hon. Members who wish to participate in the debate, I propose to limit speeches to 10 minutes between 7 and 9 o'clock. However, I appeal to those hon. Members who are fortunate enough to be called before that time to bear that limit in mind.

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

I beg to move, That this House approves the programme of reform of the National Health Service set out in the White Paper, Working for Patients (Cm. 555), and the reaffirmation of the basic principles of the National Health Service which will continue to be available to all, regardless of income and financed mainly out of taxation; and believes that the proposals in the White Paper will raise the standards of all of the health service to the high standard of the best and will lead to an extension of patient choice, a more responsive health service, better value for money and an even better standard of health care for the decade to come. I returned yesterday from a 24-hour visit to Geneva, where I took part in the affairs of the World Health Assembly, an annual gathering of Health Ministers from the member states of the United Nations who discuss the affairs of the World Health Organisation and health core policy in general.

I was struck during my brief visit by the fact that the subject of health care is now remarkably similar in many countries. Indeed, I dare assert that in practically every developed country, on both sides of the iron curtain, Governments are now involved to some degree in quite drastic reform of their health care systems.

What we are addressing—the British Government have been addressing this consistently throughout our period in office—is a great change in the problems confronting health care systems. There is an explosion in the cost of health care of all kinds. The level of demand for health care is rising at a rapid rate, largely because of changing demography and the huge increase in the proportion of elderly people in our population and in similar countries.

In countries such as ours, the expectations of patients and professionals are much higher than they were even a decade ago, and medical advance and rising expectations go on remorselessly. It is absorbing when considering health care policy to note that, whenever one looks at the affairs of a great health care system—in this case the National Health Service—one is looking at one of the great challenges facing Governments throughout the developed world. It is a challenge that must be tackled without unnecessary delay and it must be solved correctly if our great health care system is to rise to the increased costs, increased expectations, increased demands and satisfy our population.

I can promise nobody that this process of reform will be free from political controversy, because when this trade union of Health Ministers is gathered, it is amazing to discover that health is at the heart of public and political controversy in just about every major state one can mention, for the reasons I have given.

In some countries, Governments are finding great difficulty in making progress. In the Federal Republic of Germany, for example, an extremely controversial programme has been put through, largely aimed at getting down what they regard as their unacceptable costs and rescuing a bankrupt social insurance system. It is not adding to the popularity of the Government there as they carry that through.

In Hungary, on the other side of the iron curtain, the Minister of Health has been attempting to introduce new charges for patients, for their prescriptions and pharmaceutical goods, and to introduce the concept of private insurance and so on—at present a popular idea throughout the Socialist world. When I met her, I got the impression that she had had some setbacks and was having to abandon the controversial proposals that she was keen on a month or so ago.

In New Zealand, a great report was produced for the reform of that country's health service, taking its starting point from our Griffiths proposals of a few years ago and setting out proposals for a market for health care which I found attractive. The Socialist Government in New Zealand have abandoned those proposals in the face of resistance from their medical profession and are now starting again to tackle the problems of management and use of resources.

Opposition Members have a great narrowness of view on these issues. It is important for us to place in context what we are doing. We are tackling problems that are bound to face any responsible Government in modern circumstances in coping with the pace of change in health care. In this country we are determined to be more successful than others have been, and we have begun to address these problems many years before most other developed countries.

Some of my hon. Friends—indeed, some of the faint-hearted on both sides of the House—may ask, "If there are always political difficulties, why bother to reform the Health Service at all?" Last weekend Brian Walden, with whose views I seem to agree more nowadays, implied more or less as much and invited the Government to give up reforming the NHS because, as he put it, it was impossible to talk common sense to the British public about it. He implied that it should be allowed to decline unchanging and be left to its own devices. Other Ministers abroad would agree about the political difficulties.

It is an easy subject on which to alarm patients as soon as any reform is advocated. It is a feature of great professions, here and abroad, that they are instinctively suspicious about change and jealous of their practices and procedures. It is therefore necessary to embark on reform realising that it will always be a difficult and sometimes controversial process.

The reason why the Government have published their White Paper and embarked on this reform is straightforward. We want the British NHS to rise to these challenges, with which others are having to contend. We want to ensure that in this country we have a better NHS serving all our patients, even in the face of those challenges. We shall not be overwhelmed by the pressures and, once reformed, our Health Service will remain in the forefront of the world's health care systems.

Mr. Michael Grylls (Surrey, North-West)


Mr. Clarke

I shall give way shortly, but if I do so often, I shall take too long to speak in what will anyway be a crowded debate.

There are other straightforward reasons for reforming the National Health Service and for remedying problems that already exist. Although the Opposition are on the point of producing policy proposals of their own, they sound sometimes as though the Health Service belongs to them and is a perfect, unchangeable and unimproveable system which does not require reform. Although the present system is excellent, and although its principles of being free at the point of delivery, being financed out of taxation, and providing treatment on the ground of medical priority must be retained, its delivery of health care is not always perfect and could be improved.

The most obvious perception that people have of the service's inadequacies is the great variation in waiting times for certain types of surgery, which vary from place to place throughout the country—sometimes for quite inexplicable reasons—by comparison with other health authorities whichse allocations have been made in similar ways, but which in some cases keep up with the demand for specialties better than their neighbours.

Anyone managing the service and trying to identify where the taxpayers' money goes will find wide variations in the use to which that money is put. I refer to the vexed subject of drug and prescribing costs, which now total £2,000 million annually and are rising rapidly. Some general practitioners spend nearly twice as much as others on drugs per patient, even though they appear to have similar patient lists. Some GPs refer more than 20 times as many of their patients to hospital as do others. A fourfold variation is quite common, and will obviously have an effect on the ability of people locally to deliver patient care.

If one examines the detail and some of the things that the introduction of better management has started to throw up, it becomes clear that anyone who imagines that the Health Service is perfect as it is and should not be improved, but merely requires more money, is deceiving himself. In Lancashire, for example, we found a specialist in community medicine who refused to allow GPs to perform child immunisation, with the consequence that uptake rates in the area concerned were amazingly low. A London ophthalmologist decided to keep discharge decisions for all his patients to himself, but toured his wards only once a week. As a result, some of his patients waited six days in a hospital bed before they could be discharged. I could cite many similar examples. They have been dealt with, but many more have yet to be.

One great variation is the way in which patients are treated as people. The sensitivity that is exercised and the willingness to give information to patients vary from place to place, and there are many ways in which performance in that regard could be improved. That is what lies behind our White Paper reforms. If one is to reform the Health Service, one might as well reform it in a way that not only protects the service but gets rid of inequalities and raises its performance to the standards already achieved by the best, so that access to health care across the country is the same.

Mr. Grylls

Does my right hon. and learned Friend agree that, despite the rather sad and Luddite-like opposition of the British Medical Association and of the Labour party, once the public see the results of his far-sighted reforms in establishing a competitive market for health care—something there has never been before —they will appreciate that that is the only way of improving the delivery of health care to all our people?

Mr. Jeremy Corbyn (Islington, North)

There was nothing wrong with the Luddites.

Mr. Clarke

I hear some critical cries from Opposition Members. Probably my ancestors and those of many of my constituents were Luddites, so I must be careful; Ned Ludd came from my part of the world. However, parts of Nottinghamshire have moved on by comparison to those represented by our opponents and most people in the Health Service accept the case for change that I make.

What they are reluctant to do is to agree to specific proposals. We have to explain that the White Paper is necessary, for the reasons that I have given, and then take them with us in implementing the changes to produce the improved situation.

Mr. Allen McKay (Barnsley, West and Penistone)

Does the Minister accept that when looking at differences in prescribing the quality and quantity of drugs, there is some merit in looking at various areas? If area is compared with area they are never alike. Perhaps the Minister would look at the question of a practice in Gleneath which was accused by his Department of over-prescribing, to the extent that an extra post was created for a doctor to look at it. He found out that there was no over-prescribing but that the prescriptions were necessary because of the prevalence of dust-related diseases in that area.

Mr. Clarke

I agree with that entirely. It is obviously not the case that all variations between areas of practices have no clinical explanation, but we also know that in some cases there is no clinical explanation and that there are places where the medicine chests of patients are full of drugs that they do not want. Some practices carry on repeat prescribing for patients whom they have not seen for a very long time. Where those cases occur and where there are no clinical reasons, if we can catch that waste we can divert the resources to better use within the Health Service. We are aiming to ensure that where there are no clinical reasons, and only there, high prescribing costs are tackled.

Dame Elaine Kellett-Bowman (Lancaster)

Will my right hon. and learned Friend make it absolutely plain that although the immunology rate and expectation of life in Lancashire are bad, in Lancaster itself we are extremely good at immunology and the expectation of life is higher than the national average?

Mr. Clarke

The case that I described was in one part of Lancashire. The practice has now been stopped and the situation has been improved. I know that my hon. Friend is very pleased with the advances being made and the level of care attained by the health authority in her constituency.

Going on, therefore, to the need to carry people with the reforms, I believe that, despite the formidable difficulties of embarking upon reform, we are already making progress in satisfying people inside and outside the service that this is a sensible way to proceed in order to make sure that our National Health Service remains as good as it should be. In recent weeks, between the publication of the White Paper and this debate, there have been a number of very interesting developments. I can certainly think of three, that I will begin by citing, which show that the Health Service is already on the move in the direction of accepting worthwhile reforms.

The first development, which I will deal with briefly, because we debated it last week, is the advance we have made on the contract for the payment of general practitioners. I am glad to say that last week we reached agreement with the negotiators for the profession. They have agreed to commend to the profession a new form of contract which offers great benefits to the service, to patients and to GPs, particularly those who do the work and hit the highest standards.

We accepted that it was desirable to have a new contract, that we should set performance targets for the vaccination of children and the screening of women. The Government's targets were accepted for the highest payments. Those practices where a doctor makes a night visit to patients so that they see a doctor from the particular practice will be paid at a higher rate than those that use commercial deputising services and it is agreed that capitation is a good reflection of the hard work that GPs do. All those things are now accepted and I believe that the way is clear for raising the standards of the family doctor service.

Progress on that one front, which was in the air when the White Paper was produced, shows what can be achieved on other fronts where there is still controversy. We asserted to each other in discussions about the contract that we shared exactly the same aims in efforts to improve the general medical service. By sitting down together and talking about how best those aims could be achieved we were able to make progress and agree on reforms in the service for the benefit of patients. That approach offers great prospects for the other features of the White Paper. Discussion and the support of the profession are plainly a key element in ensuring that satisfactory progress is maintained.

Mr. John Redwood (Wokingham)

The fourth objective in the White Paper is particularly welcome: appointment times that mean something, and an attack on waiting lists. Does my right hon. and learned Friend think that he will receive support from both sides of the House and from the profession to ensure that that objective is implemented swiftly?

Mr. Clarke

I do not wish to discuss leaked documents about the Labour party's proposals, but Labour seems to have pinched part of its health proposals from our White Paper. On that subject Labour seems to be supporting us. I believe that the public support us very strongly, and we now look to health authorities to implement that support in practice throughout the country.

My second point about the progress that we have made is that many of the changes proposed for the rest of the service in the White Paper have already been accepted, and I find that they do not provoke controversy in discussions with the profession. [Interruption.] The hon. Member for Bassetlaw (Mr. Ashton) is trying to intervene: I do not think that he and others appreciate the extent to which discussions are turning on those parts of the White Paper that still pose difficulties. People have not noticed that key proposals are being accepted by consultants, nurses and others throughout the service.

Let me try to help the House to understand why that acceptance makes me already sure that the necessary changes will come about. I think that it would be difficult for any hon. Member to claim that he had recently met a consultant or nurse who opposed the idea of better financial management to enable both doctors and nurses and the management to know more about what they are doing and where the resources go.

It is now some weeks since I met either a consultant or a nurse who did not think that medical audit or quality control—another key issue—were a good idea, and who did not accept the Government's framework. There has been a dramatic change in opinion since four or five years ago. I have worked in the Department before, and all these ideas have quite a long history. A few years ago it was difficult to find a consultant who did not regard the idea of financial management as a commercial intrusion in his affairs, and the idea of clinical budgeting as a threat to his clinical freedom. Medical audit, when first canvassed by the royal colleges three or four years ago, was regarded as a significant threat to clinical freedom by a large proportion of the profession.

What has now been accepted with enthusiasm is the idea that the Health Service needs to know how it spends its resources. It needs management information so that it can control the use of those resources, and the continuing quality checks that medical audit will ensure. Because of that acceptance, such proposals are about to become matters of little controversy and less interest in the outside world.

A great transformation will be wrought in the Health Service. The age of the computer, of information technology and of management decisions based on a knowledge of what things cost and where the vast resources go will come into the Health Service as it came into most other giant organisations a few years ago. Personal involvement in quality and output and the comparison of performance with that in other parts of the service will also come in. Management and clinicians will acquire far more information than they have ever had about what they are actually doing for their patients, how successful their activities are and how they are using their resources.

A few years ago my favourite comparison was between the NHS and the Indian state railway, because of its vast size and the way in which it was administered. Now the NHS is about to become an up-to-date, efficient, well-managed organisation. More information will become available, particularly to those at the sharp end —the doctors and nurses in the hospitals and practices. What we must decide is what to do with that information, and the White Paper shows the way, explaining how we can use our ability to control the service, improve its performance and serve patients better.

Mr. Chris Mullin (Sunderland, South)

Has the Secretary of State seen the latest edition of "Conservative Newsline", which contains a large photograph of him under the slogan Our commitment to the NHS is absolute"? Out of the same newspaper flutters a glossy leaflet from a company called Prime Health Plus advertising private medical insurance. Does he understand that such cynicism is the basis of many people's failure to take seriously the Government's plans for the National Health Service?

Mr. Clarke

My commitment to personal choice is also absolute. Every country in the developed world, including most behind the iron curtain, is now developing private health care systems. Only the British Labour party continues to believe that they are an unwanted intrusion into health care. The reforms of the National Health Service will ensure that private health care in Britain has a strong competitor in the National Health Service, and that people will look to the National Health Service for a comprehensive service and then decide for themselves whether there is some feature of it that they wish to add to or enjoy outside it.

Mr. Joseph Ashton (Bassetlaw)

The Secretary of State said that he had consulted practically everyone in the National Health Service, but what consultations has he had with the public? Is he aware that in Nottinghamshire —his county and mine—Bassetlaw health authority has decided to set up a trust to opt out of Bassetlaw hospital? There has been no consultation with the public, almost all of whom voted Labour last Thursday. The decision has been taken by non-elected Tories with no consultation whatsoever with the public. The consultants that the right hon. and learned Gentleman talks about will all become directors and set their own salaries, as will the management who will decide about waiting lists and many other matters with no public consultation, agreement or referendum.

Mr. Clarke

Bassetlaw district health authority has taken no such decision in the terms described by the hon. Gentleman. I shall return to the reports about self-governing hospitals, but the hon. Gentleman misunderstands entirely what is happening in Bassetlaw. I shall return to that point.

I was explaining that we have achieved a substantial change of opinion within the Health Service that I would never have expected to happen five years ago. People accept the case for modern financial management and much more quality control. Almost without exception they accept that it will enable us to ensure that the money follows the patient to where the work is done best and reflects patient priorities.

The White Paper sets out a considered framework, over which we took a lot of time, showing how the new information can be used to create a better National Health Service for patients. How do we allocate resources best? In our opinion we should introduce competition and choice to ensure that resources go to where the quality of care and efficiency are highest. What about the role of the patients? We shall ensure a more patient-friendly and patient-led service by sending the resources with the patient to where, so far as is possible, he and his GP wish him to go.

Mrs. Ann Winterton (Congleton)

Will my right hon. and learned Friend give way?

Mr. Clarke

I shall give way in a moment, but I wish to continue for a little longer.

The discussion on the Health Service has already moved on from when the White Paper was published. Many hon. Members on both sides of the House have been approached by people concerned about the Health Service in the past three or four months, and I have no doubt that we have all been approached in the past week or two. Currently, the debate appears to be that we should go more slowly. All occupations have their buzz words, and the current buzz words are that it is all very interesting but we should have pilot studies, change the timetable and slow down.

Another theme that comes through strongly is the fear about the cost of taking on board the modern management systems which the Health Service, unlike other large businesslike organisations, has never had before.

Mr. Nigel Spearing (Newham, South)

It is not a business.

Mr. Ashton

It is not a business.

Mr. Clarke

I said that it was businesslike. I welcome all those suggestions and I shall address them in my speech. I welcome them for one important reason. When people come to me suggesting that we should study and go more slowly and asking about the cost of introducing the new system, they are talking about how the changes should be implemented. Already, within three months the debate has moved on, except possibly in the Labour party. The debate among everyone else has moved on to how we implement and not whether we implement. It is that matter which I propose to address now.

Mr. Geoffrey Lofthouse (Pontefract and Castleford)

Will the Secretary of State give way?

Mr. Clarke

I shall give way in a little while.

First, how we implement depends on what people mean by pace. We no longer have time for some traditional ways of tackling issues in the Health Service because they have not been so successful in the past. I will not agree to some great multidisciplinary committee being set up, which starts by studying a small number of pilot schemes and takes years over discussion and evaluation. In great public services of all kinds, one makes little progress by that means.

We had an experiment on financial management—the resource management initiative—which began on six pilot sites. There are still people at the head of the profession who say that we should not have extended that initiative until we had evaluated fully those six pilot schemes and there are even those who claim that we are in breach of an agreement. I must spell it out to such people that we are in breach of neither the spirit nor the letter of that agreement in the resource management initiative.

The initiative was so popular at the six pilot sites that we are now extending it to 50 more hospitals, which were contenders for the right to take part in the next phase of the resource management initiative. As the initiative rolls out, our methods will, of course, evolve. There will still be plenty of time to evaluate the first six sites and to apply the lessons as we extend the initiative to all hospitals. The rolling out of a process that we steadily evolve with the help of those who work on it—the doctors and nurses in the case of the resource management initiative—is a principle we can apply to other areas.

There are consultants who say they need financial management systems, but ask about the cost. We must be careful about the cost. We do not need all-singing, all-dancing computer and information technology systems straight away in every hospital and we should all be in favour of resisting salesmen who sell expensive equipment in the belief that everyone needs it. However, there will be costs. I have made it clear that, where cost is required up front for investment in new systems, we will provide it, over and above the money required to maintain progress in expanding patients' services.

We had already made £42 million available in the last public expenditure round in the autumn for rolling out the resource management initiative and other programmes for this year. Having seen where we are now and how matters are progressing, I can tell the House that there will be another £40 million of new money, over and above last year's settlement, available for the predictable costs of extending financial management systems in 1989–90. For the sake of accuracy, I had better tell the House about that in the words agreed with my right hon. Friend the Chief Secretary to the Treasury, who, as ever, has been helpful on these matters because he is committed to the National Health Service. I will be making available an extra £40 million in the current financial year to cover the additional work in the National Health Service and in my Department to begin implementing the review. That brings the total available for implementation this year to over £82 million, which will be used to provide financial information to doctors, to fund preparatory work and projects in, for example, general practitioner referral patterns and to provide resources both in staff and consultancy in my Department for the implementation of my proposals.

That new £40 million is intended to enable us to introduce the measures the doctors want. They are measures that the consultants inside the service welcome. The new money is being provided so that the costs of implementation do not cut into the provision of medical care for the patients and the planned rate of expansion. That is the second area in which there has been great progress since we produced the White Paper.

The third area in which we see progress in the Health Service was touched on by the hon. Member for Bassetlaw a moment ago. It is now being reported in the newspapers because of local discussions. Many units in the National Health Service are expressing interest in what we describe as self-governing status under the new contracting arrangements for the National Health Service. Moreover, although this has not yet appeared in the newspapers, large numbers of general practitioners are interested in the practice budgets that we propose, which give GPs more influence than ever before and more say about where their funds should go.

Let me return to the intervention of the hon. Member for Bassetlaw, as the same questions will be asked in many other places. Let us be clear what is coming in from National Health Service units to the regions. At the moment, we are receiving expressions of interest, and only expressions of interest. No hospital has yet decided to become a self-governing hospital; hospitals are in no position to decide that yet. At the moment we are receiving approaches from people who work in the service who are attracted by our new ideas and who recognise the potential for their patients. Very detailed discussions will have to follow before anyone can contemplate whether applications for self-governing status can go any further. We shall work on the applications, and the hospitals and units will acquire much more information about what is required. Everyone will be able to reach a more sensible conclusion once we know what is involved.

In the case of self-governing hospitals, everyone in the locality affected will want to know what care services the district health authority will require the self-governing hospital to provide—[Interruption.] I know that Opposition Members want to leap to oppose what they call opting out before they even know what it entails but we have reached a stage at which an explanation of what it entails might be forthcoming. We shall also need to know, in the case of every unit, what capital costs will be passed to the accounts of that unit. We shall need to know that in order to measure the unit's use of resources in future.

Mr. Spearing

This is all about money; it has nothing to do with health.

Mr. Clarke

The Labour party does not have a policy on health, except in so far as it relates to money. When asked what their policy on the Health Service is, all Labour Members ever say is that they will spend more money on it.

Our proposals are not all about money. I was about to say that there is another thing that we shall need to know about every self-governing unit. Given that all the units are attracted to our proposals by the proposition that they could improve the services that they offer their patients, they will need to work out their plans for the development and improvement of their services.

We shall need to consider how the board of trustees should be formed. We shall need to evaluate whether they are competent to run the unit. As the White Paper said, we shall also need to ensure that the consultants in the hospital are involved in the process of management.

At the moment, therefore, we are receiving expressions of interest in a proposal which is deemed to be a good idea by those who work in the Health Service. That process will be followed by a protracted period of discussion of all the details before any decisions are made. Whether we have a self-governing hospital anywhere in the National Health Service will depend on decisions made individually and case by case and probably at least a year from now. [Interruption.] Despite the wishes of the Opposition, we shall have an intelligent and continuing discussion with the units of what self-government will mean.

Mr. Hugh Dykes (Harrow, East)

Does my right hon. and learned Friend agree that, given the old-fashioned and myopic attitude of the Labour party, it is interesting that more and more staffs, patients and expert managers are keen on the idea of opting out?

Hon. Members

That is not true.

Mr. Clarke

Yes, and the reward that some of them will receive for expressing interest is the same absurd barracking from the Labour party with which it is greeting our proposals today. The Opposition have attempted to misrepresent our proposals by implying that the hospitals will be leaving the National Health Service and suggesting that the idea poses a threat to staff and patients. Despite all that, the idea has been recognised as being of substantial interest to those who work in well over 100 units in the National Health Service, who see an advantage in having more freedom of action to develop their services and use their resources as they think best.

Several hon. Members


Mr. Clarke

No. [HON. MEMBERS: "Give way."] I shall not give way to barracking.

Mr. Martin Flannery (Sheffield. Hillsborough)

It is not barracking.

Hon. Members

Give way.

Mr. Clarke

It is not barracking? The hon. Gentleman surprises me. I fail to see why I should give way to hon. Members who are already making all the noise that they want to make.

In due course we shall proceed in the same way with general practice budgets. I think that a large proportion of GPs with lists large enough to make them eligible for the first wave are very interested in the idea of controlling resources. (Interruption.] Of course; I am dealing with the pace at and methods by which we shall proceed. Of course no GP will tell anyone at the moment that he will have a practice budget. What he wants to know—[HON. MEMBERS: "They are not interested"] They are interested; they are in favour of the idea. What they and we will now need to do is to discuss how a general practice budget would operate. We shall need to discuss the level of resources required by a practice to have a GP budget and negotiate the right level of resources to enable GPs to feel confident that the system is, indeed, an advantage to them and to their patients.

The method of proceeding that I have described is based on the substantial response that we have had, which shows great interest in our ideas on the part of those engaged in hospitals and in general practice. We shall work on those ideas with people who have expressed willingness to discuss them. They will now be involved in a most protracted process of debate and discussion about the implications of the idea for the National Health Service and for their units, their hospitals and their practices in particular.

This is a careful, measured method of progressing with reform, working in partnership with those in the Health Service who want to work with us so that we can ensure that we make the use that we must make of the new information available to the service, in concert with those who recognise the new potential for improving the service.

Mr. Lofthouse

The Minister may be aware that, in the Pontefract health authority area, we are used to opting out. In 1987, on the basis of the allocation allowed by Government to shorten waiting lists, the Pontefract area health authority decided on a scheme to cover 500 operations at Pontefract general infirmary. It later changed its mind and allocated that money to the private hospital at Methley park which ended up performing 200 operations instead of 500. Three hundred of my constituents did not get their operations. That is the effect of opting out.

Mr. Clarke

The use of "opting out" to describe the process by which hospitals become self-governing is a grotesque misuse of the phrase. It says something for the parliamentary skills of the hon. Member for Pontefract and Castleford (Mr.Lofthouse) that he gave the words a completely different meaning so that he could introduce a completely different issue. All health authorities are charged with the responsibility of using their resources in the most effective way for their patients. If health authorities can find a way of using spare capacity in the private sector to the benefit of their patients, marginal costs with part of their funds, I would encourage them to do so. I shall discuss with the hon. Gentleman at some other point the success or otherwise of the exercise in Pontefract.

Several hon. Members


Mr. Clarke

I shall not give way again immediately.

There are other important matters to which we must address ourselves now that the Health Service is beginning to move down the path of reform. With everyone accepting the need for new systems and quality control and with many people exploring the prospects for self-governing hospitals and for GP practice budgets, countless questions will need to be considered. That is why we produced eight working papers, although we could have produced twice that number with little difficulty. There are many other details to be worked out in concert with the profession.

People ask about the planning for a comprehensive service. District health authorities will remain charged with the legal duty to provide a comprehensive service. They will retain all the money in their hands apart from that which goes to GPs with practice budgets who will be providing their contribution to the service, to ensure that their funds are used and distributed in the locality to ensure ready access of all their residents to a comprehensive range of services of the required quality.

People ask about limitations on GPs' rights to refer. I have dealt with GPs' rights to refer. Many people have asked about what the GPs' position will be if the DHA has the money to place contracts and plan local services. They ask whether it will inhibit the GP's right to refer where he wishes. Under the present system, if it remains unreformed, the GP's theoretical total freedom to refer to whomever he or she wants is steadily diminishing. There is no ability to refer across administrative boundaries with any funds to finance the receiving hospital for the treatment of patients.

Mrs. Alice Mahon (Halifax)

When will the Secretary of State talk about patients, not money?

Mr. Clarke

One million patients every year are transferred, and the money does not go with them, and that is a principal cause of a large number of the financial crises that hit the newspapers. The hon. Lady is so wedded to what we have that she will preserve it. She likes the fact that, sometimes, efficient units run out of money precisely because there is no finance to go with the patients when a referral is made across administrative boundaries.

GPs will be involved in the new system. If they do not have practice budgets, they will be far more involved than ever before with district health authorities in deciding how a district authority uses its funds to provide a pattern of service, first, to meet its obligation to give a comprehensive service to their patients, and, secondly, to reflect that GPs' chosen pattern of referrals for the area. Our new system will give GPs much more ability than ever before to influence how resources are distributed, particularly in referring their own patients.

Sir Michael McNair-Wilson (Newbury)

One group of people whom I should like to be especially considered are the chronically sick on expensive medication. They believe that they will be unattractive to the average GP, particularly a GP on a practice budget, who will say, "This patient will take too much of my budget, so I will try to push him somewhere else" Will such people be properly considered?

Mr. Clarke

I can give my hon. Friend an absolute assurance that, in a practice budget—[HON. MEMBERS: "How?"] A practice budget will be constructed to protect the clinical needs of the patient list. It is not even a new point; we thought of it miles before we published the White Paper. That is why we say that practice budgets should be negotiated. We cannot work on so much per head. We must negotiate with GPs a practice budget that reflects the age and chronic sickness of some of their patients and the actual costs that they are likely to incur. I give my hon. Friend an absolute assurance that nothing in our proposals will ever threaten a chronically sick patient with the risk of being refused the treatment or medicine that he or she will require.

Mr. Jack Ashley (Stoke-on-Trent, South)

I am sorry to interrupt the right hon. and learned Gentleman after so many interruptions. His answer seems to be at variance with an answer given by the Minister of State, who said that only in exceptional circumstances would that kind of provision be made. That worries those of us who are concerned about the chronically sick and disabled. Is the Minister giving the House a categorical assurance that all chronically sick and severely disabled people will have special provision with their GPs?

Mr. Clarke

My hon. and learned Friend the Minister of State, who is sitting alongside me, will speak later. He told me that he does not believe that he said what the right hon. Gentleman alleged. No doubt any misunderstanding can be sorted out later.

As I have said, a practice budget will be negotiated on the basis that it needs to reflect the likely costs of dealing with a collection of patients, taking account of their age and chronic sickness. Obviously, it will proceed only on that basis.

There are other matters with which I have no time to deal now, but they are of great importance to those who work in the service and we must resolve them by the process of careful discussion over the coming months to make sure that our changes are implemented in the right way. First, medical teaching causes a great deal of concern. On undergraduate teaching, a working party is already established, involving my Department, the Department of Education and Science, the General Medical Council and the General Dental Council—all professional interests—to make sure that the need for medical teaching is protected.

Sir Gerard Vaughan (Reading, East)

I am glad that my right hon. and learned Friend has referred to that matter, as anxieties are building up in medical schools and universities. Representatives of the Committee of Vice-Chancellors and Principals and the medical schools are anxious to help, but they would like to know what their position will be as soon as possible.

Mr. Clarke

I realise that they are anxious about undergraduate teaching. Of course, a steering group reflecting the full range of interests is already considering that matter. There is also medical and nurse training. It is essential that the National Health Service, however organised, continues to produce the right supply of trained medical and nursing manpower. We must ensure that the training needs of the service are protected by our proposals, that medical schools are not threatened and that any additional costs are covered by our proposals. We must ensure that self-governing hospitals can be required to make their contribution to the required training effort of new doctors and nurses. Plainly, standards must be the same throughout the service, and they must be set by the royal colleges, as they are now. We need to talk through all those points.

For example, I refer to an extremely important policy contained in the document entitled "Achieving a Balance", which is of great importance to the Health Service. I remain totally committed to the principle of achieving a balance. However we organise the Health Service and however many hospitals are or are not self-governing, we must retain the ability to ensure that the possibility of achieving a balance is continued so that we have the right balance between training posts and career posts. That is what I see occupying the real debate.

Mrs. Ann Winterton

Will my right hon. and learned Friend give way?

Mr. Clarke

I will give way for definitely the last time.

Mrs. Winterton

Is my right hon. and learned Friend aware that over 40 per cent. of students reading medicine are women? Is he aware also that there are real anxieties that qualified women will not be able to get partnerships in practices and that medicine for women will be greatly affected by his proposals?

Mr. Clarke

I think that the proportion is a bit higher than that. It is my personal prediction, based on no expertise in the matter, that fairly early in the next century, the majority of doctors in this country will be female. We are obviously going in that direction.

Last week, we made changes in the GP contract, designed to meet the fear that we might unintentionally deter women from entering general practice. Changes are to be made in the system of basic practice allowance, and the way in which we look at practices as opposed to individual partners for GP contract purposes, which will meet those fears. I have always thought that the fears about deterring women from general practice were exaggerated. Nevertheless, we made moves to try to accommodate them, because we were anxious to ensure that we should not create any new artificial barriers to women entering general practice. The agreement shows that we thought we had reached—

Mr. Rhodri Morgan (Cardiff, West)

Quite right.

Mr. Clarke

It is no good the hon. Gentleman trying to be more catholic than the Pope. The BMA is satisfied that we met that agreement. I fear that the hon. Gentleman is out of date.

We will proceed on the same basis. The matters to which I referred are ones on which we need a constructive dialogue with the profession. If people in the profession have fears about medical training, research and achieving a balance, they should first discuss them with us and accept our undertaking that we intend to meet them and, secondly, make a constructive contribution to the proposals about how to tackle them.

We have reached the stage at which everybody should move on from trying to find reasons why they are against each and every proposal for change contained in the White Paper to making some contributions of their own if they can think of a better alternative. Some quite senior bodies in the Health Service have not yet reached the stage of putting forward anything other than criticism of what we put forward. The time has come for us to ask for their considered reactions on subjects such as research, medical training, and so on. They are beginning to come in.

I am sure that we will get no such contribution from the Labour party, but we will get a contribution from the service. Just as the Labour party has been left behind by our move on GPs' contracts, it will be left behind by its position on Health Service reform, as it sees the Health Service being transformed in front of its eyes, so that it provides a service that is better for the patients, allows patients a bigger influence on priorities inside the service, delegates more real management responsibilities locally and produces a service of which we can all be more proud.

The common sense of last Thursday will be carried forward in future discussions to ensure that we produce a better Health Service. No doubt sometimes we will face controversy and sometimes we will find persuasion easy. The Government are determined to fight for a better Health Service to the extent that we need to. I would like to reason for a better National Health Service. I believe that all reasonable people inside the service will work with us to attain the aim of a much improved Health Service—one which will work not only for patients, as the main title of our White Paper implied, but for care for the 1990s as its subtitle implied.

5.10 pm
Mr. Robin Cook (Livingston)

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: recognises that the programme of fundamental changes to the structure of the National Health Service set out in the White Paper, Working for Patients (Cm.555), will fragment the health service, undermine continuity of care and reduce patient choice; believes that competition on the basis of price will threaten quality of patient care and standards of professional training; rejects the White Paper's proposals for increased commercial use of National Health Service funds and National Health Service facilities for the treatment of private patients; notes that there was no reference in the Conservative manifesto to these sweeping changes in the National Health Service and that since their publication they have been rejected by every organisation representing medical opinion and by an overwhelming majority of public opinion; deplores the persistent failure of Her Majesty's Government to respond to the Griffiths Report on Community Care; and calls upon Her Majesty's Government to postpone any major structural changes to the National Health Service until they can be submitted to the electorate in a General Election. I shall begin by agreeing with one of the Secretary of State's observations from the Dispatch Box. I entirely agree that we must be aware of salesmen selling very expensive products. He does, of course, come to the Chamber to sell the most expensive White Paper in the life of the Government, and possibly the most expensive in the history of Her Majesty's Stationery Office. At the end of January, the Secretary of State answered a parliamentary question in which he said that the budget for the launch of the White Paper would be £1 million. A couple of weeks later, when replying to a parliamentary question from myself' he said that the outturn cost on the budget for the launch of the White Paper had been £1,400,000. I am advised that that sum comfortably exceeds the launch cost of the last Jeffrey Archer novel.

There are a couple of ironies about that expenditure. First, there is the obvious irony of a Secretary of State producing a White Paper that claims that it will achieve cost-effectiveness within the NHS, when he cannot keep the budget for the launch of that White Paper to within 40 per cent. of the budget. An even greater irony—the one obvious way to measure the outstanding waste of his largesse—is that he does not appear to have persuaded anyone to be taken in by it. If the Secretary of State was a Labour councillor and had spent so much money to so little purpose, he would have been in severe danger of being surcharged by the Prime Minister to get her money back.

Last week I drew attention to the fact that the White Paper had been rejected by just about every shade of medical opinion. I must say that on one point I was wrong, and I shall therefore make a correction to what I said. I indicated that the one medical body that was the exception to the rule was the Conservative Medical Society. At the weekend I was distressed to read in a Sunday newspaper that the Secretary of State came under criticism yesterday from members of the Conservative Medical Society, who expressed worries about the proposals in the White Paper. Mr.Frank Ellis, a consultant surgeon from Guy's thought the proposals for some hospitals to opt out would create a two-tier system. He said: 'Those who conform will be favoured…and those who won't will tend to be neglected'. There we have it—even the Conservative Medical Society has gone overboard. I apologise to the House if I misled it last week.

I wish to draw attention to the way in which the White Paper has been rejected not only by the people who work in the NHS, but by the public who depend on the NH S. There is no better demonstration of the way in which the public have demonstrated their rejection of the White Paper than by the presence on the Benches behind me of my new hon. Friend the Member for the Vale of Glamorgan (Mr. Smith), whose spectacular victory last week was not just a remarkable victory for the Labour party, but a victory for the National Health Service. I take some satisfaction in that I was able to make my modest contribution to my hon. Friend's election. However, the 36 hours that I spent in the Vale of Glamorgan were nothing like as influential in winning votes for my hon. Friend as the three hours that the Secretary of State spent.

Last Friday I heard the Secretary of State several times express regret on television and radio that he had reached agreement with the doctors over GPs' contracts only an hour after the polls had closed, which was too late to rescue his candidate in the Vale of Glamorgan. The voters in the Vale of Glamorgan, who switched to us, were not doing so because they were distresssed by the fine print of the GPs' contracts. There were not clusters of voters hanging about outside the polling booths just before closing time, delaying their decisions until they heard what concessions had been given on the minimum list size that would qualify for the basic practice allowance.

The Secretary of State deludes himself—although I suspect that he does not delude his Back Benchers—if he believes that that was the issue. The voters were sending a clear message to the House that they do not want to see a Health Service driven by commercial demand rather than medical needs.

The voters of Glamorgan are not alone in that view. All the evidence that we have acquired in the past three months from opinion polls, hon. Members' correspondence and public meetings gives a resounding thumbs down to the White Paper. I concede that there are members of the public who have supported the White Paper. I was interested to read a report in The Scotsman on Tuesday of a public meeting in Dumfries which overwhelmingly came out against the Government's White Paper. There was, however, one voice raised at the meeting in support of the White Paper's proposals; to the distress of the Secretary of State, that one voice was raised by the town's local undertaker.

The Secretary of State keeps telling us that his intention is that the NHS should be more responsive to its consumers. In the light of all that evidence of public opinion, I suggest that he should listen to what the consumers are trying to tell him.

I was interested that the Secretary of State spent yesterday in Geneva. I confess that I only made it to the Westminster Grand Committee Room, where I met a large number of organisations representing those same consumers. There were more than 50 representatives of more than 20 organisations. Twenty of those organisations completed a questionnaire as part of the consultation. All were organisations representing particular groups of patients and users of the NHS, such as RADAR—the Royal Association for Disability and Rehabilitation—the National Schizophrenia Fellowship, the Family Planning Association, the National Federation of the Blind of the United Kingdom and the National Association for the Welfare of Children in Hospital. The answers of those 20 organisations revealed an overwhelming and profound anxiety about the White Paper's proposals. When we asked them if they believed that budgets for GPs would make them more cost-effective without affecting patient care, five of the 20 disagreed, 14 strongly disagreed and one did not know. When we asked them whether hospitals should opt for self-governing status, I concede that one out of 20 agreed. However, three disagreed and 15 strongly disagreed.

I admit that it was not a representative gathering. It was a gathering that differed from any random sampling of the public in that it consisted solely of people who were well informed about the Health Service and who had given years of service to voluntary organisations concerned with health. Their opinion was a resounding no to the White Paper.

Mr. Tim Yeo (Suffolk, South)

What will the hon. Gentleman say to the 1,000 consultants who will need to be sacked when the £43 million saved by competitive tendering under the Government is thrown away by the Labour party, if it ever gets the chance to put into practice the proposals published earlier this week?

Mr. Cook

I have met many consultants in the past three months. It has been an interesting experience for me and, I expect, for them, because there has been a degree of therapy when I have consoled them for the loss of the affection of their Government. I suspect that I have probably met 1,000 consultants during that time, but I have not met one who has expressed the least anxiety about losing his job under a future Labour Government. However, I have met many consultants who have expressed some surprise at the priorities of this Government who, as a result of their White Paper, proposed to increase the number of accountants in the Health Service by 1,000 while increasing the number of consultants by only 100, which gives a neat arithmetical guide to the priorities of the White Paper.

Mr. Kenneth Clarke

The hon. Gentleman is trying to avoid the question asked of him by my hon. Friend the Member for Suffolk, South (Mr. Yeo). If the hon. Gentleman believes that the test of a Health Service policy is to ask 20 group representatives his chosen questions on that matter in the Grand Committee Room, will he ask those groups whether they would support his party's proposals to end competitive tendering in the Health Service, which would cost the Health Service £100 million? That is the sum that we have saved by the policy that the Labour party has always opposed.

Mr. Cook

We asked precisely that question in the consultative document that I issued last September. I assure the Secretary of State that the overwhelming majority of the responses that we have received have been supportive of the fact that if one wants to run a Health Service, one needs a health team that is motivated and committed to the Health Service. Such a health team would not consist simply of consultants and the Royal College of Nursing; it would also include ambulancemen, porters, cooks, domestics and everybody who keeps a hospital functioning.

On the Secretary of State's extraordinary point that the response from those 20 organisations reflected any loading in the question, let me put this challenge to him. I will happily recall all those 20 organisations and put to them questions on GPs' practice budgets and on hospital self-governing status in any terms in which the Secretary of State cares to frame them—I should be extremely surprised if the answers were any different.

I should add that the questions raised at the meeting yesterday were much more penetrating than those in the intervention of the hon. Member for Suffolk, South (Mr. Yeo). The National Council for Carers and their Elderly Dependants asked reasonably, "What will happen to respite care when every bed in the hospital has to be paid for by contract?" Life is only just bearable for many carers because their GP colludes with them in arranging temporary admission to geriatric wards for their elderly relatives to give the carers a break. How many GPs will still do that if they have to pay for it out of their fixed budget? What price will be placed on the sanity and family life of carers in the new cost-effective Health Service?

The association called Asthma Care asked what would happen to the prescriptions of its members under the new limits on drugs budgets. The progressive management of asthma is now based on preventive medication. It is not based on waiting for acute attacks and then remedying them; it is based on prescribing before attacks happen. However, that preventive medicine can cost between £20 and £40 per month for cases of serious asthma. Because of the new drugs limits, how many GPs will feel obliged to revert to the old method of "wait and see" and wait for the acute attack—

Mr. Kenneth Clarke

. None.

Mr. Cook

The Secretary of State assures us that there will be none, but he has been much less robust and blunt in his explanation of the drugs budgets to the House and to the public than he has been in his explanation to doctors of how they must buckle-to under the new GPs' contract.

The Secretary of State would have us believe that the drugs budget is not firm and fixed but that it is elastic and will bend and give. However, I refer the right hon. and learned Gentleman to pragraph 7.16 of the White Paper, which is explicit in stating: Each year the provision made for FPS drug costs in the Parliamentary Estimates will be divided into separate firm budgets among the 14 health Regions … RHAs and FPCs will be expected to work to the budget they have been given. I do not deny that the Secretary of State is technically correct. Yes, those authorities can exceed their budget, but only if they meet the extra cost by cutting it out of other expenditure on patient care. That is freedom, but it is the freedom to freeze expenditure on prescriptions and to cut expenditure on other services.

It is dishonest to pretend that that freedom is anything other than cash limits by any other name—[Interruption.] That is perfectly true, because it is in the right hon. and learned Gentleman's own White Paper. It is also true that it is disingenuous of the Secretary of State and his hon. Friends to complain that patient organisations have been misled when they reasonably argue their well-informed anxieties about that paragraph—

Mr. Clarke

I apologise to the hon. Gentleman for intervening twice when at first I did not intend to intervene as all, but his speech is solely designed to raise fears among all the groups that he is talking about. If the hon. Gentleman is quoting the White Paper about the effect on GPs, will he quote from the relevant part, paragraph 7.19, which states: Where a GP practice exceeds its indicative budget, the FPC's first recourse will be to offer advice and"—[Interruption.] where necessary, to bring a process of peer review to bear on the GPs' prescribing practices"? That means that another doctor will give advice. Further steps will be taken only if there is no clinical reason for prescribing excessive quantities of drugs.

The hon. Gentleman's description of the White Paper is designed to instil fears into asthma sufferers or whichever group he is talking to. Does he really think that that is rising to the challenge of the events in the National Health Service, to which he should rise if he is serious about its future?

Mr. Cook

The question that I asked was not of my devising. It was brought to me by those asthma sufferers who had looked at the White Paper and felt anxiety.

Is the Secretary of State willing to say now that he will withdraw the clear and explicit statement in paragraph 7.16 and say that there will not be firm budgets in the regional health authorities, that the regional health authorities will not be expected to work to such a budget, and that he will compensate them if they exceed that budget[Interruption.] The right hon. Gentleman cannot claim that those questions are irrelevant. If GPs are to remain free to exceed their indicative budgets, will the Secretary of State advise the Southwark and Lambeth family practitioner committee—

Mr. Jerry Hayes (Harlow)


Mr. Cook

No, I shall not give way to the hon. Gentleman because I am addressing my question to the Secretary of State. We are entitled to know whether we are dealing with a fixed budget. Is it a cash limit or, as the Secretary of State would have us believe, something that can be ignored?

Mr. Kenneth Clarke

The patient will look to his GP for his prescription. It is clear in the White Paper that no patient need fear that his doctor will refuse to give him the medicine he requires. No doctor will be driven into bad clinical practice. Regional health authorities do work to cash limits now for the hospital service and they will work to cash limits. The regional health authorities' cash limits will not—

Mr. Cook


Mr. Clarke

No, I am not taking—

Mr. Cook


Mr. Deputy Speaker (Sir Paul Dean)

Order. Two Members of the House cannot be on their feet at the same time. I call Mr. Cook.

Mr. Cook


Mr. Clarke


Mr. Cook

No, I am on my feet—[Interruption.]

Mr. Clarke

On a point of order, Mr. Deputy Speaker. In my experience, when an hon. Gentleman has the courtesy to give way, he cannot then revoke his giving way, decide that he does not like what is being said and leap in to try to take half my answer which he will then no doubt use out of context in the way that he has just used those quotations from the White Paper.

Mr. Deputy Speaker

We had better get on with the debate. I call Mr. Cook.

Mr. Cook

Now we have it absolutely clear. It could not be clearer. The Secretary of State has just said that regional health authorities are, so far, under cash limits for hospital expenditure and that they will now be under cash limits for drug expenditure as well. We now have that clearly and firmly on the record. Those who are concerned about people with high prescription costs have every right to be concerned and to bring their anxieties to the House.

Mr. Clarke

Will the hon. Gentleman give way?

Mr. Cook

No. I have given way three times to the Secretary of State, and I shall now proceed with my speech.

I shall turn to those hospital sectors to which the Secretary of State has just referred.

Mr. Kenneth Hind (Lancashire, West)

On a point of order, Mr. Deputy Speaker. Is it right for the hon. Member for Livingston (Mr. Cook), having given way, then to stand up because he does not want my right hon. and learned Friend to complete his answer which the public want to hear?

Mr. Deputy Speaker

I remind the House that a large number of hon. Members wish to participate in this debate. Let us get on with it.

Mr. Cook

I am mindful of your observations, Mr. Deputy Speaker.

The Secretary of State was good enough to say that a large number of hospitals had expressed an interest in opting out—[Interruption.] Will my hon. Friends allow me to proceed? [Interruption.] On the contrary, I have succeeded in doing exactly that which I am accused of not being able to do. I have been through the list that contains a number of reputable trade journals and health service journals. It is an interesting list. There are hospitals which are not in the list of those which have submitted an interest in opting out.

There are currently six hospitals in the resource management initiative which, the House will recall, was to have been the means through which hospitals would acquire the information to price a contract and the key to unlock the door to opting out. Of those six hospitals in the resource management initiative, five wrote to the Secretary of State saying that they had resolved not to express an interest in opting out. They all went into the resource management initiative because they were interested in better financial management. They all welcome, as did those consultants who have worked in the resource management initiative, the opportunity to manage their resources. However, they never entered into it on the basis that it would be paving the way to opt out. There is not a hope—

Mr. Clarke


Mr. Cook

The Secretary of State addressed the House for 52 minutes and he has already intervened three times in the 20 minutes of my speech. Of course, I shall as a matter of courtesy give way to him again on this occasion, but I would like to point out that other hon. Members have rights in this House.

Mr. Clarke

The hon. Gentleman repeated something which he has said before about the letter sent by five of the hospitals in the RMI that were never, particularly, candidates for self-governing—[Interruption.] They were never special ones. The hon. Gentleman said that five of them had indicated that they were definitely not candidates.

I have a letter from Mr. Meecham, a consultant to the Wirral health authority at Arrowe Park hospital which was written to me after the hon. Gentleman first made that rather startling assertion. I shall read the relevant part about the statement that the hon. Gentleman made and which he has just repeated. It says: I certainly did not feel that any part of our letter made a judgement about self-government and would not have wished it to do so. I was amazed and dismayed therefore when a great deal of the coverage in the national press talked of the hospitals involved rejecting self-government or refusing to opt out. I certainly had not intended any such interpretation to be made. I had regarded our letter as a plea for taking it one step at a time rather than being rushed along without assessment of pilot projects being taken into account. Quite how the national press made the interpretation that they made, I do not understand. The national press interpreted it in that way because the hon. Gentleman did. Arrowe Park will, in due course, decide whether it wants to be self-governing, as will the other five hospitals. It is totally untrue for the hon. Gentleman to say that those hospitals have rejected self-government and untrue for him to repeat it today.

Mr. Cook

It would not be magnaminous of me not to recognise such a useful intervention. I assure the Secretary of State that if he wishes to read any more such letters during my speech, I shall cheerfully give way to him.

The Secretary of State's difficulty is that he is left with other hospitals in which there is barely a hope that they will have the adequate pricing information to opt out by April 1991, despite the haste with which the Department is cobbling together a software package that cuts corners. I note that the Secretary of State's director of finance information engagingly described that as a "quick and dirty approach" to the problem.

One reason that I am confident that some of the hospitals in the list will not be ready for opt-out in 1991 is that three of them have yet to be built and a number of the others are scheduled to be closed before 1991, including Much Wenlock hospital. I do not wish to disparage Much Wenlock hospital, which I am sure in its own way is a centre of excellence. However, it is plainly not one of the 300 major acute hospitals that we were originally told were prime candidates for opt-out. The dragooning of Much Wenlock cottage hospital into the list of hospitals for opt-out reveals a certain desperation.

The most telling demonstration of the fact that the Government are having difficulty in selling the concept is the frequency with which management has been obliged to express interest in flat defiance of the medical staff. I mentioned that five out of six hospitals in the RMI had decided to express no interest. The sixth, Guy's hospital, has expressed interest. Last night, the consultants at Guy's were so fed up with having Panama ballots by the management board, that they called in the Electoral Reform Society, which, in a ballot, discovered that two out of three consultants regretted that Guy's had not joined the other five hospitals in their letter to the Secretary of State.

Even more startling is the case of Leicester, where 140 consultants gathered and voted unanimously against opt-out. Subsequently, at a closed meeting of the management board, it was decided to nominate Leicester

Why is medical opinion so overwhelming in rejecting the concept? What is it that worries the profession? First, they are worried that it will fragment the Health Service. The proposal in the White Paper is written by people who see what happens to the patient in hospital as an isolated episode, with no connection to what has gone before or after. A simple model is one in which the patient collects his or her travel voucher from the local district general manager; the patient disappears to travel the long distance to the hospital in which the contract has been chosen by the district general manager, not by the patient; the patient may never before have been diagnosed; there may be no commitment to community services in the area from which the patient comes; the patient may have no prospect of returning as an out-patient; and there is no access to the medical records of the patient.

It is bizarre that the Secretary of State should describe such a concept as one that treats patients as people. The consultants have not been taken in by the idea that extra money will follow any extra patients attracted. They have been sharper in seeing through that fraud than the right hon. and learned Gentleman's Back-Bench colleagues. The structure proposed cannot produce extra funds for the hospital sector because there is no proposal to provide extra funds for it. The cheerful notion that everyone's hospital can receive more money by opting out rests on a simple delusion. As the consultants at Guy's hospital in their letter to The Independentthe other day observed: The only way we can get more money for Guy's is by concentrating on what is profitable, not what is needful.

Mr. Ashton

Is it not a fact that if a hospital chooses to opt out, it will have to take on a huge debt to buy its own buildings and equipment from the Government? In many instances, it will only be able to service that through extra fund-raising, sponsorship or selling off land.

Mr. Cook

My hon. Friend understates his case. The truth is that not only hospitals which opt out will be faced with these charges. Every hospital in the health sector will be faced with them. They will be faced with a payment on capital charges, not just for rent for the roof over their heads but for every piece of equipment in the building worth more than £1,000. Heaven knows what additional costs that will entail by way of administration of the immense, ponderous effort of gathering together such a mammoth inventory, merely to enable Conservative Members to know where every piece of equipment worth £1,000 is located.

To return to the argument about whether money will follow the patient: even to succeed in selling treatments that are profitable rather than needful, these hospitals will have to compete against each other merely to stand still. The fundamental dishonesty in the White Paper is that it continually presents competition as resulting in an increase in quality—because the hospitals compete on quality—when the White Paper is really written with the intention of lowering the cost to the NHS by obliging these hospitals to compete not on quality but on price. And the first victim of competition on price will he the quality of patient care.

Anyone who doubts this has only to remember that the contracts will be awarded by health authorities desperately juggling to make ends meet now. On Tuesday, the National Association of Health Authorities issued a statement pointing out the difficulty that it was having coping with 8 per cent. inflation on a budget based on a forecast of 5 per cent. It now calculates—

Mr. Tony Favell (Stockport)

Will the hon. Gentleman give way?

Mr. Cook

I shall happily give way to the hon. Gentleman in a moment. His interventions—he has made one in every speech that I have made in this Parliament —are always worth hearing.

The National Association of Health Authorities now estimates that the cumulative under-funding of the hospital sector in the lifetime of this Government exceeds £3 billion. That is why hospitals up and down the country are running out of money to treat their patients.

Mr. Favell

I greatly resent the hon. Gentleman saying that hospitals that give good value for money do not give good service. Stepping Hill hospital in Stockport has twice been top of the value-for-money league in the north-west, and it gives an excellent service.

Mr. Cook

I am terribly sorry if I caused the hon. Gentleman offence; I shall make a point of not giving way to him next time.

There are undoubtedly many excellent hospitals which provide value for money, such as the one to which the hon. Gentleman referred. Why on earth is it necessary, then, to turn the whole system upside down to tackle the problem of under-funng—

Mr. Hind


Mr. Cook

The hon. Gentleman has already raised a point in my speech, and once is enough for anyone, apart from the Secretary of State.

The consequence of this under-funding was perfectly illustrated only yesterday in a parliamentary answer given to my hon. Friend the Member for Don Valley (Mr. Redmond). It confirmed that, of the 11 body scanners in operation in the Trent region, seven had to be paid for by public appeal. That is the type of Health Service to which we have been reduced—the Health Service of the collecting can, a Health Service in which the harsh reality is that large numbers of health authorities end each year broke. In such circumstances, they will have no choice but to award their contracts on the basis of where they can obtain the cheapest ones.

Mr. Jerry Hayes (Harlow)

The hon. Gentleman has raised a valid point. One of the difficulties at present is that, since there is an efficiency trap, beds and wards are closed at the end of the year because hospitals run out of money. Under the proposals in the White Paper, which will make the money travel with the patient, does he agree that precisely the opposite will obtain and hospitals will be given a financial incentive to open the 20 per cent. of NHS beds that are closed for stupid economic reasons?

Mr. Cook

I must try again, perhaps a shade more slowly. There can be no removal of the problem of under-funding at the end of the financial year, because no more finance is proposed for the kitty. Even if the hon. Gentleman is correct that some hospitals will attract more money for the patient—[HON. MEMBERS: "Ah!"] Let us assume for a moment the hypothesis proposed by Conservative Members, in which these hospitals will try to undercut each other and will therefore receive no extra money. The corollary of the hon. Gentleman's argument is that other hospitals will face the problems of bed and ward closures even earlier in the year because they do not have the necessary resources.

The most spectacular, technicolour failure of the White Paper was also the most conspicuous omission from the Secretary of State's speech. The right hon. and learned Gentleman addressed the House for 52 minutes in his own speech and for seven during mine without once alluding to the words "community care". The White Paper manages to run to more than 100 pages on the NHS without a single proposal for better patient care in the community. That is a failure that fully matches the deplorable failure of the Government to respond to the Griffiths report one year and two months after its publication. If the Secretary of State wishes to tell us that we must now wait for another White Paper, I shall cheerfully give way to him for the fifth time so that he can name the date when the Government will give their response to the report.—That has managed to silence even this Secretary of State.

Every now and again we see the consequences of this neglect. Last night I sat in the Library and read yesterday's report by the British Geriatrics Society on the abuse or elderly people. It makes harrowing reading. It contains case histories of frail, elderly people, battered and bruised in body and emotions, and often abused by close caring relatives who have been driven to distraction by the strain of constant attendance without break, sleep or help.

I was particularly moved by the case of a daughter who gave up her flat to move in with her mother and sleep on her sofa. The daughter was finally found trying to strangle her mother with a towel after a day in which, in 24 hours, she had been called 17 times to lift her mother on and off the commode.

This type of condition is the major challenge facing the health and social services at the end of this century. We must provide care and nursing for the growing number who find themselves in conditions that cannot be cured but for whom appropriate services and support from the Health Service can make the difference between pain, squalor and isolation on the one hand, and comfort, dignity and a life of interest on the other. The White Paper is wholly silent on how we should assist these people.

Only one help is offered for the health care of the elderly—the tax relief for private medical cover. No one could read the report by the British Geriatrics Society and still believe that this proposal is relevant to a single one of the case histories I have mentioned. It is a proposal as fatuous in its irrelevance to the real health needs of the elderly as it is central to the political dogma of Conservative Members.

Here we come to the real threat posed by the White Paper. It would be a mistake to judge it as no more than a ragbag of wrong-headed impractical proposals, full of glaring omissions. There is a thread that holds it together. To do the Secretary of State justice, he has a strategy. His strategic objective is to destabilise the National Health Service and replace it with a commercial one. It is a strategy that is not difficult to spot. It keeps breaking to the surface all the way through the White Paper. It breaks through in the suggestion that opt-out hospitals should use NHS facilities for private patients, in the suggestion that general practitioners should use NHS money to buy private treatment for their patients and in the obligation on health authorities to give equal preference to private hospitals in awarding contracts for medical treatment.

We are at the start of a long journey. We can already see where we will end up—with market medicine as it is practised across the Atlantic, where 30 million Americans have no medical cover, where health means organisations are put on the second floor to discourage expensive, disabled people from enrolling, and where patients die in casualty rooms while the accountant is finding out who will pay for them.

If that does not move Conservative Members, let me warn them about what happens to well-heeled people like the people whom they represent. American women are twice as likely to have their wombs removed as British women. American men are two and a half times more likely to have their prostate rebored as are British men, and three times more likely to have their gall bladders removed. That is not because they have any greater need for those operations but because the people who sell the operations believe in what they sell. When a doctor examines a patient, he comes to the conclusion, "Your gall bladder is worth more to me than it is to you." Market medicine gives the worst of both worlds. It denies the poor and the unhealthy the treatment that they need, and it cons the healthy and the wealthy into treatment that they do not need.

We are in danger of losing a Health Service that is motivated by dedication and replacing it with one that is driven by financial targets. We have had plenty of occasions recently to note the danger of what we will lose and how important it is. We have been able to note it in the succession of tragic events with major loss of life during the past 18 months. Hillsborough is the latest in that succession. We have had Piper Alpha, Lockerbie and Clapham. On every one of those occasions it has been the ambulancemen, the casualty departments, and the nurses of the National Health Service who have turned out to handle the emergency. It is to them that we turn on such occasions.

The Prime Minister has been assiduous in visiting each disaster. On every occasion she has been good enough to say how wonderful the emergency services have been, as they were, but they are just as wonderful between disasters on every other day of the year when they do not provide the opportunity for a photo call. If those services are to be there when they are needed, we have to sustain them all the year round. We must give them the resources that they need to do the job. We must heed the advice that they offer on the future of the service. Above all, we must give them the commitment that we believe in the service that they provide. It is because right hon. and hon. Members on the Government side do not believe in that service that we will vote against them tonight.

5.52 pm
Sir Gerard Vaughan (Reading, East)

Because so many hon. Members wish to speak, I shall speak only briefly. There was a great deal of laughter, particularly from the Opposition Benches, during the speech of the hon. Member for Livingston (Mr. Cook). I found what he was saying distressing; and it was increasingly distressing as he went on. I worked for the whole of my life in the National Health Service until I came to the House.[Interruption.] I will not indulge in the sort of remarks that have just been made.

What troubled and distressed me, and should distress the whole House, was the constant attempt of the hon. Member for Livingston to undermine people's faith in the Health Service and to create anxiety among people who do not understand what is happening and alarm in places where it should not exist. I would have expected from the spokesman for the Opposition a much more serious look at what the Secretary of State has recommended.

May I remind hon. Members that the National Health Service was started on an all-party basis? Today the Opposition are attempting to undermine the service. [Interruption.] Yes. They are a backward-looking, unserious group of people who are not taking proper account of what has been proposed by the Secretary of State.

The hon. Member for Livingston quoted the Conservative Medical Society. I was at the meeting to which he referred. What he said was a total travesty of what happened. My right hon. and learned Friend will agree. I am an honorary consultant at Guy's; what the hon. Gentleman said about attitudes within Guy's was also a complete travesty of what is happening in the hospital. When he goes round hospitals I wonder whom he talks to. Is it only his union chums, who wish to be activists within the Health Service? They are not the people who talk me.

Mr. Max Madden (Bradford, West)

On a point of order, Mr. Deputy Speaker. The hon. Gentleman is disputing whom my hon. Friend speaks for. Do you think that in the course of his remarks he will make a disclosure of his interests which, according to the Register of Members' Interests, include the directorship of Private Medical Centres plc and the joint chairmanship of Spahealth Ltd.? Do you think that in his trip down memory lane the hon. Gentleman has overlooked the fact that he has those relevant interests which bear directly on the debate?

Mr Deputy Speaker

The House knows that it is customary for hon. Members to declare their interests during debates.

Sir Gerard Vaughan

I have nothing to say. They would not be in the Register of Members' Interests if I was worried about them. [Interruption.]

Mr. Deputy Speaker

Order. Sedentary interventions prolong debate and waste valuable time.

Mr. Allan Rogers (Rhondda)

on a point of order, Mr. Deputy Speaker. The hon. Gentleman also has strong connections with the British pharmaceutical industry. Will he declare those interests before proceeding with his speech?

Mr. Deputy Speaker

We had better let the hon. Gentleman get on with the speech.

Sir Gerard Vaughan

I am grateful, Mr. Deputy Speaker. As I said at the start, I propose to speak briefly. I wish to congratulate my right hon. and learned Friend on what he is proposing for the National Health Service. He is putting forward his proposals with great courage and determination. A great many doctors and nurses have been talking to me and telephoning me to tell me how much they support my right hon. and learned Friend's proposals.

Some doctors have been telephoning me not to criticise what my right hon. Friend has proposed but to ask what it all means. That is where part of the problem lies. The Secretary of State is putting forward very complicated proposals that are difficult to understand. They need much explanation. Opposition Members find it easy to use them to misrepresent people's attitudes.

Mr. Harry Greenway (Ealing. North)

No doubt my hon. Friend will consider the question of resources. Will he draw attention to the £2 billion to £3 billion more that is going into the Health Service in the current year? [Interruption.] The Labour party is wearing its heart on its sleeve about resources—[Interruption.]

Mr. Deputy Speaker

Order. There are too many speeches going on.

Mr. Greenway

Is my hon. Friend aware that the Labour council in Ealing put up the rates on Ealing hospital by £500,000 two years ago and that it is putting them up by another £500,000 this year? Labour does not care.

Sir Gerard Vaughan

My right hon. and learned Friend the Secretary of State is talking about evolution. Opposition Members do not seem to realise that, as the proposals in the White Paper are put into effect, so the situation will change.

Mr. Thomas Graham (Renfrew, West and Inverclyde)

Does the hon. Gentleman realise that some Scottish Members have been inundated with letters about the ending of the care attendance schemes in September? Those schemes have given carers the respite that they need to enable them to continue caring for their mums and dads and sons and daughters at home rather than have them go into hospital, yet the Government are deaf and dumb in the matter. They have not come to the aid of those carers or of the patients that they look after. There has been no emphasis on community care. I do not like to criticise hon. Members who are sincere, but they must look at what we are seeing. I am being sincere when I say that the Government are condemning many carers who cannot take any more. Please take that into consideration.

Sir Gerard Vaughan

I know in whose hands the NHS is safest—my right hon. and learned Friend's.

My right hon. and learned Friend is right when he says that the introduction of more information and of medical and clinical audits will change the situation. For the first time, people will begin to know where the money is being spent and where there are places for the treatment of their patients.

Recently, in my constituency, I had the problem of a lady who required a hip operation and was kept awake every night in pain. The waiting list in our locality for that operation is two and a half years. When I asked the health authority to inquire where else she could go it could not provide that information. It did not have the resources to find out where she might go. I had to phone round and find a hospital where she could be admitted virtually immediately. That should not be done by a Member for Parliament; it should be done as a matter of course by the local health authority, and that will be possible when the information comes through in the way that my right hon. and learned Friend has proposed.

No doctor would object to a medical audit. It is agreed on all sides that they would be of benefit to us. It is regarded in the same way as a consultant regards a second opinion. If it agrees with him, it strengthens his hand, and, if it disagrees with him, he is interested to know why somebody thinks the job could be done better in a different way.

I shall not go on any further. I know that Opposition Members will be pleased because they do not want to hear too much from someone who has been working in the field. Anyone who goes round the hospitals, as I do, will hear people complaining about the frustration created by delays and the waste under the present system.

My right hon. and learned Friend was right to remind us of what is going on overseas. That is relevant because every other major country is facing the same sort of problems that we in Britain face. Unless we face up to that, we shall not have the services or the reduced waiting lists that we wish. Therefore, I strongly support what my right hon. and learned Friend is trying to do in this difficult area.

6.2 pm

Mr. John P. Smith (Vale of Glamorgan)

Thank you, Mr. Deputy Speaker. I hope that you and hon. Members will bear with me while I make my maiden speech in the course of this important debate. I should like to start by thanking you and all hon. Members for the wonderful welcome that I was given on Tuesday when I took my seat and also to thank hon. Members on both sides of the House for the individual welcomes that I have received. I hope that the warmth that has been shown towards me will continue for many years.

It is customary in a maiden speech to pay tribute to one's predecessor and, if possible, to avoid controversy. The first custom I am sure that I can meet without difficulty, but I am not so sure about the second custom, given the controversial nature of the debate. But I thought that a safe formula would be to refer to my predecessor's maiden speech in 1951. Unfortunately, it was controversial. Sir Raymond Gower referred not only to the burning issue in Wales of devolution, but to the unbalanced economy and the adverse effect that that was having on his constituency and south Wales.

Therefore, I went even further back, to the maiden speech of Dame Dorothy Rees. Surprise, surprise, I found that she discussed the crisis in housing, homelessness and the problem of eviction, a major issue at the time, and the unbalanced economy. I was going to go back even further until I was told that Lynn Ungoed Thomas was an expert on the NHS and its introduction, so I thought that it might be better to miss that as well.

It is a great privilege for me to pay tribute to Sir Raymond Gower. He commanded tremendous respect within his constituency for 38 years, not least my respect as I had the honour of standing against him at the last general election. During that time, he helped his constituents tremendously. He was definitely a consensus politician and most certainly a one-nation politician. That is why he gained so much respect.

The best tribute that I can pay to the man is to refer to an experience that I had in 1979 when I contested a local election and we had the general election at the same time. I was canvassing for myself when I knocked on the door of a family who referred to themselves as Labour supporters all their lives. They said that they would vote for me in the local election but for Sir Raymond in the general election. I asked why. Surprisingly, they did not say that it was because he had helped them on a particular issue or that he was a good constituency Member of Parliament. Instead they said, "He is a friend of the family." For constituents to refer to their Member of Parliament as a friend is a great tribute, and if I can live up to that I shall be very proud indeed.

My constituency is a beautiful one, as many hon. Members know, having been there in the past three or four weeks. It is made up of the industrial town of Barry, which is celebrating its centenary this year and comprises approximately 50 per cent. of the population, and the beautiful rural Vale of Glamorgan with its rolling green hills, lush farmland and one or two nice suburbs.

My constituency has done reasonably well. It enjoys a higher than average household income and wealth in Wales, and the majority of people there consider themselves middle class. That was why I was delighted to be elected by them last week.

I have no doubt that one of the major issues in that election—in fact, the major issue—was the NHS. The matter is simple. With few exceptions, one's level of income or social status do not matter. My constituents, and, I believe, the British public, recognise that private medicine cannot meet the nation's health needs. In particular, it cannot meet the health needs of the chronically sick, the disabled and the elderly. That message came across clearly during my campaign.

My constituents were not concerned just about the reform of the NHS. My constituency already has major long-standing health issues with which to deal. For example, my constituency does not have a major casualty unit and that is completely unacceptable. It is dangerous in two ways. First, people have to travel long distances to receive emergency treatment, and, secondly, should there be an emergency or accident in the home, mums will often wait until the following morning to go to the local part-time minor casualty unit, thinking that they are doing the best thing by not putting pressure on the Health Service. That can be dangerous, because the hours immediately after a knock, a scrape or an accident are important.

We do not have, and have not had for some time, an adequate ambulance service in the constituency. In the western Vale of Glamorgan, one ambulance serves the entire area between 6 pm and 10 pm and between 12 midnight and 8 am. If there is more than one emergency, it has to be decided to which one to send the ambulance, and I have pointed out the problem of long distances. It was heart-rending when, during the by-election campaign, I spoke to a local lady, Mrs. Margaret Taylor, who told me how she lay in the road in Llantwit Major town centre for 45 minutes awaiting the arrival of an ambulance following a road accident.

In addition, we are faced with the proposed closure of the children's orthopaedic unit in Rhydlafar hospital, which is on the border of my constituency and in that of my hon. Friend the Member for Cardiff, West (Mr. Morgan) but which is used by my constituents. We are also faced with a proposal to shut the most popular hospital in the Vale of Glamorgan, Sully hospital, because clearly, in view of its location, it is a prime development site. It is a beautiful hospital and my constituents do not want it to be closed.

The proposed reforms in the White Paper were the icing on the cake. All the problems to which I have referred are problems of under-funding and none of them will be met by the proposals in the White Paper. Indeed, when I had the privilege of having a private meeting with general practitioners in the constituency, before making any reference to the proposals in the White Paper they made it clear that under-funding was the major problem facing the NHS.

It has been a privilege to have this opportunity to make a short and non-controversial speech in a most important debate. I wish to thank my hon. Friends for all the help that they gave me during the by-election campaign, and I extend special thanks to the Secretary of State for Health for the assistance that he gave me. I look forward to making far more controversial speeches in the future.

6.12 pm
Sir Barney Hayhoe (Brentford and Isleworth)

The hon. Member for the Vale of Glamorgan (Mr. Smith), who has come to the House after a memorable by-election victory, has lived up to the traditions of the House in every way in his maiden speech. He spoke with great fluency and absolute sincerity. His speech highlighted local issues of great concern and he paid a most gracious tribute to his predecessor, Raymond Gower, who was a well-loved colleague of hon. Members in all parts of the House and of the staff at all levels. I am not sure how long the hon. Gentleman will remain here, but we shall be eager to hear him again, perhaps in a more controversial mood.

Before dealing with the main issue of the debate, I must first declare my interest with a pharmaceutical company, as outlined in the Register.

What a contrast there was in the opening speeches. I congratulate my right hon. and learned Friend on a reasonably argued and realistic speech about improving patient care. The hon. Member for Livingston (Mr. Cook), on the other hand, used his considerable skills to make some amusing cracks, which we enjoyed, some political points, but little else, apart from a moving section concerned with community care.

I imagine that hon. Members on both sides are waiting anxiously to hear the Government's response to the Griffiths report, which was published in the middle of March last year. It is important for the Government to declare their position soon on the important matters raised in that report.

The fundamental issue facing the nation is how to improve our highly cost-effective—at least compared with other systems of health care in other countries—National Health Service. The service can of course be improved, and must be made better able to meet the increasing needs of patients, needs which have been amplified by demographic factors and by the pressure of medical advance. More attention must be concentrated on prevention. We do not have a National Health Service so much as a national illness service. The more that we can move towards a genuine Health Service, by dealing with prevention, the better.

Mr. Michael J. Martin (Glasgow, Springburn)


Sir Barney Hayhoe

I normally give way but I will not on this occasion. More than 90 Minutes of the time available for the debate has already been used by the Front Bench speakers. Mr. Speaker has appealed for short speeches because so many hon. Members are anxious to take part.

The White Paper contains much that is good but, regrettably, too much that is questionable and ill-defined. Although the review arose from the funding crisis in the NHS of 1987–88, the White Paper says little, if anything, about money. To borrow a comment from a distinguished former Prime Minister, it is a menu without prices.

I am quick to welcome the increased funding that was announced by the Secretary of State this afternoon to help with some of the proposals in the White Paper, and I welcome the substantially increased resources for the NHS announced in the White Paper on public expenditure. But the White Paper that we are discussing is not only a menu without prices; it is a menu with attractive dishes, some without recipes and others untried and untested.

The White Paper is strong on objectives. Who can quarrel with seeking to improve consumer choice, with pressure to achieve higher standards and extended medical audits, with exerting market pressures to try to ensure the most effective use of resources, with more local control, whether in hospitals or elsewhere in the service, and with measures designed to use more effectively the taxpayers' money that is devoted to the NHS?

The White Paper is, however, weak on detail. The hon. Member for Livingston referred to the serious and notable omission of anything about community care. As I said, more must come from the Government soon for that area. The White Paper is a brilliant piece of Civil Service drafting because it is capable of sharply differing interpretations by those who read it.

True to form, the Opposition parties have gone over the top with their criticisms and forecasts of doom and disaster, never recognizing—they have not said a word about this today—that if their economic policies had been pursued, the resources to provide improved health care, better education and improved social security benefits would not have been available. One must always remember that we are able to devote more resources to these services because of the success of our economic policies.

Not surprisingly, the response of the British Medical Association, the doctors' trade union, was shrill. However, the considered criticisms made by the Joint Consultants Committee deserve careful consideration. The JCC speaks on behalf of the royal colleges and its views must be taken carefully into account by the Ministers concerned. The consultants' co-operation is of the highest importance in any change within or development of the Health Service. The Government's decision to reject the recommendation in the doctors' and dentists' pay review body award of £1,000 extra for consultants was a perverse and curious way of seeking those consultants' co-operation with the reforms that lay ahead.

The White Paper is capable of differing interpretations. The subject of drug budgets was referred to a few minutes ago in a slightly acrimonious exchange. The White Paper makes it clear that drug budgets for GPs and for practices are indicative. My right hon. and learned Friend the Secretary of State has emphasised time and time again that no patient will be denied required medication because of lack of money. However, there is a basic inconsistency between that clear statement and the firm drug budgets that will be imposed on regions and on family practitioner committees.

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

indicated dissent.

Sir Barney Hayhoe

My hon. and learned Friend the Minister shakes his head, but I have yet to see spelt out any assurance to the contrary. I shall be very pleased if that is given. It appears that, because mention has been made of firm budgets at the regional level—my right hon. and learned Friend himself used the phrase "cash-limited"—those outside the House have interpreted that as overriding my right hon. and learned Friend's comments about indicative budgets and there being no possibility of a patient suffering as a result of them.

Mr. Mellor


Sir Barney Hayhoe

Perhaps my hon. and learned Friend will allow me to finish making this point.

My right hon. and learned Friend the Secretary of State stresses, quite rightly, the vital point that general practitioners will not run out of money for their patients' prescriptions and that there is no question of their scrips bouncing when they are presented at the chemist, as would a cheque if no resources were available to meet it. Nevertheless the dilemma remains, and it would be helpful if it could be resolved.

I remember well that when I served in the Treasury and in the Department of Health and Social Security, the Treasury was always seeking to cash-limit the drug budget. In seeking to control public expenditure, obviously it would do so. However, the reference in the White Paper to firm drug budgets for the Health Service as a whole and at the regional level owes nothing to the Department of Health but I suspect was inserted by the Treasury representative. I am pleased that my right hon. and learned Friend has repeatedly stressed the importance of general practitioners remaining unconstrained by cash limits. I am happy to leave it at that.

Mr. Mellor


Sir Barney Hayhoe

The same rule must apply to my hon. and learned Friend the Minister as to others. He will have an opportunity to respond when he winds up.

I congratulate my right hon. and learned Friend the Secretary of State on reaching agreement on a contract for GPs. This matter should not have been muddled up with the White Paper anyway. I shall not apportion blame, but it is a pity that the contract could not have been got out of the way before publication of the White Paper. It is splendid that agreement has now been reached. I only hope that, when the members of the BMA meet in larger numbers, they will not disown their negotiators. That would be very serious and would damage the prospect of making real progress in improving health care in this country.

My right hon. and learned Friend made reference to another dilemma when he spoke about the speed at which the proposals could be implemented. The White Paper is clearly unrealistic in its apparent time scales. I am glad that the words now being used by Ministers appear to qualify these timings. Professor Alan Williams of the centre for health economics at York university, in commenting on the proposals for improving the efficiency of the NHS, stated that they have much to commend them. But they are thrown together with all sorts of untried ideas, and set for implementation in a recklessly short time span, mostly without pilot testing, experimentation or evaluation. Pursued in a more deliberative and selective manner, with time for the collection of evidence and mature reflection, they could do the NHS a lot of good. Pursued with such haste, in this authoritarian and dictatorial manner, it just seems irresponsible. My right hon. and learned Friend confirms that pilot projects and controlled experiments are not buzz words either at Richmond house or at No. 10 Downing street —but perhaps staged implementation or realistic programmes will be adopted. They are essential for success. Steady progress and development are better than a wild rush to upheaval—and perhaps to electoral disaster.

I am glad that the White Paper contains none of the wilder radical proposals for overturning the present, largely tax-funded, basis of a Health Service that is available to all and free at the point of delivery.

I have sought to make it clear that I am not all that enamoured by the White Paper. Parts of it could certainly have been much better, but it could have been much worse. At least it is clear that its desirable objectives provide a basis for sensible and reasonable development and for discussion between Ministers, civil servants and representatives of the professions. I am prepared to give my right hon. and learned Friend the Secretary of State the benefit of the doubt—perhaps I should say of many doubts—as I believe that we both want a better National Health Service providing better patient care. With good will, that objective can command general support.

6.27 pm
Mr. Ronnie Fearn (Southport)

There has been attack, counter-attack, accusation following accusation, words spoken, written and shouted about the National Health Service review and its implications, which has led to the burying of the reasons for that review in the first place. Not long ago, the House was in the throes of a debate about the Health Service crisis in response to the almost nightly scenes of young children, the elderly, and other seriously ill and chronically sick patients being refused admission to our hospitals and to the life-saving treatment that they desperately needed. All that was the result of a lack of beds and resources. We all agree that that situation was brought about by systematic and chronic underfunding. A consequence of those debates and of the general furore over the crisis in the hospital services was that the Prime Minister announced a thorough and extensive review of NHS resources.

One year later, we find not only a White Paper full of holes and omissions that are not filled by the working papers, but one that fails to examine in any detail the financing and funding of the country's Health Service. There is no commitment to inject new resources; merely a tinkering at the edges with the old by transferring them from one area to another, including in and out of the private sector, in the hope that this will in some way cut costs while improving services. This purely a pipe dream.

The Health Service needs more hard and ready cash. Just this week, the National Association of Health Authorities has provided evidence that the review completely ignores. Its report shows an underfunding in England alone of £490 million this year with cumulative underfunding of £billion. Those figures show that the pressures on the National Health Service are continuing at an alarming rate and are likely to do so in the foreseeable future—something of which those who work in and those who use the service are very well aware.

It is hardly surprising, therefore, that the lack of any commitment to the adequate funding of these services is clear from the Government's White Paper. This has led patients and professionals to believe that the review was designed not to improve care but to cut costs.

Mr. Philip Hunt of the National Association of Health Authorities, which is by no means a blanket critic of the review, is reported to have said: It is very vital for the government to recognise and understand this history of financial pressures on health authorities if the reforms proposed by the white paper are to be successful or for the benefit of patients. There has been much publicity over the opposition by doctors to the Government White Paper. I know that many of my hon. Friends have received very many letters and have been besieged by general practitioners and hospital doctors all expressing their concerns. But perhaps Dr. F. J. Parkinson of Redditch, who is not at all impressed by the Government's commitment to funding, is the best example. In a letter to the newspaper Pulse on 6 May this year, he wrote: I believe that the NHS review is a smokescreen for the underlying problem with the NHS. As the Commons Select Committee so rightly stated, the service is grossly underfunded. The proposals do nothing to tackle this problem and offer little that will benefit ordinary patients. The writer describes himself as a member of the Conservative Medical Society. He continues: As a Conservative I feel very ashamed at the manner in which the review has been presented—the white paper is a thoroughly bad document. The schemes outlined are vague, untried and really do not seem likely to benefit patients. It is not very often that I find myself in agreement with a Conservative gentleman, but in this case I am in complete agreement.

My own stand on the matter of resources for the NHS has never been in doubt. I have often said, and said in the House, that how much a country can afford to pay for its health service is a matter of political will. We can afford a lot more than we are paying now and I would like to see a minimum of 2 per cent. increase over and above the NHS pay and price inflator on a long-term plan. I would like to see pay awards fully funded and proper provision made for any reforms or projects that the Government introduce. For instance, I would have no hesitation in committing Social and Liberal Democrats to fully funding the restructuring of the nurses' profession along the lines of Project 2000.

While on the subject of funding, I want to make it clear that Social and Liberal Democrats continue to oppose and would like to see abolished the recent tax relief to the elderly for private health insurance. We would also like to see the charges for eye tests and teeth checks abolished immediately and, in the long term, all such charges dispensed with.

One of the biggest failures of the White Paper is the total lack of costing of any of the proposals. This is very odd coming from a Government which prides itself on the use of marketplace methods. It is even more strange to watch the full-blown attempts to sell the product when the Government have no idea of the cost of the product, whether there is a market for it or, worse still, if the product is capable of working at all. It is even more disconcerting when I realise that it is my and other taxpayers' money that is paying for this folly.

I cannot understand why the Government did not attempt to test this product first. Is the Prime Minister concerned that pilot projects may show too many faults in the design, or is it due to sheer arrogance that pilot schemes have not been introduced? Worse still—I hesitate to make such a suggestion—is it that the proposals are all part and parcel of the Prime Minister's proclaimed aim to roll back the state, and will it therefore be implemented whatever the cost, in both financial and human terms?

Ministers justify these proposals with claims that they will improve patient choice and patient care. I agree that it may be easier for patients to change doctors but, with doctors rushing to increase their list sizes and incentives given to encourage them to form large group practices, how much choice will the average patient have? How many doctors will be within easy reach? How many of them will be women? There are patients who prefer to see a women doctor but, with the pressures to increase list sizes, many women will find it difficult to run or even join a practice, as has been mentioned already. In rural areas—this was referred to in the debate the other night—where doctors are few and far between, choice is already limited and will remain so.

In 1983, the Social Services Committee recommended an optimum list size of 1,700. Will the Minister tell me what has changed since that time? Social and Liberal Democrats believe that doctors need to spend time with their patients, and we would seek to lower the list size at present proposed.

Primary health teams with greater involvement for district and practice nurses, midwives and health visitors would free the doctor for more active diagnostic and preventive medicine and create a real community health service—a concept obviously alien to the authors of the present proposals.

The White Paper makes little provision for particular groups, such as the elderly, many of whom rely on community-based health services. Where is the guarantee of choice and improved care for them? In many respects the proposals may lead to a reduction in services as a result of hospitals becoming self-governing trusts.

These proposals will diminish health care in the hospital catchment area. Core services are imprecise and the term "local area" is not defined, making it very difficult to know whether people will have access to a full range of services within their own area. As the market and profit play a vital part in the Government's view of the Health Service, it is doubtful whether the present range of services will stay intact. This is even more doubtful when it comes to resource-draining services such as geriatric arid long-stay care.

The White Paper takes very little account of discharge procedures, after-care services, ambulance and transport services and many other aspects of patient care.

Major hospitals opting to become self-governing trusts will have a knock-on effect on other hospitals and services. The problems of lack of funding, lack of staff and poor pay will be shifted round the country, which will merely exacerbate them. Already many hospitals are suffering not only from a shortage of nursing staff but from shortages in all staff groups. The private sector, as well as other industries, contribute to this shortage. Obviously, hospitals not restricted by national pay agreements will attract the most qualified staff, making it very difficult for other hospitals in the same area or adjoining areas to attract the necessary personnel.

I know that the university medical schools are very concerned about how this proposal will affect their interrelations and responsibilities. They, of course, play a very important part in teaching, training and research. Centres of excellence will destroy the aim of universal provision of health care and the concept of a community-based comprehensive Health Service.

Dr. Michael Clark (Rochford)

I am surprised to hear the hon. Gentleman say that the creation of centres of excellence will destroy universal provision. Surely the whole idea of such centres—whether they specialise in health care, science, education or any other subject—is to set examples for others, and a centre of excellence in the Health Service will provide such an example. It will lift the quality of provision, and should not be criticised.

Mr. Fearn

I hope that the hon. Gentleman does not think that I was criticising. Centres of excellence already exist which are doing a good job. I feel, however, that my point is a good one.

The Government are embarking on a course that has not been navigated. Ray Robinson of the King's Fund Institute, writing in the British Medical Journal, has said: Self governing hospitals will represent an untried form of organisation operating within an untested market environment. He continues: The white paper is about implementation not experimentation. The review is certainly not about patients and health care. It is about management systems, accounting and information systems, and virtually nothing else. It ignores community care and the effects that the proposals will have on such services. Social and Liberal Democrats believe that community care should be a major priority for any Government, and we would introduce proposals along the lines of those recommended by Griffiths—which we consider solid and strong—with a commitment to provide adequate funds.

Where in the proposals is the "broad front" approach that Social and Liberal Democrats believe is so necessary for good health promotion? Where does it mention accident prevention, occupational health, social policy and environmental pollution, among other issues? Where does it discuss additional taxes on industries whose products lead to ill health?

Where is the patients' charter—mentioned in three speeches so far—to show that the Government really have the patients' interests at heart? We should like to see a guarantee of patients' rights, including the right to full information about their own medical condition and the options for treatment, the right to hospital treatment within a specified period and the right of access to a comprehensive complaints procedure. Where are the proposals to allow a patient to choose one of the alternative disciplines in medicine and treatment? Where is the choice of care for pregnant women? The White Paper virtually ignores maternity care and midwifery.

Where in working paper No. 5 is the guarantee that NHS buildings, of which most date back to 1918, will be brought up to an acceptable standard? We believe that an ambitious building programme is required to bring those buildings into the 21st century. In my constituency, Southport, a new hospital was opened last week by His Royal Highness Prince Charles. That hospital is the latest in the country and is exceptionally good: it will be a centre of excellence. We are very lucky, but many others are not so lucky.

Where in the proposals is the chapter on democracy and accountability? Social and Liberal Democrats believe that there should be a decentralisation of power in the Health Service, along with decentralisation of accountability. Elected representatives of the public should be involved in supervising the management of services.

At best the review is totally inadequate and a missed opportunity; at worst it will destroy the basic principles of our National Health Service. I would, however, commend it for one reason: it has united the nation in opposition.

6.43 pm
Sir David Price (Eastleigh)

One of the documents referred to on the Order Paper as relevant to our debate is the fifth report from the Select Committee on Social Services. I suggest to hon. Members who are not entirely enamoured of the White Paper that they may prefer to rally round the consensus politics contained in the Committee's 64 conclusions and recommendations. We reported seven months before the Government produced their White Paper, and having read the White Paper more than once—as well as the eight working documents—I still prefer our report.

Let me join every other hon. Member who has spoken so far in complaining that the White Paper says nothing about care in the community. The subtitle of the White Paper is "The Health Service: Caring for the 1990s", yet 14 months after the Griffiths report the Government are still saying that they will tell us "quite soon." In my view, community care is central to a future strategy for the Health Service.

I think that most people who have studied the service over the years will agree that it has handled critical cases remarkably efficiently; their criticisms relate to deficiencies in the treatment of chronic cases. The majority of such cases are not in hospitals but out in the community, and with the "greying" of Britain they are becoming increasingly significant. Put in supermarket terms, it is the rising problem of the shelf life of us oldies. I trust that I carry the House with me when I say that future policy on community care is mainstream in any sound strategy for health care as a whole.

As you have invited us to be brief, Madam Deputy Speaker, I shall deal with only one point. In my view the central proposal in the White Paper is the concept of an internal market within a publicly financed Health Service. My right hon. and learned Friend hopes that, by introducing the spur of competition—that is the phrase that he uses—by distributing funds for health care through a system of contractual relationships and by separating purchasing from providing bodies, the Government will make the NHS more efficient and services for patients—now to be regarded as consumers—will improve. That, I think, is a fair potted version of the essence of the White Paper.

This is an entirely new method of distributing health care. I am aware of no example elsewhere in the world of such an internal market within the public sector. It is therefore an entirely unproven proposition, which is why, in its report last July, the Select Committee recommended caution and trial. We said: If the concept of the internal market is to be taken further, it will require to be very carefully planned, monitored and assessed to ensure that too high a price is not paid for its benefits. It should not be introduced nationally before thorough piloting has been done. That remains my view.

I know that my right hon. and learned Friend has thought about pilot schemes and has so far rejected them. I beg him to think again, particularly as the Health Service has not sufficient accountants, computer staff, personnel managers or contract managers to move at the pace that he intends. Let me remind him of what the late Lord Hugh Cecil wrote as long ago as 1912 in his famous book on "Conservatism": The surgeon dissects a dead body before he operates on a living one and operates upon an animal before he operates upon a human being: the mechanic makes a working model and tests it before he builds the full-sized machine. Every step is, whenever possible, tested by experiment in these matters before risks are run. In this way the unknown is robbed of most of its terrors". That is precisely what my right hon. and learned Friend has failed to do. He has not robbed the unknown of most of its terrors, as the reactions of the medical and nursing professions have shown. His basic premise that the introduction of competition in to the National Health Service will ensure a better deal for patients is highly questionable. It is certainly unproven.

I refer the House to what the Financial Times said in its leader on 21 April: The United States, the country with the most competitive system, has by far the highest costs: it spends around 12 per cent. of GDP on health care compared with 8 to 9 per cent. in Europe. Britain, the country with the least competitive system, has the lowest costs, spending less than 6 per cent. of GDP. Yet there is no evidence that the average Briton is less healthy than the average West German or American. Nor is the United Kingdom record on innovation poor: in many fields the treatment available in the United Kingdom is among the best in the world. Thus the basic premise of my right hon. and learned Friend's White Paper that increased competition will provide better health care remains totally unproven. The NHS would be once again reorganised, this time on an unproven premise. I do not know whose bright idea it was —some anonymous economic guru? I respect my right hon. and learned Friend's common sense too much to ascribe authorship of the White Paper to him. I have a feeling that he is arguing a dock brief.

Does that mean that nothing should be done about the known weaknesses of the National Health Service? Certainly not. I remind the House of what we said in the Select Committee report last July: Our principal recommendation in this Report is that the strengths of the National Health Service should not be cast aside in a short term effort to remedy some of its weaknesses. At present it is not possible to demonstrate which of the weaknesses of the National Health Service are a consequence of lack of funding and which reflect institutional deficiencies. We went on to declare: A programme of persistent improvement … will provide a more effective way forward for the National Health Service than the search for a radical reconstruction of the service". That may seem to my right hon. and learned Friend to be too slow a way of reforming the National Health Service. He appears to be a Secretary of State in a hurry, but what is the hurry? The National Health Service is not collapsing around his head.

I repeat my warning to my right hon. and learned Friend not to cast aside the strengths of the National Health Service in a short-term effort to remedy some of its weaknesses. I ask him to reflect upon the Aesop fable of the tortoise and the hare. He may fancy himself as the hare in the outside track, but I remind him that the tortoise won that famous race. My right hon. and learned Friend must try to carry public opinion with him, especially the medical and nursing professions, many of whom are not employees but independent contractors within the service.

I am not convinced that my constituents wish to see their GPs become born-again competitors, let alone medical yuppies. If the House thinks that I exaggerate, let me quote from my right hon. and learned Friend's speech to the annual dinner of the Royal College of General Practitioners: So in the coming months I will be asking patients to ignore the complaints of GPs who are reluctant to compete. GPs are being asked to compete for each individual's custom as a patient and they are being asked to compete for each individual's money as a taxpayer. We will all get an even better standard of service from those who compete successfully". I wonder whether we will. A good bedside manner or a good bazaar manner—I know which I prefer and which my constituents prefer.

I therefore beg my right hon. and learned Friend to abandon his ambitious idea to be a hare, to be a pace-setter, and to content himself with being a good, efficient tortoise. I invite him to take his time about the proposed reforms; to initiate some pilot schemes; to add a lot of green edges to his White Paper; and above all to consult and discuss with an open mind. If he bounds ahead at his present pace, he may well end up not a victorious hare, but politically a jugged hare. That would be very nasty for him. It is not a fate I would wish upon him. I invite him to join us tortoises.

6.54 pm
Mr. Doug Hoyle (Warrington, North)

Unlike at least one Conservative Member, I wish to declare an interest. I am the joint president of Manufacturing, Science and Finance—a union with 40,000 members ranging from consultants to professional white collar workers, junior hospital doctors and GPs. I also speak on behalf of the 625,000 other members of the union and their families who use the National Health Service.

I have followed the Secretary of State's career with great interest. I have seen him in the Department of Health, I have seen him as the Chancellor of the Duchy of Lancaster at the Department of Trade and Industry and I have seen him back at the Department of Health. Today he seemed most uncomfortable. He appeared to be what he is by profession, a barrister, reading a brief with which he was not particularly happy. He did not give us the answers that we were waiting to hear and, as we have heard, he did not provide the answers that his hon. Friends expected. The best advice I can give the Secretary of State is to go away and think again.

No right hon. or hon. Member would deny that there is room for improvement in the National Health Service. It is highly successful and cost-effective, but we must always consider the priorities. The National Health Service demands money. As the hon. Member for Eastleigh (Sir D. Price) said, Britain spends a smaller proportion of GDP on the National Health Service than other European countries do, certainly less than our fellow members of the EEC, except Spain, Portugal and Greece. Surely we do not want to be reduced to that level.

I believe that by providing a universal Health Service, we provide a better service than other European countries. Certainly it is extremely efficient. The White Paper does not take into account what is at stake. The National Health Service is treating people. We are not dealing with items on a production line. The White Paper is all about cost-efficiency. It is not about providing more resources and, of course, it will lead to higher administrative costs but not a better service to the people who use it.

When the Secretary of State was discussing the White Paper—and there was very little discussion of it—why were the people who use the Health Service not consulted? I suggest that had the people who use the Service been consulted, quite a different White Paper would have been presented to us today. If the Secretary of State had consulted those who use the National Health Service he would know their opinion. I see that the hon. Member for Birmingham, Northfield (Mr. King) is in his place. No doubt he will make a speech later. I do not know whether he uses the Health Service, but certainly the Ministers at the Department of Health do not use it, apart from the Secretary of State who always claims to do so.

It is a great pity that Ministers do not use the service more, especially the Prime Minister. If they did, we should have a different White Paper. If people had been consulted, they would have said that rather than urging GPs to have bigger lists, it would have been better to have a reduction in the number of people each GP treats, so that hard-working GPs would have more time for each patient.

I will now deal, specifically, with the proposals in the White paper. Paragraph 2.13 says: Local managers…will…re-examine all areas of work to identify the most cost-effective use of professional skills…there is also scope for more cost-effective working in other professions, some of which, such as physiotherapists, speech therapists and chiropodists, make little use of non-professional helpers. What does that mean? Does it mean that non-professional people will give physiotherapy? The mind boggles if that is the intention. Does it mean that there will be non-professional speech therapists? How will that help people with speech deficiencies? We need more speech therapists who are paid decent salaries, which is quite the opposite of the proposal.

Mr. Jim Cousins (Newcastle upon Tyne, Central)

Is my hon. Friend aware that already there are speech therapists who are, in a sense, non-professionals? Areas where the pay that speech therapists can command is low are unable to recruit them, so some hospital administrations have reclassified speech therapists as clerical and administrative workers so that they can pay them higher wages surreptitiously and so attract more staff.

Mr. Hoyle

I am grateful for that intervention. I am sure that my hon. Friend agrees that that situation is nonsense. The truth is that the pay of speech therapists is low because it is an almost 100 per cent. female profession and that is one of the problems. Shall we have non-professional chiropodists attending to people's feet? The mind boggles.

Paragraph 3.12 says: NHS Hospital Trusts will be free to settle the pay and conditions of their staff, including doctors, nurses and others covered by the national pay review bodies. What does that mean? The MSF has already been told by a leading London teaching hospital that it will pay more in certain grades, but that there will be fewer people in those grades. People such as speech therapists are already overworked and they can hardly cope with their work loads. If some of them are paid more and there is a reduction in numbers, an inferior service will be offered.

Paragraph 9.12 says: The Government believes that there is scope for much wider use of competitive tendering beyond the non-clinical support services". One of the lessons already learned from competitive tendering in the Health Service is that it gives an inferior and less effective service and the person who suffers is the patient. God forbid that competitive tendering should be applied to professions.

According to today's newspapers, at least 140 hospitals are interested in opting out, which means that 200 hospital units could be affected. In Warrington district health authority, Warrington district general hospital is interested in opting out. If the core hospital opts out, it will be impossible for Warrington health authority to plan health care for an expanding area. That will be the case for many health authorities where major hospitals are intent on opting out and it will be impossible to plan health care.

Mr. Flannery

When the Secretary of State was speaking, a whole crowd of us wanted to know who would take the decision to opt out, and although he later intervened four times himself, he would not give way. We do not know whether it will be a democratic process or an undemocratic process. The Secretary of State funked the question every time and would not tell us who will take the decision to opt out.

Mr. Hoyle

I agree with my hon. Friend that we want the answer from the Dispatch Box tonight and I hope that the Minister of State will take note of our comments. From the White Paper, it appears that almost anyone can ask for opting out, including the loosely termed "leagues of friends"—whatever that means. Ultimately, it will be the Secretary of State who will decide, not the people who know about the health priorities in their area. That is the wrong way to run the Health Service, especially as it will mean that local needs will not be taken into account.

We know that the hospitals that opt out will receive a major share of resources, which will be their pay-off for opting out. If the hospitals that opt out receive more, they will attract more consultants, more nurses and more hospital staff. As a result, hospitals that have not opted out will become inferior. They will be unable to attract staff or to provide the same medical services to the people who need them. That is not a desirable state of affairs.

Until now, health authorities have been able to plan for the needs of their area. We want to retain that local input and we want them to be able to plan in that way. The White Paper says: Health authorities…are neither truly representative nor management bodies. That is correct in a sense, but the White Paper proposes to take away the representative bodies by taking away the people from local authorities who serve on them. There will be five non-executive members, probably drawn from business, five executive members who are managers of the health authorities and hospitals, and a non-executive chairman.

To what extent will the new bodies be accountable for the health of the district? The Minister must give us an answer. What say will local people who use the Service and the staff have in whether local hospitals opt out? What say will they have in how the health authorities conduct their business? There will be no local input. How will local people who are patients be able to affect decisions about health care in their district? The Minister must answer that question.

Is it desirable that the managers of hospitals should be members of the governing body and so run them? If managers are below par, who will bring them up to scratch? Managers on the management body are hardly likely to bring themselves up to scratch, so surely independent people should do so. I can envisage great difficulties arising.

I might say something about all this other nonsense —for example, the suggestion that to raise money local health authorities might sell insurance services in hospitals. I suggest that the last thing that people want to be offered when they are ill in hospital is an insurance policy. An even more nonsensical suggestion is that health authorities might sell cars on hospital forecourts. I do not know where that suggestion came from, but having heard the Secretary of State try to sell his White Paper I am inclined to ask who would buy a used car from him; it would be a brave person indeed. Let us stop all this nonsense.

I think that what is in prospect is privatisation little by little. The Government are afraid of saying, "We will privatise the NHS"—

Madam Deputy Speaker (Miss Betty Boothroyd)

Order. I remind the hon. Gentleman that Mr. Speaker announced that the 10 minutes rule would be applied.

Mr. Hoyle

As you know, Madam Deputy Speaker, I have given way to one or two of my colleagues, but I shall finish my speech within my 10 minutes. I have nearly—

Madam Deputy Speaker

Order. The hon. Gentleman has had his allocation of time—10 minutes from 7 o'clock.

Mr. Hoyle

Indeed, Madam Deputy Speaker, and I am almost ready to finish. [HON. MEMBERS: "Oh."]

We shall end up with what they have in the United States—a cheque-book service with high administrative costs which takes into account people's means rather than their needs when they go for treatment. What we need in this country is a service financed—

Madam Deputy Speaker

Order. I must ask the hon. Gentleman to resume his seat.

7.11 pm
Mr. Tony Favell (Stockport)

I shall confine my remarks to the proposals for self-governing hospitals. I do that because today Stepping Hill hospital, together with Stockport infirmary in my constituency, announced that it was one of six units in the north-west to express an interest in becoming self-governing. 1, for one, am mightily pleased. For many years now, I have felt that the two hospitals in my constituency offering acute services would be far better placed if they ran their own affairs, free from influence and interference from the region or from Whitehall.

I must declare an interest because long before I was elected to the House in 1983 1 was a director of a retail pharmacist. I have had an interest in health in a minor way —first as the secretary of the Conservative health committee, then as a member of the Select Committee on Social Services, then as a PPS in the old Department of Health and Social Security and now as a PPS in that most benevolent godfather to the NHS of all, the Treasury.

I have been convinced that the real power over what goes on in hospitals—in wards, operating theatres and out-patient departments—is far too remote from the people who actually administer health care. The proposals for self-governing hospitals will give units the opportunity to control their own destiny, and I am delighted to hear that Stepping Hill hospital, with Stockport infirmary, could be one of them.

The accident and emergency department, orthopaedic department and ENT facilities are at the Stockport infirmary while all the other facilities are at Stepping Hill. Perhaps my hon. and learned Friend the Minister will give me a little of his time to allow me to explain the difficulties that Stockport infirmary and Stepping Hill are experiencing because they are on separate sites. Between them they have 930 beds. Because they are on a split site, there is a constant parade not only of specialists but of patients between them. Not only is that far from satisfactory; it is dangerous to patients.

At present, we have a once-in-a-lifetime chance of disposing of the infirmary and I would wholeheartedly support such a move because the neighbouring Station approach in Stockport is being developed and the infirmary could be disposed of for a small fortune. The unit could then be placed on one site at Stepping Hill, thereby enhancing services and making life a great deal more satisfactory for the staff.

Despite the problems that arise because the unit is on a split site, the standard of treatment is high. The service is caring and cheerful and in recent years—as I said in an intervention in the speech of the hon. Member for Livingston (Mr. Cook)—the unit has come top of the north-west value-for-money league for both in-patient and out-patient cases.

I pay tribute to Fred Richards, the district health authority chairman and Peter Milnes, its general manager and to other members of the authority who have had the confidence in Stepping Hill and the Stockport infirmary to suggest them for self-governing status. If the proposal is accepted by my right hon. and learned Friend the Secretary of State I have no doubt that the hospital services in Stockport will be even better for staff and patients alike and I believe that the same consideration would apply to general hospitals throughout the country.

I am convinced, as I said, that the decision-making process is far too remote. The unit in my constituency has an annual turnover of £25 million, yet a capital scheme of more than £15,000 has to be referred to the district health authority. Larger schemes go to the regional health authority, to Elephant and Castle and then to Whitehall, passing through dozens of bureaucratic hands and committees. Far too much information on day-to-day management matters is referred upwards to Richmond house and, as my right hon. and learned Friend the Secretary of State said earlier, far too little finds its way into the hands of those who really know what is going on —the sister, the consultant and the unit manager, who constantly complain that very little of the information that they collect, which is subsequently processed, finds its way back to them. I am glad to hear that my right hon. and learned Friend has plans to correct that.

The long tail of bureaucracy will be docked when hospitals become self-governing. Information systems will be needed but it will be much easier to have an information system for a single unit than a system serving the whole of the acute hospital sector.

Staff are bound to fear the unknown; we all would. My right hon. and learned Friend has made it crystal clear, however, that the salaries of personnel will be unaffected, as will their terms and conditions, unless they opt for a package that they consider advantageous. That could well happen, as free-standing hospitals will have a keen interest in retaining the best of their staff. Today I spoke to Derek Caldwell, the excellent unit general manager of Stepping Hill about the proposals to make Stockport infirmary and the Stepping Hill hospital self-governing. He said that he looks forward to the change and to being able to provide far better conditions for the nurses who work there. He is enthusiastic about the possibility of creche and welfare facilities and better shift patterns to give those who work at the unit a better quality of life.

Patients, too, are bound to be better off. Recently, I went to Belgium, and I think that my experience will be of interest to the House. In Belgium, the percentage of GDP spent on health is very similar to that spent here. Some of the hospitals are built by local communes, some by the state, some by universities and some by groups of doctors. There is a multiplicity of providers of care. The cost of treatment is met by national insurance schemes and, as here, treatment is largely free. The national insurance scheme covers virtually the whole of the population and is popular with doctors, patients and staff.

I met the chief administrator of Antwerp university hospital. I asked him, "What is happening with the waiting lists in your hospital?" He said, "What do you mean?" I said, "How long would one wait for a hip replacement?" He said, "About a week." I said, "How can they do it within that time?" He said, "If we do not do it, the hospital down the road will do it." That is precisely what my right hon. and learned Friend is proposing for patients in the United Kingdom. He has my wholehearted support. I cannot wait to support him in the Lobby tonight.

7.19 pm
Mr. Jack Ashley (Stoke-on-Trent, South)

I warmly congratulate my hon. Friend for the Vale of Glamorgan (Mr. Smith) on his fine maiden speech. He will make a major contribution in the next two years, and an even bigger contribution two years after that when our party forms a Labour Government.

A special group is affected by the proposals; I refer to disabled people. For them, the White Paper is a menacing document. The omission to mention disabled people is menacing. It demonstrates that their long-standing problems will be neglected. There is no mention in the White Paper of disability, and only a passing mention of the mentally handicapped. Bearing in mind that 6.2 million disabled people are important customers of the National Health Service, such studied neglect and total disregard is disturbing.

Despite its name, the National Health Service is not solely concerned with health. For some people, perfect health is not possible. The National Health Service rightly concerns itself with their welfare and rehabilitation and doing what it can to improve health and the quality of life.

Disabled people today are apprehensive and anxious because their needs, which are different from those with acute illnesses, will be even more neglected after the Government use their usual majority to implement their proposals. There is no reference to the serious shortage of qualified therapists whose skills do much to make disabled people's lives tolerable when their limbs malfunction.

People who need hip operations rightly get operations, but those whose limbs do not work are not given proper provision. There is no mention of staffing improvements to care for people with hearing difficulties, and there is nothing about vital support services. There is not even a suggestion of safeguards to reassure disabled people that existing services will be maintained. Let me quote one glaring example. Many people in this country need wheelchairs and artificial limbs. That service is to be incorporated into health authorities in 1991. It is not mentioned in the White Paper, either, and I do not understand why.

The health of disabled people is just as important as that of anybody else. When people lose their limbs and become immobile, they will find that the Disablement Service Authority has advised general practitioners to look hard at whether artificial limbs or wheelchairs are needed. That means that they will be carefully scrutinised before they get an artificial limb or a wheelchair. They will be means-tested. What sort of Government would impose that kind of hard, steely approach on people who require that vital service? For the first time in decades, severely disabled people will have to fight to get artificial limbs or wheelchairs.

There is nothing for which the Secretary of State or his sidekick, the Minister of State, should be proud. Those people should be properly assessed, fitted with limbs and provided with wheelchairs, rather than be deprived of them. [Interruption.] There is absolutely no point in the hon. Member grinning. I am making a serious point about disabled people. There is nothing to smile about. I am accusing not the Secretary of State but one of the Government Whips.

The major deficiency of the White Paper is its failure to acknowledge and react to the importance of co-operation between the agencies that give disabled people essential support. I refer to the hospital service, primary medical care, and social service departments. All those agencies act in concert to provide whatever pattern of services is required for each disabled person. They are inextricably interlinked and intertwined. If there is reduced NHS commitment, there will be less co-operation and no certainty that essential information is transmitted and that each piece of the jigsaw will be present when it is required. As a result, a disabled person's quality of life will be diminished.

The philosophy behind the White Paper is that we will no longer aim for the best possible treatment for everyone but will focus on value for money. Of course it is right to examine and improve the efficiency of acute services. I do not blame the Secretary of State for doing that. He is quite right to attempt it. But disabled peoples' problems do not respond to the cut of the surgeon's knife. How will value for them be measured?

I hope that the Minister of State will listen to my next point, because I did him a disservice a moment ago. I want the Secretary of State also to listen. The White Paper includes some words about a Health Service being more responsible to patients' needs. However, a doctor at the BMA conference said that the White Paper proposals would act as a great disincentive to GPs to take disabled people into their practices. Their needs could fall by the wayside.

Disabled organisations are unhappy about the proposed changes that give financial incentives to doctors to have a minimum of costly patients. For example, diabetics cost £500 more a year than the average patient. If a diabetic family were to move into an area, how welcoming would a local GP be? GPs have always been the gatekeepers of hospital provision, but, for the first time, they will have an interest in restricting it. Even though most GPs are people of integrity and humanity, it is a backward step to create a system that provides incentives of precisely the wrong kind.

Before the Secretary of State gets too annoyed, I inform him that I challenged him when I said that the Minister of State had said that special provision would be made only in exceptional circumstances for chronically sick and disabled people, who would be more expensive to the Health Service. In his reply, the Secretary of State said that the Minister of State had denied using the words I had attributed to him. The Minister was right to deny those words, because they had been, in fact, used by the Secretary of State. The Secretary of State was asked whether doctors would seek to remove patients from their lists on budgetary grounds. His reply included the words in exceptional cases adjustments will be made in respect of individual patients who need more costly treatment"—[Official Report, 4 April 1989; Vol. 150, c. 85.]

Madam Deputy Speaker

Order. I remind the right hon. Gentleman that he has had his ten minutes.

Mr. Ashley

I am sorry if I have exceeded my time. I must sit down now. If I have done any injustice to the Secretary of State, I am sure that the Minister of State will correct me.

7.30 pm
Mr. Patrick Ground (Feltham and Heston)

At the end of his speech, the hon. Member for Livingston (Mr. Cook) made a comparison between operations carried out in hospitals in the United States of America and those carried out in this country. He said that a substantial number of operations carried out in American hospitals were of dubious value. I think that he was really saying that he was proud of the Health Service, because fewer such dubious operations are carried out in National Health hospitals.

I found that to be one of the hon. Gentleman's most interesting comments, because, for the first time, he was holding up a standard for the Health Service. I believe that that is of considerable value and is, perhaps, the core of the philosophy behind the Health Service, which is that the aim of the Service should be to provide medicine and treatment for everyone who needs it, based on sound medical judgment. I hope that whoever winds up for the Opposition will give an indication of whether they accept that basic philosophy of the Health Service, which was touched on by the hon. Member for Livingston. It is not simply a question of the number of operations or treatments performed; there is also the fact that necessary and useful treatment is being given to everybody who needs it.

I find it difficult to understand in the present structure of the Health Service how that standard can be obtained, and how we can be sensibly advised about the attainment of that standard, without doctors in hospitals and in general practice playing a much bigger role in determining the priorities of the Health Service, which too often are determined, in effect, by administrators and by constraints on budgets at the end of the year. Therefore, one of the features that I welcome in the White Paper is the greater potential role that will be given to consultants and to general practitioners in determining those matters within the limits, and perhaps to some extent beyond the limits, of their practices.

I believe that the principal fear to which the proposals have given rise is the fear of a significant number of patients that, as a result of the proposed indicative budgets, they will not get the medicines and the treatment that they need under the Health Service. 1 have read the White Paper and the working papers that touched upon that subject and I believe that, on a fair reading of those papers, there is no need for those people to have such fears. It is plainly not intended in the White Paper to do much more than to give a nudge to practitioners, who are or may be over-prescribing or who have the most expensive drug budgets, to consider other ways of treating their patients which are more in line with general practice and which would be equally good, and probably better, professionally. Paragraph 7.15 of the White Paper makes it clear that the White Paper's proposals are certainly not intended to prevent people from receiving the medicine that they need.

It has never been possible in the Health Service for a doctor to have unlimited powers of prescription. There have always been means of dealing in one way or another with over-prescribing. I believe that most people with whom one discusses the Health Service, and who have a good knowledge of what is going on within it, accept that there is some over-prescribing, and many think that there is a substantial amount.

Some patients feel that their doctors have not done their jobs unless they have given them a prescription at the end of their visit. It is too easy for many doctors to satisfy their patients in that respect, because they feel that that is what is required of them. Publicity is needed to encourage patients to question the treatment that their doctors recommend, to ask them to justify the medicines that they are being prescribed and to satisfy themselves that they are useful and that they will not have side effects that will nullify any benefit.

The variations in prescribing that are reported in the White Paper are striking. There are variations between £26 a head in some practices and £48 a head—nearly double —in other practices. It is clear that there is an immense variation, too, in the practices of general practitioners in referring patients to hospitals. In fact, there is a variation of as much as twentyfold. Some general practitioners do the parliamentary equivalent of hon. Members writing to the Minister on virtually every matter that comes before them. Obviously, there is room for a much more sensible practice for prescribing medicines and referring patients to hospital.

Some Opposition Members have exaggerated the rigidity of the indicative budgets, because paragraph 7.17 of the White Paper makes it clear that practices may exceed their indicative budgets for good reasons. Good reasons will be acceptable reasons for going over the top of the budget.

Taken as a whole, the fears that some hon. Members have expressed about the proposals in connection with general practitioners are exaggerated. The proposals should be applauded for the opportunities that they will give for better standards of medical practice, better prescribing and for a more sensible method of referral. Above all, they should be applauded because they will involve general practitioners and consultants much more in the determination of priorities and in the actual spending of money in the Health Service and I believe that that could be of considerable benefit to the Service.

7.40 pm
Mr. John Hughes (Coventry, North-East)

It is possible that the Government's White Paper would never have come to the House if the quotation above Southwark council house was enshrined above the entrance to this Chamber and reminded each hon. Member that the people's health is the highest law. Unfortunately, that philosophy is not contained in the White Paper.

If there has been one constant and unchanging facet of the Government in the past 10 years, it has been their attitude towards the National Health Service and in this instance the constant has been their duplicity. The recently published White Paper is the culmination of that duplicity and it is a good illustration of the dictum that you can fool some of the people all of the time and all of the people some of the time, but you cannot fool all of the people all of the time.

No one in the real world is under any illusion other than that the White Paper is simply one more step in the deconstruction of the Health Service. It is privatisation by another name. Although some commentators are happy to parrot the Downing street advice and may believe that devolution and improvements are part of an agenda for change, their voices are outnumbered. The Secretary of State's White Paper has invited almost universal scorn and has forged some unlikely alliances.

The people who have spoken up against the White Paper—the GPs, the consultants, the junior doctors, the nurses, the Health Service workers and, most importantly, the public and the patients—may have been ignored by the Government but they have not been misled by a Government headed by the greatest scalpel wielder of all, who is not noted for her sensitivity when wielding that instrument and whose cutting philosophy has savaged the Health Service.

The proposals reflect that inhumane philosophy. They are accountancy proposals, set to balance the books numerically at a grossly under-funded level. They are asset-stripping proposals, which will fragment and decimate the Health Service. They will spawn a Health Service unable to respond to a crisis situation and unable to provide in a foreseeable and especially cold winter the future urgent treatment that will be required by 40,000 to 60,000 elderly citizens who cannot afford to heat their homes or to pay for gas or electricity and whose lives are at risk from hypothermia. The proposals ignore the reality of life in Tory Britain. They gloss over the decimation of service in the past 10 years.

The proposals also ignore and gloss over the treatment of the mentally ill who are now subjected to a conveyor-belt system in which they occupy beds on throughput basis. The pertinent fact that has not escaped the Government—the accountants—is that more hospital beds are required for mentally ill patients than for any other type of patient. The Government have realised that if they can get rid of those mentally ill patients, they can either close the hospitals or push other patients through the system. That is being encouraged by the new management pay structures, by which managers are paid bonuses on the rapid discharge of mentally ill patients. Those patients are sent home on a weekend's leave and when they return, their beds are occupied. They become community flotsam and eke out a miserable existence, roaming the streets.

A crisis exists and the Government's proposals will compound the problem with the voluntary organisations being left to pick up the bill. The Salvation Army carries the brunt of the problem. It provides shelter for the mentally ill who are forced to roam the streets. However, even the Salvation Army is under constraints and that is why so many people with a history of mental illness now exist in squalid bedsits or cardboard boxes.

The Government's proposals fail to make allowances for the disparities in health that can still be observed. Far removed from this cosseted Chamber exist members of our society whose circumstances are a condemnation of the callous system. We step over them when we use the Underground and we see them sleeping in doorways, but we ignore them, and these proposals also ignore them.

The great inequalities and disparities that exist between communities that live side by side in the same region are becoming increasingly clear from fresh evidence. Numerous studies at local authority and ward level have pinpointed pockets of poor health that correspond to areas of social and material deprivation.

One advantage of the present National Health Service is that an overview of the health needs of the nation could be given consideration and that that could be reflected in long-term strategic planning. The nation's health would suffer if long-term planning were inhibited.

The Government and their advisers follow the outlook of Burke and Hare. The Government, the Tory think-tanks, the Adam Smith Institute and all the other scavengers and agents of scavengers have had their eyes on the Health Service for a long time. They measured it for a coffin years ago. One can only imagine how they must have salivated as they studied the books, how their palms must have begun to sweat as they read the accounts and the inventories, and how they must have sighed when they began to comprehend just how much of the people's money was wrapped up in the National Health Service, just waiting to be liberated into their clammy little hands.

However, there was an obstacle—the public would not wear it. Opinion poll after opinion poll told the Government of that, so it was necessary to plan a waiting game. The Health Service was kept short of funds and in due course it was forced to begin a sale of its assets. We know the formula. Bed closures plus rationalisation of service equals closures of hospitals plus disposal of sites. In Coventry, where my constituency lies, this has meant the closure of two hospitals and a number of smaller units in the 10 years of this Prime Minister's Government.

Nevertheless, it was still just a trickle. The problem confronting the Government was how to turn this trickle of equity leakage into a flood, on to which a fully privatised Health Service could be launched.

The White Paper is the solution to that dilemma. Having starved the National Health Service for 10 years of the revenue allocations with which to run its service and having starved it of the capital resources with which to develop its sites, the National Health Service has a good deal of excess capacity. In my constituency, for example, the Coventry Walsgrave hospital has the capacity to handle 8,000 more operations annually, yet patients suffer unnecessarily because the surgeons are prevented from carrying out as many operations as they would like despite the obvious demand. Although theatres are available to carry out the operations, they cannot be staffed because of lack of money.

Having dictated that health authorities must appoint new managers for each of their hospitals, having encouraged them to employ managers with experience in industry, the Government are now proposing to create hundreds of little businesses out of those hospitals— businesses which undertake work on behalf of the health authority but which can just as easily undertake work on behalf of the private sector. That is the crux of the matter.

The proposals are supposed to be based on the Government's belief that the market is a superior mechanism for the allocation of resources. I do not believe that, because there is not a shred of evidence to support it and although I might believe many things of this Government, I do not believe that they cannot read. They know that private health services throughout the world are a shambles and that they are inefficient and costly to run. We need only to look at the number of unnecessary operations carried out in the United States of America, the vastly greater administrative costs of private systems, the tangle of litigation with massive amounts of money diverted, not into better health care, but into solving the legal mess. Those systems fail to provide for the elderly, mentally ill, physically handicapped and so on.

The Government's White Paper will reduce the National Health Service to the same sort of shambles as a private health care system. It will sink a greater proportion of resources into the pit of that adminstration, reduce the responsiveness of the National Health Service to be able to identify the need, and divert the nation's resources to those who are already well served. The key to that is the privatisation of hospitals, to remove them from public control and put them in the hands of managers in ready-made or management-manufactured groups who are prepared to soil their hands.

Madam Deputy Speaker

Order. The hon. Gentleman has used his allocation of time.

7.51 pm
Mr. David Atkinson (Bournemouth, East)

The review of which the White Paper is the outcome was called for by my right hon. Friend the Prime Minister in reponse to widespread concerns about the performance of the National Health Service. My response to previous concerns over the years has been that the NHS, like the welfare state, was conceived during the last war and was based on the conditions that existed before it, and that half a century later, our health services should be encouraged to reflect the ambitions of today's families and their ability to afford to provide for their health needs privately.

For some time, 1 have supported the concept of a health tax, which would be separate from income tax, which would bring home the real cost of the NHS to taxpayers and which could be rebated for private cover. There was no other solution to remedy the unrelenting growth in the demand for resources, and the sheer cost to the Health Service of the growing number of elderly people and of advanced medical technology. The royal commission said as much in 1979.

There was no other way to avoid the series of crises that have scandalised the NHS over the years, or to end the more recent horror stories about health authorities running out of money, wards being closed and operations being postponed that prompted this review. In 1982, the think tank report to the Cabinet recommended precisely that: a shift from a tax-based Health Service to private insurance. As the House knows, the Prime Minister was totally opposed to this privatisation of the Health Service, and she abolished the think tank that proposed it.

Surely there can be no greater evidence than this, together with the massive increases in resources that the Government have provided, of their commitment to a state-run, National Health Service, paid for out of general taxation and free at the point of delivery. The White Paper confirms that commitment, and I congratulate my right hon. and learned Friend on its aims and the ingenuity of its proposals. I bitterly regret the reactions that we have received from the British Medical Association and from our constituents who have been inspired by some of its members.

I accept that some reactions that I have received from my doctors have been constructive and helpful. However, I utterly condemn the way that some doctors, although by no means all, have totally misled their patients into writing to us, without having any idea what the White Paper proposes. I have received far too many sad and distressing letters from patients such as diabetics, who rely on continuous medication and have been told that, in future, they could be denied treatment. I have received letters from patients who have been told that hospitals are to go private, doctors will be forced to take on more patients than they can handle and to limit the cost of medicines that they prescribe and that treatment will be related to income. None of those statements is true, and it is wholly irresponsible for doctors to scare patients, especially elderly ones, in this way. I believe that the BMA has lost much good will as a result of its campaign.

I turn to what is actually proposed in the White Paper. I welcome the downward delegation of responsibilities to local level, and the option for hospitals to become self governing within the NHS. That will result in the sort of better-organised, more personal hospital service of which local communities were once proud and which many of my constituents feel has been lost in recent years due to excessive bureaucracy and the disappearance of matrons and local hospital boards.

There is no reason why any hospital should not be free to offer its services to health authorities and practices outside its own area. Every hospital is different and develops its own expertise and specialities. My right hon. and learned Friend has emphasised that there is no question of hospitals ceasing to provide non-profitable services. The opportunities that will arise from the proposed new funding arrangements, with money following the patient and the ending of RAWP, the Resource Allocation Working Party—which has been so unfair to my own district health authority—will be better appreciated when they are better understood.

The availability of practice budgets is an imaginative idea which, I am sorry to say, appears to have been widely misunderstood by GPs, who have overlooked the fact that it is optional and entirely voluntary, and is available only to those larger practices already experienced in handling larger budgets. A budget-holding practice will have greater flexibility to use on behalf of its patients and wider opportunities to obtain quicker treatment from the most appropriate hospitals at a price that can be negotiated. That must be in everybody's interest and will bring down waiting times considerably.

It cannot be right to permit a system that tolerates waiting times of a year or more for treatment in one district, when the same operation can be obtained in a few weeks in another district. In my district, the current waiting time for dermatology is five months, for neurology nine months, and for ophthalmology six months. Those waiting times are totally unacceptable. The White Paper proposals will enable GPs to know where the quickest treatment can be obtained and make it available to their patients. My only concern is that there will be adequate transport arrangements for patients who seek treatment outside their own areas and adequate post-operative treatment when they return. I look forward to my hon. learned Friend assuring me on both those points in his wind-up speech.

The proposed encouragement of longer patients lists has also been misunderstood. No professionally responsible practice will give less time to patients because it has opted to accept those who have asked to be added to its lists. It is in demand because of its good reputation, which it has earned at the expense of other practices known to be less caring. Patients usually know who are the best doctors and who are the ones who are never there. Under the proposals, the hardest-working doctors will be properly rewarded, and that has to be right.

Similarly, no good doctor will prescribe inappropriate medication because of the introduction of indicative drug budgets. There was no evidence that this was the case following the introduction of the limited list, which was greeted with howls of protest five years ago and which has now enabled an extra £300 million to be spent elsewhere on improving health services. When it is realised that only 3.5 per cent. of all prescriptions are for patented products, it becomes self-evident that the remaining 96.5 per cent. of the drugs bill open to generic prescriptions represents an enormous potential for savings that has been estimated at an annual saving of £700 million.

It has been clear for some time that the Griffiths reforms for more efficient management of our health authorities have proved a disappointment. I fully accept the White Paper's proposals for streamlining their management. I should, however, record the opposition of my borough council to the proposed removal of councillors from the local authorities, although they will not be precluded from serving on local authorities if they have a management role to contribute.

I am glad that the White Paper does not seek to abolish the community health councils, one of which I served on myself. They can provide a much more effective channel for local views, including those of local authorities, on the quality of local services. It will be up to them to hold local health authorities, hospitals and practices accountable for their findings.

As my right hon. and learned Friend knows, I remain critical of him for not referring in the White Paper to the Griffiths report on community care, which is now more than a year old. I anticipate that he will put that right as soon as possible. Apart from that, I offer a warm welcome for his proposals. Given our record of more resources, doctors, nurses and treatment than ever before, they can only help to make a good National Health Service even better.

8.1 pm

Mr. Jim Cousins (Newcastle upon Tyne, Central)

As the Secretary of State said, the debate on these proposals is moving on. It is moving on from the ground of principle, which the Government have already decisively lost, to the ground of the implementation of this extraordinary contraption—the network of cash limits and contracts. On this new ground, the Government's prospects are, if anything, much worse than they were on the ground of principle.

Wriggle though the Government may, it is clear that the network of budgets is intended to constitute cash limits. Cash limits have already been extended for the first time to family practitioner services under the Health and Medicines Act 1988 which recently became law. GPs fully expect, and are entitled to expect—and the wording of the working papers gives them good grounds to expect—that these budgets will become cash limits.

We are also told in the working papers that the contracts which hospitals which opt out make for their patients are to be legally enforceable. We are told that it is to be hoped that that will not necessitate too much litigation, and that some arbitration mechanism may be introduced. I suppose that, if a person has a coronary bypass operation at an opted-out hospital, and it goes wrong, he will be uncertain whether to head for the High Court or the hospital.

These are real anxieties. The administrative machinery that these working papers are intended to promote gives grounds for considerable anxiety. On 22 March, a document was sent out from the NHS management executive to regional health authorities, and it has received all too little publicity. It set out what the regional health authorities must do by 5 May—a date that has already passed. Among the proposals in the document are not only suggestions for employing a great many extra staff administrative staff and for the creation of a great many administrative positions in all sorts of individually specified support services, but a hard-to-find proposal that regional health authorities should have expressed a view by 5 May on whether blood transfusion and ambulance services should be put out to contract. These are the forced administrative marches on which the Government are having to embark to get the proposals through.

The Secretary of State has repeatedly said that the doctors have started from a basis of outright rejection of the proposals, but some of the most telling criticisms of the proposals have come from doctors who support them. I instance, from my region, Mr. Brendan Devlin, who supports the White Paper's proposals and is a consultant at North Tees general hospital. He says that he is worried that the consultants' car park will be completely taken up by the Porsches of yuppie accountants. It is clear from that that many people who have a right to be wary of what the future holds, and who have already expressed themselves on political and administrative grounds supporters of the White Paper's proposals, are fearful about whether they can be implemented.

The Government will also change the mechanism by which cash allocations start to flow through the system. The principal element in these cash allocations is to be a bob-a-nob one-allocation per head of population. We are assured in the White Paper that that means that resources will automatically flow to areas of growing population, but it is not pointed out that they will also automatically flow away from areas in which the population is declining.

The system of allocations proposed for practice budgets, prescription budgets, and regional and district health authority budgets cannot be implemented merely on a per capita basis. The system will not bear the weight. The hon. Member for Bournemouth, East (Mr. Atkinson) has already celebrated the end of the RAWP mechanism, but he should be careful lest, as the Government's proposals go into operation, something far more horrendous than RAWP replaces it—a mini-RAWP for every NHS authority and hospital, and for every general practitioner in the country. The information that the Government have at their disposal cannot bear the weight of such a system, and they are foolish to try it.

Our information about prescription budgets leads to the amazing conclusion that the lowest spend per head is in Oxfordshire, and the highest spends are in Merseyside, the north-west and the north. There is nothing surprising about that; what is surprising is the belief, in the face of that information, that the Government can allocate these resources on a per capita basis and expect matters to continue just as they are now in the north-west, Merseyside and the north.

There are certainly grounds for grave concern. Abolition of RAWP and the introduction of per capita budgeting is disastrous news for areas which have depended upon RAWP and in which per capita spends are higher than the national average because of the make-up of the population. It may be of interest to note that this is not just a north versus south issue. Areas where prescription spending is very high in the south include Dorset, which includes Bournemouth, and the Isle of Wight, which includes Ryde, Shanklin and Ventnor—all areas in which inconvenient elderly people hang on and in which per capita spending will work against them.

These proposals are an administrative nightmare and an absurdity. The Government should be cautious about pressing forward too rapidly with this sort of proposal. We do not have the administrative machinery in place to support their implementation or to protect the Government from the inevitable disasters that will ensue.

For several years now, the Government have cash-limited hospital services; now they are starting to cash-limit general practitioner services. By means of the poll tax/community charge, they are cash-limiting local authorities' social services. How will the strain of caring for the growing numbers of elderly people on whom the bulk of health and social service money in spent be taken up? We cannot put a price tag on a stroke patient, a mentally handicapped patient or mentally ill person. The attempt to do so will be foolish and will produce widespread public unrest: it will not work. When I visited the largest voluntary aided hospital in central Brussels recently and saw over the door the sign, "We take American Express", I saw what the Government intend. The proposals are not working for patients; they are working for lawyers and accountants.

8.9 pm

Mr. Robert McCrindle (Brentwood and Ongar)

I support at least the broad thrust of what the Government are seeking to achieve in the proposals outlined in the White Paper. Unlike those who are wholly critical and negative in their submissions on the White Paper, I do not see the proposals as necessarily cast in stone. I hope during the next few minutes to express a few reservations, all within the general ambit of broad support for the Government's proposals.

I can never understand why those who oppose the Government's proposals for reform of the National Health Service seem to consider that, alone among our national institutions, after 40 years and with some obvious imperfections, the National Health Service should remain unchanged. There are many things that few of us wish to change, but there are areas that demand attention as the whole structure of the country changes during the 1980s and as we move towards the 1990s.

I am slightly concerned about the speed with which the Government seem to be aiming to introduce the changes. There has been a good deal of discussion in the debate about the hare and tortoise and so on. While I do not want pilot schemes, inevitably some self-governing hospitals will get into operation more quickly than others. We should watch carefully the progress of the early self-governing experiments. I should be happy if my hon. and learned Friend the Minister could assure me that that is the broad intention of the Government.

It is difficult to understand why critics of the proposals assume that we have either the proposals for change embodied in the White Paper or increased funding of the National Health Service. By no means are the two mutually exclusive. The reason why there is no reference in the White Paper to increased National Health Service funding is that is not a new policy. We have been increasing beyond the rate of inflation the amount spent on the National Health Service all through the decade during which we have been in office. I am irritated when some people, instead of submitting positive proposals, assume that we have the White Paper proposals or increased funding. My support for the proposals depends upon the assumption that we shall continue to improve funding of the National Health Service.

Although the Secretary of State has dealt with the matter already, I hope that the Minister will forgive me if I return to the point about the elderly people who have been frightened by the expressions of opinion of a number of people opposed to the proposals. They have said that, when the proposals are fully implemented, there will be real difficulties in taking care of the elderly patients on doctors' lists. As I understand it, the allocation which it is proposed to make to a general practitioner will take full account of the fact that there is an age relationship in the composition of the doctor's list. I note with approval that my hon. and learned Friend the Minister is indicating assent. He cannot repeat that assurance too often.

In a wholly irresponsible way those who have been criticising the proposals have been unnecessarily and cruelly frightening old people. Old people have come to me —I suspect that my hon. Friends have had the same experience—saying that they are fearful of the consequences of the proposals; they think that they will be excluded from their GP's list for no other reason that the fact that they are aged. It is high time we nailed that lie.

I approve of the concept of self-governing hospitals, although we should be careful not to pursue the idea at such a pace that we risk damaging a new tier of choice for medical care. We already have the private sector and the National Health Service. They will continue, but an additional tier of choice for medical care should be welcomed rather than criticised.

Critics have given the firm impression that self-governing hospitals will be outside the National Health Service. I hope that my hon. Friend the Minister will take the opportunity in reply to the debate to make it crystal clear to people outside the Chamber that self-governing the hospitals may be, but outside the Health Service they will not be. I cannot stress that sufficiently. Malign propaganda of the blackest sort has been put around by, I regret to say, some members of the British Medical Association who should be ashamed of having done so.

In self-governing hospitals we are talking about an experiment. Certainly they will be a new dimension in health care. If a hospital decides to go along the self-financing route and finds later, for one reason or another, that that is not successful or if it wants to reconsider its decision, what will happen? I am not clear about whether such a hospital could be readmitted to the National Health Service. I should be grateful if the Minister would turn his attention to that.

On the question of prescribing, I have no doubt that there is a vast amount of over-prescribing by some doctors. The implication that the Goverment, as the representative of the taxpayer, have no responsibility for taking account of wide disparities in prescribing is folly in the extreme. I support the discouragement of expensive over-provision of drugs by some GPs in comparison to others that we have all noticed.

About five years ago we were told that the introduction of the limited list would affect the clinical judgment of general practitioners and that all we were interested in was saving money. In one year of operation of the limited list, we have saved £75 million. I ask hon. Gentlemen on both sides of the Chamber how many complaints they get today from GPs or from patients that we are providing a less good service than we set out to do when the National Health Service was introduced.

I echo the sentiment of some of my hon. Friends that the White Paper proposals are one arm of an important reform. The other arm must inevitably be community care. We are having a slightly disjointed debate in that we cannot relate some of the attractive proposals to what we plan to do on community care. I hope that we shall get a response to the Griffiths report as soon as possible.

We are accused of privatisation of the Health Service. Do not hon. Gentlemen on the Opposition side—

Ms. Joan Walley (Stoke-on-Trent, North)

May I point out that there are also honourable women here?

Mr. McCrindle

I beg the hon. Lady's pardon.

Do not hon. Members recall that, when an investigation was mounted a year and a half ago, the whole idea was that it would lead to privatisation? Some hon. Members on the Government side, including myself, expressed great concern about that. It is the fact that privatisation is not being proposed that allows me to lend my warm support to the proposals in the White Paper.

8.19 pm
Mr. Terry Davis (Birmingham, Hodge Hill)

I am delighted to have an opportunity to congratulate my hon. Friend the Member for Vale of Glamorgan (Mr. Smith) on his election and his speech. It is always exciting to be elected to the House of Commons, but it is especially exciting to be elected in the circumstances that he was. As for his speech, he combined humour with sincerity and we all look forward to listening to him again.

I have several things in common with my hon. Friend. One is that we are both members of the MSF which has a large number of its members working in the NHS, and 1 am sponsored by my trade union. I am also vice-president of the Socialist Health Association, which for decades campaigned to establish a national health service. It was on the basis of its work that the NHS was eventually created in 1948.

I have never heard anyone in the Socialist Health Association or in the Labour party claim that the NHS is a perfect institution. Nye Bevan himself would never have made that claim. We all know that the NHS needs to be improved and extended. It needs to be improved in the whole range of services known as community care and it needs to be extended in the sense that the influence of the Department of Health should be extended, into other policy areas, because we shall never improve the health of the British people unless we tackle the problems of unemployment, poverty, inadequate and unsuitable housing and a whole range of other social evils.

We have never pretended that the NHS is perfect, but the White Paper has nothing to do with those issues. It is concerned with one thing and one thing only—the cost of the NHS. That is not surprising, because it owes its origins to the traditional Tory obsession with keeping public expenditure as low as possible in order to make the maximum amount of room for tax cuts. That is what the White Paper is all about.

We all know that during the period of the Conservative Government the Health Service has had more money. Its money has increased by, on average, 1.6 per cent. in real terms every year. But we also know that the Health Service needs an extra 2 per cent. in real terms every year to take account of changes in population, improvements in medical techniques and other factors. The truth is that under this Government there has been a real cut in the money available for the NHS.

The Government are not concerned with trying to reduce the cost of the NHS by removing the causes of ill-health; they are trying to do it by relying on the traditional Tory belief in competition. They are particularly concerned with reducing the cost of the hospital service and they want hospitals to compete for patients and to compete on price. The whole point of the White Paper is to bring the ethics of business and the economics and techniques of the retail trade into the NHS.

The Government want to convert hospitals into health supermarkets. Everything will depend on what can be done most profitably and on the relationship between what it costs to provide a particular treatment or perform a particular operation and what patients or their doctors are prepared or can afford to pay. That is what is at the heart of the White Paper.

People in hospitals will become used to phrases such as "what the market will bear". The criterion for deciding whether treatment or an operation can be provided will be the gross profit margin, not an assessment of need. The prime consideration will be the cost of treatment, not its effectiveness. Everything will be based on what is cheapest, not what is best, and particularly not what is best value for money.

It has been said that the White Paper is a charter for accountants. That may be true, but it does not stop there. It is not only accountancy that will be extended in the hospital service: a sales and marketing department will have to be introduced for the first time into local hospitals. What is the point of providing an operation at a lower price than any other hospital if that fact is not advertised? Hospitals, like supermarkets, will be driven to advertise their prices. Sales and promotion will become the order of the day. It is not just accountancy that will expand: there will be a new department to promote, advertise, peddle and push hospitals to doctors.

General practitioners will be on the receiving end not only of sales representatives of drug companies, as they are now, but of the same sales techniques and promotions from hospitals as well. General practitioners will become small traders with their practice budgets. It is bringing hospitals into a vast market place.

Forty years ago, the main achievement of a Labour Government was to take the health of the British people out of the market place. It must be the top priority of the next Labour Government to repeat that achievement.

8.25 pm
Mr. Alan Haselhurst (Saffron Walden)

I find it difficult to understand why the White Paper should be greeted with such an incredible fuss. I rather suspect that many people have not read it, and their reaction may be based on the BMA's reaction to it or on local comments put out by doctors and others, not least Labour politicians.

A number of factors have helped to make the reaction sharper than it deserves to have been. There has been some confusion over the general practitioner's contract. I hope that those issues have now been settled and that we can have a more rational debate about the White Paper. I made a summary of the points raised with me so far by local doctors and when the points relating to the contract were taken away there were many fewer controversial points left for discussion.

There is a fear of change. People are extremely cautious about changes in the NHS. There is an element of the hypochondriac in everyone, and people are prepared to imagine the worst circumstances and wonder how they will fare.

The Government may have underestimated the yawning gap that already seems to exist between their record on the NHS and people's perception of it. Conservative Members take it for granted that the amount of money spent by the Government has increased from £8 billion per annum to more than £26 billion per annum. A constituent wrote to me the other day and said that those figures were widely accepted as false. The fact that someone can say that of publicly audited figures shows how far we have to go in proving our bona fides in our proposals for the NHS.

The other difficulty has been that the reorganisation towards the centralisation of acute services on a district general hospital, a process which began long before the Government took office, has had the effect of taking acute services away from people, making people suspicious of any reorganisation in the NHS. They feel that specialist services have had to go further away from them and they see that as deprivation.

The situation is ripe for misunderstanding and for mischief makers such as the hon. Member for Livingston (Mr. Cook), who made a disgraceful speech this afternoon. The difficulties for the Government may be compounded because the White Paper is long on description but short on explanation in some key areas. Many patients have got it wrong, many doctors are confused and there is genuine doubt in some quarters about how some of the new ideas will work when implemented.

One of the problems that we have experienced in my part of Essex for some time is that money has not been moving with patients, and I welcome the fact that it will do so under the new system. I am grateful for the idea that there should be per capita funding. That will be helpful to my constituents. The population of Essex has grown as the population of London has fallen, yet the resources have not come with those people at the same rate. If practice budgets will be a further reinforcement of the new arrangements I am prepared to welcome those as well. It is amazing how various aspects of that reform are being misrepresented. It is being suggested that patients may be forced to have the cheapest forms of treatment, but the matter should be examined from the other point of view, when it will be appreciated that the proposal will give doctors greater clout to obtain the better treatment that they want for their patients.

It is unsatisfactory that people must wait 24 months for a cataract operation if they want to go to their most local hospital in my constituency. If they were prepared to travel not a great distance, they could have the operation within a month. Under the present system, that choice is not represented to patients as clearly as it should be. I hope that it will he in future.

Some GPs in my area worry about access to other hospitals, especially when they are in other district health authority areas and, in some cases, in other regional health authority areas. There is great concern, for instance, about continuing access to Addenbrookes for people in the Saffron Walden area. I believe that, under the practice budget, doctors will have greater clout in securing access to Addenbrookes. Under the existing system they have come under threat of losing the right to refer patients to that impressive hospital.

But there is need for clarity on how contracts will operate in practice. By definition, a contract requires agreement on both sides, so while it may be said that a group practice or district health authority may negotiate a contract with a hospital, that does not mean that it will get a contract with a hospital. What will happen if a hospital refuses to make a contract with a DHA or group practice? Will there be a narrowing of choice for non-budget holding practices, whether they choose not to be budget holders or are not big enough to he budget holders?

Where the district health authority must negotiate on behalf of the GPs in its area to get in its contract the services that it wants, will there be a genuine meeting of minds between GPs and the DHA? GPs are sometimes influenced by their desire to refer patients to a particular consultant as opposed to a particular hospital. Can contracts be made so that GPs may pick and choose between consultants and hospitals?

As some of my hon. Friends have pointed out, there is fear in the minds of some patients, in relation to indicative drug budgets, that doctors will put cost before effectiveness in prescribing. I do not believe that there is any foundation in that fear. Doctors will not overturn all their professional judgment in such a way. It is unfortunate, however, that some doctors have been prepared to play to that fear, so I understand why people have become worried.

The limited list experience shows that it is possible to achieve further savings. My father practised as a pharmacist for nearly 60 years. He regaled me with tales of the over-prescribing that could occur and the preference that some had for one drug over another when there was no generic difference between the two. There is scope for further improvement.

To say that there is scope for improvement is not to castigate all doctors as irresponsible. My local doctors, favoured for the most part with modern premises for their practices, are working well with the PACT—prescribing analyses and costs—system, and some believe that that is the core of the future approach. They wonder whether we need move so fast to indicative drug budgets. At least the principle exists. I see nothing wrong with the idea of medical audit, especially when that audit on GPs is undertaken by other GPs.

I hope that the Secretary of State will go to some trouble to persuade the more cautious GPs that there are new opportunities as a result of the Government's plans. The Government hope that the practice can be a place where more can be done at the expense of more being done of a minor nature in the hospitals, that in future GPs will be paid for their efforts in that respect, and that if GPs have a particular interest in pursuing a line of medicine, they will be rewarded for that in a way that they are not rewarded now. It must be made clearer that such opportunities exist and that general practice will become an enriching experience in the widest sense under these plans, rather than a narrower, restrictive experience.

The White Paper contains some interesting, radical and imaginative ideas which merit not hysterical rejection but careful study. The fact that the Government are prepared to face these issues should be warmly welcomed.

8.35 pm
Mr. John McFall (Dumbarton)

I begin by congratulating the Prime Minister on enabling me to hold a real old-style political meeting in my constituency. Such a meeting was called three weeks ago to discuss the National Health Service—it was convened by GPs in the area especially to discuss the White Paper proposals, and more than 350 people turned up.

They came from all social classes because of their concern about the effects of what the Government propose. At the conclusion of the meeting, a resolution was passed deploring the White Paper proposals, which I forwarded to the Minister. I shall therefore articulate the concerns of my constituents on some of the issues that concern them.

On Sunday I met an 82-year-old who has had his legs removed in recent months. He asked me to express his point of view to Parliament and to tell the Secretary of State that he wants to be looked after in the same way that my father was cared for after he had his legs off. For 10 years, my father was cared for by local district nurses. My constituent wants the same quality of care. I hope that the Secretary of State will take that and similar issues seriously and explain, when he replies to the debate, what proposals he has for people such as my constituent.

The Government have not been able to convince anyone of the wisdom of their proposals. Certainly they have not convinced the medical profession. They have not been able to convince the nation of the need for these changes because the blueprint for the White Paper plan was drawn up without reference to the users of the NHS. It was an exclusive group of people who drew it up. One had to be a Member of Parliament to be on the panel.

Indeed, one had to be not just any Member, but a Tory Member. Even that was not enough. One had to be a Cabinet Minister.

That exclusive and closed group of people decided what was best for the NHS and the 55 million people of Britain. The changes sprang from an ideological perspective. They were not based on any objective analysis of the current position of the NHS or of the needs of society. That comes as no surprise to us, because the Prime Minister is on record as saying that there is no society. It must be easy for the Government to determine policy in that manner, because they have only ideological tenets to go on; there is no pragmatism in their approach, and that means that inconvenient facts cannot get in the way of what they want to achieve.

I have had more than 200 responses from my constituents and over a score of GPs have put their views to me on this subject. It is only fair, therefore, that I should articulate to the House some of the points that they have made, and I trust that the Minister will give full answers to those points. For example, one GP wrote to me saying that he was already doing much of what was being proposed. He wrote: For the last 15 years as a practice we have performed paediatric developmental assessments on our pre-school population. More than 90 per cent. of children are given all their routine immunizations within the practice. My part-time female partner has organised within the practice a Well Woman Clinic for all our female patients aged between 25 and 60. We do all our own night visiting. Three years ago we produced a practice information leaflet for patients and last year the practice produced an annual report. We have just purchased a second computer. Finally, we are interested in health education, having been instrumental in setting up 'The Vale of Leven Health Promotion Project. That GP went on to write: I point these facts out simply to show that this letter does not come from someone opposed to change or who practises medicine simply with the aim of maximising income. I firmly believe that the White Paper proposals will undermine good general practice. Writing about capitations fees, he said that he failed to understand how his standard of medicine would be improved by increasing the emphasis on the capitation element of his remuneration. He wrote: If I set about chasing heads, since there are only 24 hours in the day, I will have less time to spend on each patient. Equating good medicine with high patient numbers is arrant nonsense. He wrote about the money-follows-patient argument: The White Paper says that 'the GP is the patient's key adviser'. This is true but I can foresee my being unable to refer my patient to the most appropriate consultant if that consultant works in a hospital outwith my Health Board area. My ability to refer such a patient will depend on my Health Board having made sufficient provision with the outside hospital. This obviously will not be a restriction in areas where patients can afford private medical care and thus medicine will become two-tier, with those who can afford it getting high quality care but those who depend on the NHS getting what their local Health Authority can afford. That is a perverse version of patient choice, particularly for the poor, who do not have the money to move from hospital to hospital. Even if the patient can rustle up the money, one can be sure that their relatives might not be able to afford it.

In their White Paper, the Government insist on 20 hours' consultation per week, when GPs must see their patients face to face in their surgeries. One general practitioner writes: At present, I do not do so but in an average week I do spend 45 hours in clinical medicine, 3 hours in practice administration and am on call for a further 25 hours (and being 'on call' usually entails going out in the evening to see patients and having disturbed sleep one night in four). What price the Government's rationale for 20 hours' consultation in the light of that?

As to increased choice, another GP writes: The principle that practice budgets will lead to increased choice for patients is fundamentally flawed. I have freedom of choice at present to refer my patients to any specialist that I like and the proposals in this White Paper can only restrict that. These proposals if implemented will also mean that some of my patients will have to travel longer distances for their care. Another general practitioner writes about the place of women doctors: As a woman doing part-time work in general practice, it appears that the present proposals may well prevent me continuing to practise medicine. In Scotland just the other day, the organisation Women Doctors for Choice was reported as commenting that the emphasis on capitation payments discourages doctors from taking on extra partners, as that would reduce their income. That provision will discriminate against women GPs, and when one remembers that females consult their doctors four times more frequently than males, that must mean less choice for female patients too. One doctor also comments: I note that the needs of the chronic ill, elderly, mentally ill and mentally handicapped appear not to warrant comment in the Paper. The White Paper puts a price on the patient's head. The Government say that it is their intention to help people, but they will do so only in part. They will not go the whole way. The White Paper proposes a system such as that of the United States, where 40 million people have no private health insurance whatsoever and in addition, 1 million people every year transfer to a different hospital purely on financial grounds. The White Paper will do nothing for the community. My constituents tell me so, and I hope that the Minister will listen and will at least give them an intellectual response to the points they make.

8.42 pm
Mr. Richard Alexander (Newark)

I join other right hon. and hon. Members in congratulating the hon. Member for the Vale of Glamorgan (Mr. Smith) on his excellent and enjoyable maiden speech. My right hon. and hon. Friends will clearly endeavour to win back that seat in the next general election, but meanwhile we wish the hon. Gentleman well, hope that he will enjoy his time in the House, and look forward to hearing him speak again.

To listen to some of the attacks made on the White Paper in the House this afternoon and outside it on other occasions, one would think that all was well with the Health Service and always had been. Basically all is well, but our critics ignore the fact that just over a year ago, people were marching in the streets and constituents were writing to us about the Government's intentions. Despite ever-increasing funding, the Health Service seemed to be failing to deliver in certain respects. The public were asking where the money was going and what was wrong.

As a consequence, the most fundamental review of the Health Service since it began 40 years ago was undertaken. Since the conclusions of that review and the publication of the White Paper, my right hon. and learned Friend the Secretary of State and virtually every Conservative Member has been subjected to one of the most abusive, damaging and misleading campaigns that I can remember since first entering the House. The Opposition's knee-jerk reaction was predictable. They shamelessly used the Health Service and the public's concern as a political weapon, and their allies in the British Medical Association conducted a campaign of misinformation that was at the very least unhelpful, and which in many cases unjustifiably played on the fears of the most vulnerable in our society —the old and the sick.

Some of that propaganda was contradictory. It was claimed both that the Government were forcing doctors to take on more patients than they could cope with, and that they were forcing doctors to turn away the old or chronically sick. The contradictory nature of those accusations seems to have gone unnoticed, for smear and innuendo are what matter. Some patients are told that doctors may be limited in the extent to which they can investigate unusual symptoms, while others are warned that restrictions will be placed on the amount of money that doctors can spend on drugs. Some critics send out letters with death's heads on them. One of my constituents wrote to the local newspaper saying that she was told that the number of doctors would be reduced as a consequence of the White Paper.

That is all very nasty stuff, and completely one-sided. The White Paper's critics never tell patients that some doctors have been over-prescribing for years and that the monitoring of drug budgets is meant not to cut necessary expenditure but to defeat unnecessary prescribing. Neither do the critics reveal that the cost of drugs is now more than the cost of the doctors prescribing them, that some doctors prescribe twice as much as others, and that the White Paper's objective is to root out bad practice and to encourage the best. The critics' motto is, carry on, doctor; throw more money at the problem and then ignore it.

That is not the way in which I want to see the Health Service progress. Instead, we must honour the principle that has held good for 40 years of a comprehensive Health Service available to all regardless of income, and financed mainly from taxation. Instead of guerrilla warfare, let us start again, by accepting my right hon. and learned Friend's total commitment to the NHS. Let us recognise that funding has increased by 40 per cent. even after inflation, from £8,000 million in 1979 to £26,000 million this year. Let us accept that there are now 7,000 more nursing and midwifery staff and 14,000 more doctors, enabling many more people to be treated.

We must recognise also that wide variations in the provision of health care still occur throughout the country; that people wait much longer for operations in some areas than others; that the cost of treatment differs by as much as 50 per cent. between hospitals; and that there are enormous variations in drugs bills as between one GP and another. We should start by accepting those indisputable facts, and conclude that improvements can be made to the overall operation of the Health Service that have very little to do with the amount of money that is spent.

My right hon. and learned Friend the Secretary of State should acknowledge in turn the genuine concern felt by Health Service professionals that certain significant details have yet to be spelt out. Most right hon. and hon. Members have received a helpful briefing from the Royal College of Nursing and from the Association of Community Health Councils that are couched in much less strident language than that used by the BMA. Their concerns should be examined and my right hon. and learned Friend should respond to them directly. So much opportunity for excellence is provided by the White Paper that one can only be saddened by the hostility with which it has been met by some Health Service professionals.

A shining exception to some of the attitudes of the Health Service to the White Paper concerns the proposal to allow health authorities and hospitals to become self-governing trusts. The Opposition's reaction to this locally and nationally—the hon. Member for Bassetlaw (Mr. Ashton), who is in his place, referred to it this afternoon—was predictable. They called it back-door nationalisation and said that real patients would not be treated, that it was just taking the Health Service into a privatised area. Such fears are nonsense, but the fact that nowhere in the White Paper are these things ever suggested does not deter the Opposition at all.

The Bassetlaw health authority, which partly covers my constituency, has expressed an interest in becoming a National Health Service trust. It is not proposing to opt out. It has not even decided to become a trust. It has simply expressed an interest. It has consulted widely, with consultants, with the staff and with the Manchester health authority. The opposition has been totally political and I condemn the blanket refusal even to consider looking at the proposal. It gives an opportunity and a possibility for our health authority to come out of the clutches of the region and be able to run its affairs as it knows best. It will, I believe, be the patients who gain, and the losers will be the party politicians and those of the Left who try to deprive the patients of its benefits.

8.51 pm
Mr. Ieuan Wyn Jones (Ynys Môn)

I have listened with great care to Conservative Members trying to defend the NHS proposals. There has been great paranoia on that side as they have constantly tried to defend proposals which are clearly indefensible.

I listened with great care to the hon. Member for Brentwood and Ongar (Mr. McCrindle). He came to the House tonight, apparently, to nail a few lies, as he put it. He came to the House to tell us that self-governing hospitals will not be outside the NHS. I have read the White Paper and I agree with him that that is what is proposed in it. But what we, our constituents and doctors worry about is what it will lead to eventually. It is the first step towards privatisation and that is what Conservative Members have failed to tell us tonight. They hide behind the words in the White Paper, knowing perfectly well that the Government really want to privatise the NHS.

The Prime Minister herself prefaced the White Paper by saying that the needs of the patient would be paramount. That word is used in the Children Bill as those of us who have been on the Committee on that Bill know. The Minister of State knows exactly what I am talking about because he, too, is on that Committee. We have looked in the dictionary and we find that "paramount" means of the greatest importance, or pre-eminent. But we do not get the impression that the paramountcy of the patient's needs is the thread that runs through the White Paper.

The Prime Minister uses another phrase: to secure the best value for money. That, in my view, more accurately describes the way the Government look at the changes in the NHS. To be charitable, on the one hand it means keeping a tight budget, but on the other it means making do with fewer resources by imposing budgetary controls on doctors' practices and self-governing hospitals.

The Government claim that the overwhelming hostility to their proposals stems from wicked doctors spreading fishermen's tales. They also hide under the cloak of that now well-worn phrase "We cannot get our message across." We have heard it all again tonight—a combination of doctors, an antagonistic press and a hostile Opposition making matters worse for the Government in trying to get their message across.

My belief, shared by my constituents, is that these proposals are inherently wrong and that the public have been right. Time after time in the last few weeks we have heard the public speak with a united voice. That is why the hon. Member for the Vale of Glamorgan (Mr. Smith) is in his seat; the public of Wales spoke on the Government's proposals for the NHS. I congratulate him on his victory and it would be churlish for any hon. Member to deny that it was due to the fact that the Government have failed miserably to tell us what they really mean by the NHS proposals.

What is also significant, and the Government must take this on board, is that in that same election a GP stood on an anti-NHS-proposals platform and he did not gather the small number of votes a normal fringe candidate gets; he polled almost 1,000 votes. The Government must surely remember that lesson.

Why are people unhappy with these plans? It may be unpalatable for those on the Government Benches, but it is true to say that we in Wales have an emotional attachment to the National Health Service because we know that the architect of that Service came from Wales. But even judged against hard facts, this review will spell disaster for the patients and hospital services in Wales. In Gwynedd, for example, we have seen this year proposals to close small village or community hospitals because the area health authority has, it says, been starved of cash. I am pleased to see the Minister who has responsibility for health at the Welsh Office in his place. He and I have debated these issues about hospitals in Gwynedd.

We have heard even from Conservative Members tonight the view that the community care provisions of the Griffiths report have not been debated. There is not a single community hospital in my constituency that meets the criteria set out by the Department of Health and there is no plan to build one in the immediate future. In addition, very much as the right hon. Member for Stoke-on-Trent, South (Mr. Ashley) said about disability, there are no discernible plans to develop services for the elderly. We all know of terrible situations in which constituents ring hon. Members late at night distressed because hospitals have told them that their elderly relatives have to leave and find a home elsewhere. This lack of co-ordination between the Health Service and social services departments of local authorities is something we must discuss. That is why it is vital that we discuss the Griffiths report quickly.

In terms of the rural scene in Wales, the element of choice is meaningless. How can a doctor in Holyhead make a choice about which hospital is most suitable for his patient? The nearest acute hospital is 20 miles away and he has to make arrangements to travel there. Where does he go if Bangor cannot take the patient or the waiting list is too long? He goes to Bodelwyddan, which is 70 miles away. The choice is meaningless in rural Wales.

I believe that these plans are doomed to failure. All the brave words of the Secretary of State, and, I expect, of the Minister in responding, will not convince people that the reforms are necessary and in the best interests of our people. It would be far better for the Government to save face tonight and withdraw these plans than to destroy the Health Service and be destroyed at the next election.

8.59 pm
Dr. Michael Clark (Rochford)

There is little doubt that the National Health Service is a respected British institution, and those who have used it seldom criticise it. Until recently, however, most of us received complaints in our postbag from people who had not used it, and who wanted a better service. Those complaints came because expectation was greater than provision.

Now we find that there is nothing wrong with the Health Service at all. Constituents are writing to us, "Please do not change the Health Service: leave it as it is." Doctors, too, are writing to say, "Do not change anything. We have the finest health service in the world." Even doctors who have, in the past, written to complain are telling us to leave the service as it is. They are saying that for the time being, that is: I suspect that if we leave the service as it is it will not be long before they write again to complain that they want a review of the Health Service because they think that it should be improved.

Those who say that we should leave the service as it is add a proviso. They say, "Leave it as it is, but give us more money." They do not acknowledge that, over the past 10 years, real-terms funding has increased by 40 per cent.

Following the introduction of the White Paper, I met doctors in my constituency in small groups of four or five. I managed to see between 25 and 30. I did a deal with them: I said that I would see them whenever they wanted, wherever they wanted and, within reason, for as long as they wanted. I would listen to and respect their views, and would put them to the Minister even if I did not entirely agree with them. [Interruption.] Are not hon. Members in the House to represent the views of their constituents? Do we represent only the views with which we agree? I think that most hon. Members on both sides of the House would agree that they represent their constituents' views.

The doctors' side of the bargain was that their views would be put to me first hand, not second hand through the agitation of the old, the sick and others in need of health care. The doctors respected the deal, with the exception of one practice. I have listened to their views: I have read the report of the general medical services committee: I have made written and oral representations to my right hon. and hon. Friends. I have honoured my side of the bargain with doctors in Rochford, Rayleigh, Runwell and South Woodham Ferrers. Unfortunately, as I have said, one practice did not honour its side.

My speech has two aims. The first is to represent again the doctors with whom I struck a bargain; the second is to refute the misleading information put out by the practice to which I have referred. Let me begin by saying that it is a shame that the White Paper and the GPs' contract were allowed to be on the agenda on the same time. I agree entirely with my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe) that the contract should have been dealt with eeparately, and should have been out of the way before the White Paper came into the arena.

What did the doctors whom I saw wish me to communicate to the Health Ministers? First, on the contract side, they were worried about the targets for immunisation and cervical smears. I am delighted that there has been agreement on two levels of target, a higher payment at high percentage levels and a lower payment at lower percentage levels.

The doctors were also worried about the "face-to-face" rules, which they feared would be too bureaucratic, and about the fact that the target of 20 hours excluded home visits, which they considered unfair. I tended to agree with them about that, and I am delighted that my right hon. and learned Friend has amended that proposal as well.

Some senior doctors were naturally concerned that their pensions would be affected by withdrawal of seniority payments. They also made the fair point that someone who has been a GP for a long time is worth more than someone straight out of university who still has considerable experience to gather. I am pleased that, in consultations with the GPs' negotiating committee, my right hon. and learned Friend has amended that as well.

The doctors were also apprehensive about practice budgeting, which they thought might be time-consuming and complicated. They feared that it would be difficult to budget for outside patient services. I did not necessarily agree with what they said, but I promised to make their views known. They were also anxious that commercial decisions should not override medical ones—and rightly too—but they had no objection to any pay review looking at their expenditure, whether budgetary or otherwise.

Doctors and, indeed, some of my constituents are concerned about the make-up of the family practitioners committee. The doctors point out that it is proposed to include only one medical man among the 11 members. My constituents say that there will not be enough lay people on the committee: there will be far too many administrators, and it should be more evenly balanced.

Of course, some doctors were sceptical about self-budgeting hospitals. The Southend and Rochford hospitals, however, have seized the opportunity to volunteer to become self-budgeting, and are looking forward to better funding as a result.

The practice that put out false propaganda made none of its views known to me at first hand: they all came through sick and elderly people who were anxious about that false propaganda. Let me give some examples. It was claimed that GP services would be cash-limited, leading to a rationing of care. The truth is that any savings from efficiency will lead to extended care. The practice said that hospitals would be encouraged to become budget holders, whereas in fact they are to volunteer. It also said that the sum of money per patient was equivalent to an X-ray or a short course of drugs, and that if a patient needed a hysterectomy she would use up the share of the whole street in which she lived. The truth is that there will he no cut-off of funds, as was pointed out by my hon. Friend the Member for Brentwood and Ongar (Mr. McCrindle).

The practice said that doctors would receive financial incentives to ask patients to go private, and that if they did not go private, doctors would have to put them in the cheapest possible hospital. The truth is that there are very few incentives—the only incentive to go private is the tax relief for old-age pensioners—and doctors will be encouraged to send patients to the most convenient hospital with the shortest waiting list.

The doctors say that they will be offered rewards for not treating patients, or for delaying their care. That is a gross travesty: I cannot even find the proposal in the White Paper that they have twisted. It is complete invention. They also say that the Government want GPs to become "rationers" of health care, and thus take the blame for the underfunding of the NHS, which the Government will then use as an excuse to end the Health Service as we know it. The truth is that the Government want more partnership in the NHS, and want to carry GPs with them.

I hope that my right hon. and learned Friend will take note of the points that have been properly and courteously made by the majority of doctors in my constituency, both those that I have quoted in my speech and those included in my written representations. I also hope that he will refute the scurrilous, irresponsible and unprofessional propaganda from that other practice.

9.7 pm

Ms. Joan Walley (Stoke-on-Trent, North)

I, too, am here to represent my constituents, particularly the many women among them. I am extremely pleased to have an opportunity to speak. It should be pointed out that so far no woman Member has spoken, and the concerns of women—especially the many women carers about whom we heard earlier, and who are given no information in the White Paper about the future of community care—should be put on record.

We are talking about a paving Bill. There has already been a paving Bill for the privatisation of water; now we have one to bring about—presumably following the next general election, which the Conservative party mistakenly thinks that it will win—the wholesale demolition of the National Health Service, privatisation and complete dependence on market forces.

We thought that the White Paper would deal with the crisis in the NHS. That crisis in north Staffordshire means that some of my constituents will have to wait until December 1990 for an orthopaedic out-patients appointment and there is a 30-week wait for ear, nose and throat appointments. There have been hospital closures, the Health Service uses rundown buildings and the ambulance service cannot operate within its guidelines. The area suffers from demographic changes and there is great concern about the future of community care.

It is disappointing that the White Paper addresses none of those issues. My constituents know that. Certainly the electorate in the Vale of Glamorgan know that, and I take great pleasure in welcoming my hon. Friend the Member for Vale of Glamorgan (Mr. Smith) to the House. The GPs also know that. The GPs in north Staffordshire with whom I have spoken, including those at the Tunstall practice who called me to an urgent meeting to brief me about the debate, said that they felt disquiet about the future of the Health Service.

It is clear that in future health authorities will be brokers, handing out money for low-cost services. A letter from the north Staffordshire district sub-committee of the Staffordshire local medical committee expressed great concern about people who depend on prescriptions. The Secretary of State did not give us a categorical assurance that there will be sufficient money to cater for those people who, quite justifiably, depend on prescriptions, such as chronic asthmatics, those who suffer from cystic fibrosis, those who have severe angina and those who require dialysis. I feel strongly that, if the proposals are carried out, people who need eight or nine drugs will be paying a tax on illness, because they will have to pay more for those drugs. I noticed that the Secretary of State made no response to the intervention by my right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley).

As for the size of GPs' lists, the GPs in Tunstall told me that they will each have an extra 500 people to treat. It is quite clear that the more people there are on a GP's list, the less time there will be for minor surgery, immunisation, counselling following still births and all the essential aspects of preventive medicine. GPs who treat terminally ill patients, who require a considerable amount of time, will be penalised.

I am sponsored by COHSE, the Health Service union which has submitted detailed and responsible forecasts of how the Health Service could look in future, taking into account the need to use the present management structure to evaluate the information systems, which, together with new investment, could produce the Health Service we all require.

I know that many hon. Members wish to take part in the debate, so I conclude by quoting a letter from a constituent who, along with many other people, feels very strongly about the proposals. She wrote: I hope public apathy does not allow these proposals to be passed as I am sure that the dark days of pre National Health Service days should not be allowed to return. I do not always support all Labour party issues but I think Mrs. Thatcher is a woman completely devoid of any compassion towards those less well off members of society and the sooner she is defeated the better for the country as a whole. The Opposition consider that there is nothing more important than the health of the people and that that should be the highest law. For that reason alone, I hope that the Government will take note of the many important points that have been raised in the debate.

9.13 pm
Mr. James Couchman (Gillingham)

I recognise that I have only two minutes and I shall make only one brief point. The first paragraph of the final chapter of the White Paper reads: The proposals in the White Paper put the interests and wishes of the patient first. They offer a new, exciting and potentially rewarding challenge for all who work in the NHS. They add up to the most significant review of the NHS in its 40-year history. And they amount to a formidable programme of reform which will require energy and commitment to carry it through. The last sentence of that paragraph strikes a particular chord, because without energy and commitment on the part of all staff, from consultant to cleaner, the patient will certainly be denied his or her best interests.

The proposals are not revolutionary, but they are certainly not a gentle touch on the tiller. They will represent a substantial change in the relationship between the patient and the GP and between the GP and the hospital service. I welcome most, if not all, of the proposed changes. As a former health authority chairman, I am all too well aware of the inertial bureaucracy of the Service over the past 15 years.

I should like to ask my right hon. and learned Friend one question. Why did he not make the White Paper a Green Paper, or at least a White Paper with very green edges? If Health Service staff and consumers had felt that my right hon. and learned Friend was entering into genuine consultation on those far-reaching proposals, the hostility which has built up over the past three months and which has been echoed by the Opposition, would have been avoided. People who have had an input into change are much more committed by their contribution to that change, even if it is not precisely the change that they would have designed.

Even at this late stage, I urge my right hon. and learned Friend to dissipate the angst that has been created by greening up the edges of the White Paper and conceding that pilot studies in, say, two regions for a short time would strengthen the case for change and should be conceded.

My right hon. and learned Friend showed a commendable and statesmanlike willingness to compromise on the GPs' contract and achieved a result satisfactory to all of us. A demonstration of such flexibility would give credence to my hon. and learned Friend the Minister of State's statement to the Institute of Health Service Management that the plans contained in "Working for Patients" were not tablets of stone and that as a sensible person he was keeping his ears flapping. I trust that my right hon. and hon. Friends will keep their ears flapping.

9.15 pm
Ms. Harriet Harman (Peckham)

Conservative Members have scorned our assertions that the White Paper is about privatisation. The Secretary of State said that talk of privatisation is simply scaremongering. But it is evident that the White Paper is dripping with commitments to privatisation. GPs will be expected to use their budgets to buy private health care for their patients. District health authorities will be expected to use their budgets to buy health care in private hospitals. Opted-out hospitals will be expected to sell National Health Service treatment to private patients. Capital charges are being introduced to make NHS services more expensive compared with private health care, to drive more GPs and more district health authorities into the arms of private hospitals.

The Finance Bill contains a direct cash subsidy for private medicine, and, as my hon. friend the Member for Newcastle upon Tyne, Central (Mr. Cousins) pointed out, even blood and ambulance services are to be sized up for privatisation. Even if the Secretary of State believes his own denials that the White Paper is about privatisation, we set no store by that. The White Paper says that it is about privatisation and the Prime Minister means it to be about privatisation. She made that perfectly clear when she said in the House on 31 January: those who can afford to pay for themselves should not take beds from others."—[Official Report, 31 January 1989; Vol. 146, c. 164.] Even if the Secretary of State has not got the Prime Minister's message, doctors, nurses and the public have.

The White Paper aims to create a two-tier Health Service. The spirit in which the Prime Minister has produced the White Paper is truly authoritarian. The Government were to propose profound changes in one of our most important institutions, but there was to be no consultation—doctors, nurses and patients were not to be consulted. Consultation was rejected because the Government believed that it would only slow things up. As the Secretary of State and his Ministers found, it was much quicker to insult people who dared to disagree.

From the outset, it was made clear that the only views to be sought were from those who could make suggestions about how the hare-brained schemes could be made to work. Counter-proposals were never allowed on the agenda and there was no Green Paper, as the hon. Member for Gillingham (Mr. Couchman) has pointed out. There are to be no pilot projects, and we have been told that those, too, would just waste time. This untried experiment is being unleashed on us with a haste that has astonished even those who credit themselves with thinking up the ideas in the first place.

The proposals are already being implemented even as we discuss the plans and long before Parliament has had time to approve them. Regions are already nominating hospitals for opting out. The London hospital has already advertised for a finance director to run it after the Secretary of State, in due course, makes his decision that it should opt out. The South East Thames regional health authority's general manager has given up his job to take up the post of running Guy's hospital, supposedly after the Secretary of State has decided to opt it out, and his salary is to be paid by a carpet millionaire, Sir Philip Harris.

Family practitioner committees are already identifying what the Government hope will be the first wave of GP budget holders. I suggest that all hon. Members obtain from their own family practitioner committees the papers drawn up to show how the proposals about GPs will work in the local area. I looked at the plans of my own family practitioner committee. They are interesting because they talk firmly about over-spending practices. The practices described as over-spending practices will be cash-limited. How are we supposed to believe that GP services will not be cash-limited if they are described by family practitioner committees as over-spending practices and when it is also mentioned that the sanction against over-spending practices will be the withholding of remuneration? If that is not a cash limit, I do not know what is. All that I have described is already happening, yet it is not until today that the Government have brought the proposals to this House for discussion.

The White Paper lays down that those who work in hospitals, still less the community that depends on those services, will have no say in opting out. The decision is to lie simply with the Secretary of State. All the talk we have heard from Conservative Members about their hospitals deciding that they will opt out is nonsense. For a start, who in the hospital has made the decision? Who has been consulted? The White Paper makes it clear anyway that the decision is to lie with the Secretary of State and with him alone.

This week, the doctors at Guy's hospital have demanded a veto over the plans for Guy's to opt out. They want to have a say in the matter before Guy's is opted out of the National Health Service. Perhaps the Minister of State will tell us later whether he will respect the demands of those doctors to have a veto, or whether he will simply ride roughshod over their views.

Mr. John Redwood (Wokingham)

In November 1987, the hon. Lady said in the House that there was nothing wrong with the NHS that a couple of hundred million pounds extra would not put right. As the Government have put in 40 times that much in the past two years, does the hon. Lady agree that the funding problem she identified is now resolved?

Ms. Harman

No, I certainly do not agree that the funding problem we have talked about over and over again has been resolved. How can the hon. Gentleman say that the funding problem has been resolved when—[Horn. MEMBERS: "You said it was."] No, we have complained constantly about the underfunding, which still causes long waiting lists. [Interruption.] I hope that hon. Members will listen. Forty-one per cent. of children have to wait more than six months for paediatric surgery. That is a problem of underfunding as beds are closed.

Local representation is to be struck off by local representatives being taken away from district health authorities and replaced by centrally appointed managers. The White Paper is the result of a review by closed minds behind closed doors.

In his speech today, the Secretary of State made great play of the agreement that he says exists around the stated objectives of the White Paper. It is true that his extraordinary political acumen has enabled him to recognise that every one wants better health care, but that is as far as the agreement goes. Everyone else believes that the objectives that he embraces will not be achieved by the plans in the White Paper and everyone else believes that the White Paper will frustrate attempts to improve the quality of care. The Secretary of State claims that one of his objectives is to improve the quality of care, but one of the strongest threads of criticism against the White Paper is the concern that it will undermine 'the quality of care.

Health authority managers, who have no medical training and never see a patient, will negotiate where to place the contract for operations, and they will place the contract where it is cheapest. They know how to count costs—that is what they have been trained to do and the reason why the Government have recruited them—but neither they nor anyone else knows accurately how to measure quality and outcome.

The internal market of competition—which, extraordinarily enough, the Secretary of State failed to mention today, although it is the core of the White Paper—for contracts between opted-out hospitals and private hospitals would put at the very heart of the system a pressure to cut costs with no countervailing safeguard to protect standards. My hon. Friend the Member for Birmingham, Hodge Hill (Mr. Davis) rightly pointed out that, put simply, patients will be sent where treatment is cheapest, rather than where treatment is best. To compete, hospitals will have to cut costs and to cut costs, they will cut corners. When they cut corners it will cost lives.

The Government state that competition in health care will improve quality, but the opposite is the case. The more intense the competition, the worse the patient fares.

Mr. Phillip Oppenheim (Amber Valley)


Ms. Hannan

The hon. Gentleman may say it is rubbish, but he should listen to some of the evidence. A study in The New England Journal of Medicine, the most authoritative medical journal, found: There are significant associations between higher mortality rates …and the intensity of competition in the market place. Professor Alan Maynard, who is the director of the Centre for Health Economics at York, which is a designated research establishment for the Department of Health, followed up that point by saying: The risk with competition …is that inferior patient outcomes may result.

Mr. Hayes

The hon. Lady said that she wanted some evidence. I am sorry to keep harping on about it, but the South Glamorgan health authority has contracted out all its—

Ms. Harman


Mr. Hayes

The hon. Lady gave way. Perhaps she will be courteous enough to allow me to finish the point. I am not aware of any rules of procedure that allow anyone but you,. Mr. Deputy Speaker, to stop me. With the greatest respect, I shall finish my point. South Glamorgan health authority has contracted out all its open heart surgery to a private hospital in Southampton, which means that patients are moved to hospitals where their open heart surgery is dealt with quickly. It does not cost them a penny and the South Glamorgan health authority—

Hon. Members

Is this a speech?

Mr. Deputy Speaker (Mr. Harold Walker)

Order. Interventions must be brief.

Mr. Hayes

I was trying to make a brief intervention but the hon. Member for Peckham (Ms. Harman) would not—

Mr. Deputy Speaker

Order. Ms. Harman.

Ms. Harman

That intervention was a total waste of time. I obviously have a particular affect on the hon. Member for Harlow (Mr. Hayes), as he made exactly the same intervention in my last speech. I hope that in my next speech he will restrain himself.

The point is that the Government will not listen to any evidence about the destructive effects of competition because it does not fit in with their dogmatic allegiance to the free market. We should be encouraging co-operation between hospitals, not competition.

Dame Elaine Kellett-Bowman

On a point of order, Mr. Deputy Speaker. Is it in order for the hon. Lady to mislead the House by saying that the Secretary of State—

Mr. Deputy Speaker

Order. I hope that the hon. Lady is not alleging that the hon. Member for Peckham (Ms. Harman) is deliberately misleading the House. If she is, she must withdraw.

Dame Elaine Kellett-Bowman

I am suggesting that the hon. Lady did not listen and therefore did not hear the Secretary of State refer to the internal market.

Mr. Deputy Speaker

In that case, it is not a point of order.

Ms. Harman

Thank you, Mr. Deputy Speaker. I did not think that is was a point of order; I could not tell what it was.

On the point about quality, perhaps we need look no further than private nursing homes. We shall then see how the quality of care suffers when there is an attempt to keep profits up. The Government have already privatised nursing homes—[HON. MEMBERS: "What about Southwark?"] I shall tell hon. Members about Southwark. The point about Nye Bevan lodge and Southwark invites a comparison between the council's response in that case and the Government's response to the numerous scandals of abuse, ill-treatment and neglect in private nursing homes. Southwark council learned hard lessons and was very concerned; it acted with the Department of Health to try to ensure that it never happened again. The Government, on the other hand, have evidence before them but take no account of it.

Let me remind the Government of some of that evidence. They have privatised nursing care without the consent of the House by shutting geriatric wards and cottage hospitals and providing a bottomless pit of social security subsidies to the private nursing sector. The Government are totally unconcerned about cruelty and neglect in those nursing homes because they are businesses, and the Government look only at the health of the bank balance, never at the health of the patient.

Take, for example, the private Old Rectory nursing home in Northampton. Patients there were assaulted, intimidated, taunted, tied into beds and chairs and left unsupervised. Staff levels were inadequate and prescriptions were altered.

Take the private Old Dairy nursing home in Enfield, where eight heavily dependent patients were routinely left completely on their own with no staff to look after them. And take the private nursing home near Colchester, where a 14-year-old girl doing a holiday job had to insert catheters in elderly women.

These cases are not isolated examples; they are the tip of the iceberg. Yet the Government have done nothing about it. They have not acted on the recommendations of the registered homes tribunals. They do not give district health authorities enough resources to police the private nursing homes.

Mr. Kenneth Clarke

It was this Government who introduced legislation giving the health authorities the power to supervise the private homes sector and, if necessary, to refuse licences. We were concerned about allegations of low standards and gave local authorities, in the case of residential homes, and health authorities, in the case of nursing homes, legal powers that they have never had before so that they could license homes or decide not to license them. The complaint to which the hon. Lady referred should now be taken up with the authorities to which we have given these important powers.

Ms. Harman

The Government set up the registered homes tribunals but they file their decisions in the basement of the Department of Health. They never look at the recommendations made by the tribunals, which say that things are going badly wrong in the private nursing home sector. The right hon. and learned Gentleman cannot just shake his head, because even the private Registered Nursing Home Association has said that it is concerned about what it describes as "the cowboy element" in the industry.

The White Paper is a charter for that cowboy element to move into our hospital services. The Secretary of State has claimed that one of his objectives is to increase choice in health care. Under this White Paper, patients' choice will be restricted rather than widened.

I challenge the Minister to respond to my next point; he has not done so in the past. Where is the choice for the patient who is told that he can no longer go to his local hospital because the Secretary of State has opted it out and it has dropped the services that he needs? As my right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley) said, where is the choice for the chronically ill patient who cannot get the GP of his choice because the GP thinks that he cannot afford it under the practice budget cash limits? Where is the choice for the patient who wants to get a second opinion but whose GP is reluctant to authorise it because he is getting to the end of the financial year? Where is the choice for the patient who is told that he must go to the hospital picked by the DHA manager? Where is the choice for the patient who must go to the hospital where the GP placed the contract at the beginning of the year?

Certainly there are choices in the White Paper, but they are not choices for patients or doctors. The choices in the White Paper are for managers and accountants. The choices that they will make are cheap, cheaper and cheaper still.

Inequalities will occur in the Health Service at primary care level also as patients rally round GPs who have had their budgets cash-limited and make voluntary contributions into their health centres and local GP practices. As a result, inequalities in health care will increase. The Secretary of State has engaged in the bogus argument that everyone who objects to the White Paper is in favour of the status quo. That is absolute nonsense. The Health Service is buzzing with ideas for improving care and finding new ways of delivering services. There is no shortage of ideas in the Health Service, but there is a shortage of cash. There is also a shortage of preparedness on the part of the Government to listen to the ideas that are coming out of the Health Service. The Government are frightened of those ideas because they are frightened that they might have to invest in them.

It is nonsense to say that Labour has no alternative proposal. Unlike the Government, Opposition Members have consulted patients, doctors and nurses. Unlike the Government, we have emphasised the basic necessity of increasing resources. Unlike the Government, we have a programme for making a reality of community care. We want to see a localisation of services to make access easier. We want to see the integration of acute and community services so that services fit the patient, rather than the other way round. [Interruption.] It is Conservative Members' fault if the Secretary of State is complaining about the time. He cannot go forward with his proposals because the public are blocking his way, and he cannot go backward with them because the Prime Minister is blocking his way. I predict that he will need to seek treatment in the John Moore memorial hospital.

The Prime Minister predicted that she would achieve victory in the Vale of Glamorgan. I am happy to welcome my new hon. Friend the Member for the Vale of Glamorgan (Mr. Smith), and I congratulate him on his excellent maiden speech.

The Prime Minister has done a remarkable thing with the White Paper. She has forced the nation to re-examine its values. That re-examination has reinforced those values, and this White Paper affronts them. The Prime Minister has finally gone too far. Whatever will happen in the vote tonight, the Government have lost. People realise that the real change that the Health Service needs is a change of Government.

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

I add to the welter of tributes that have been paid to the maiden speech by the hon. Member for the Vale of Glamorgan (Mr. Smith). It was a most graceful speech that was exceptionally well received by hon. Members. From that performance, the hon. Gentleman has won himself many friends in the House, and I wish him well in his career in the House.

Exactly a week ago, my right hon. and learned Friend was able to reach an agreement with the representatives of the General Medical Services Committee about the GPs' contract. That agreement reflected a willingness on the part of the negotiators to accept a performance-related contract that will make it much easier for the National Health Service—the primary care system that we depend on so much—to become much more comprehensive and to add several important stimuli to good performance, not least the move to a 60 per cent. capitation level.

It also reflects a willingness on the part of the Government to make some changes to the contract that was originally proposed. I shall not list those changes, but they pertain to important matters, such as the retention of seniority payments and a reduction in some of the target levels set for vaccinations and cervical smears. That, too, reflects a willingness on the part of the Government to listen to what was said either directly to us by doctors or by the representations that were made by hon. Members following meetings that they had had with general practitioners in their constituencies.

My hon. Friend the Member for Gillingham (Mr. Couchman) said that he hoped we would keep our ears flapping. That evidence has shown that we do flap our ears and that we shall continue to do so.

My hon. Friend the Member for Rochford (Dr. Clark) said that he had met members of every practice in his constituency and that he had sent us representations. He did not propagandise about the proposals, but he joined many colleagues in sending us practical suggestions on how the contract should be improved. We have read, learnt and inwardly digested their points, and I hope that all those who have played a part in the process will have felt that it was worth while after the happy outcome of last week.

That is the way in which we will continue the task of implementing the White Paper. Of course, the White Paper sets a framework—which it is the duty of the Government to provide—for the future of this vital national institution. However, a great deal of the detail remains to be worked through following the lead given in the working papers. We welcome even critical contributions—provided that they are not empty attempts to do away with the debate —if they are genuine responses on the practicalities of schemes that in the end will be tested and judged by their practicality. In implementing the White Paper, we are looking for a phased implementation of those ideas. I say that especially to my hon. Friend the Member for Brentwood and Ongar (Mr. McCrindle) and my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe). Every opportunity will he taken to look at what experience teaches us about those initiatives, so that others who come along behind can be influenced and, if necessary, adjustments can be made.

It is a crucial starting point in the debate to ask what has happened to the National Health Service over the past 15 or 20 years. As Aneurin Bevan said, "Why look in the crystal ball, when you can read the book?" It is important before we start to look to the future—especially some of the things that Opposition Members have said about the future—that we look at what has happened in the past. I do not want to dwell on what happened in the 1970s, but we know that there were years, such as 1977–78, when there was a fall in NHS funding. Overall, during the years of the last Labour Goverment, there was a fall in the proportion of the gross domestic product that went on the National Health Service. We know that there was a cut of 33 per cent. in capital spend on the NHS during those periods.

Every hon. Member will have a similar story to tell about a hospital in their areas, but almost every year of this decade since the Government were elected, more than £1 million has been spent on capital improvements, such as new operating theatres and a new burns unit in the Queen Mary's hospital, Roehampton, which is in my constituency. In the last year of the Labour Government, £35,000 was spent on capital improvements at that hospital.

One of the extraordinary things about the speeches that we have heard from members of the Labour party today is that they have not contained one word of apology or explanation for what happened during those dismal years. Never was the National Health Service less safe in a Government's hands than it was when the Opposition were in power. Following a point made by my right hon. Friend the Member for Brentford and Isleworth, we have not heard a word of explanation of what would have been the consequences for the NHS in the 1980s if the economic policies of the Opposition in the 1970s had been pursued. What we know is that, if the NHS had been funded at the same level at which they left it, we would have been spending £18.5 billion on the NHS this year, instead of £26 billion. That is the difference between a Conservative and a Labour Government.

However, when one looks at what has happened in the 1980s, one finds a sharp contrast. Expenditure has tripled in money terms and has increased by 40 per cent. in real terms. About 1.5 million more in-patients are being treated and 3.5 million more out-patients. We have tens of thousands more medical staff and they are much better paid. A nursing sister who was paid £96 per week at the top of her scale in 1979 is now paid over £300 per week under this Government. We are beginning to reach a level where we need not be ashamed of what we pay our nurses.

In primary care, we have 20 per cent. more general practitioners, 20 per cent. more dentists and 50 per cent. more support staff. It is no wonder that the size of the average patient list has decreased. It is no wonder that, for the first time in this decade, we can move into preventive medicine. It is over 70 years since the first health committee recommended that we should have preventive medicine in this country.

When one considers the capital size of the equation, one sees much more starkly what benefits the wise and prudent financial management of this decade has brought the NHS. We have a forward programme of NHS capital building of over £4 billion, and 500 projects of over £1 million each are either being built or are rolling forward. What a difference from when the Labour party was in power.

The hon. Member for Livingston (Mr. Cook) pointed out how well the NHS has coped with the many tragedies that have taken place in the past 12 to 18 months. Sadly, however, he turned that into a point of criticism as if the facilities in those hospitals had been tried and found wanting. Far from it—he knows that the unfortunate people who were injured in the Clapham incident, the disaster in the borough for which I am a Member of Parliament, were taken to a brand new accident and emergency unit which had been opened only the week before in one of the largest new hospitals in Europe. Indeed, that hospital will soon have the largest medical school in Europe. That would not have been possible with the 33 per cent. cut in capital programmes that we had under the Labour Government. In their last year in office, they spent just over £300 million in capital spend. This year we expect to spend over £1 billion and perhaps as much as £1.2 billion.

That is not happening just because more money is coming from the Treasury. It is coming about because of better management and because what the Opposition sneer at as commercial principles have been brought to bear on the NHS. In their last year in office, under £10 million-worth of NHS property was sold; this year we expect to sell nearly £300 million-worth of redundant land. That money will not go into the Chief Secretary's back pocket, but into further new building for tomorrow's NHS.

Mr. Morgan

It is evident that if tub-thumping were the same as health care, we would indeed have been doing well under this Government. However, if what the Minister has just said is correct, can he explain why a fortnight ago Gordon Harrhy, the general manager of the health authority in South Glamorgan, when attempting to explain why he has to close the children's ward in the Prince of Wales hospital in my constituency, said, "Although the Government go around saying that more money is being put into the Health Service, I can tell you" —he was talking to the audience of Radio Wales—"as a manager of the largest health authority in Wales but one, that we have actually had less money every year."

Mr. Mellor

It is not possible to have less money every year—[Interruption.] —because in every year, both in cash terms and in real terms the money allocated to the NHS has increased.

The hon. Gentleman has touched on a point to which I am coming. It is said for those people who come to such debates—there are far too many among the Opposition —who simply say that a large cheque or an additional sum of money is what is needed. The reality, and one of the driving forces of the White Paper, is that, even with an expanding health budget, one must still be super-efficient to cope with the increasing demand being placed on the Service. That is why it is such nonsense for the hon. Member for Peckham (Ms. Harman) to say, as she always says, that at any given point in time we need a certain amount more money, because even if that amount is put into the Service, the problems are just as great as they were before, for all the reasons that I am about to come to.

Back in 1976 when the British Medical Association was abusing the Labour Government even more lustily than it is abusing us, a BMA spokesman said that the NHS needed an extra £2 billion. Since that time, the NHS has received an extra £20 billion, but it still faces difficulties, because of demographic pressure. As my hon. Friend the Member for Eastleigh (Sir D. Price) rather charmingly said, it is due to the increased shelf life of the oldies. I think that he included himself in that memorable phrase. Demographics means that an aging population will obviously require more intensive health care.

Other reasons for the difficulties include medical advances and the greatly improved capability of the Health Service to deal with many conditions that were not treatable years ago and the increased expectations of people who want operations for conditions such as hernias and varicose veins, which used not to be treated operatively years ago. There is also a call for preventive strategies. We do not have to provide a service merely for the sick but look after those who may think that they are well, but who are not. Such people may have a problem, perhaps breast cancer or cervical cancer, of which they are unaware. However, if they are screened properly, the condition will not only be picked up, but will be cured. Those are the improvements that we are seeking.

If the NHS is to cope with the pressures of the next decade, it has no choice but to change. I shall pick up two points made by my hon. Friend the Member for Brentwood and Ongar in a most compelling speech. There was no answer from the Opposition to his question: why should the NHS be the only institution that does not have to change? The people who care about the NHS are those who want it not to be a mausoleum but to move with the times. It is not a monument to some past era of Socialist domination but a living, vital part of a modern community and must be treated as such.

The White Paper seeks to establish three basic principles: first, the need for more consistent quality in the NHS; secondly, that the NHS should be more responsive to its patients; thirdly, that it should offer value for money. Value for money is a concept that has been sneered at monotonously by Opposition Members. My hon. Friend the Member for Stockport (Mr. Favell) presented a clear and compelling example of why value for money matters —that of his own local hospital, Stepping Hill in Stockport, on which it is worth dwelling for a moment or two.

There are 11 hospitals in the north-western region that treat over 20,000 cases a year. The figures for 1986–87 show that Stepping Hill hospital treated 29,000 patients at an average cost of £605 per patient. In the other ten hospitals, the average cost per patient was between £630 and £1,107. However, Stepping Hill hospital offers an excellent service to my hon. Friend's constituents.

The question that must be asked when considering the problems in the NHS is whether the hospitals that are charging the taxpayer 50 per cent. more to carry out the same procedures offer a better service or merely charge more.

Mr. Andrew F. Bennett (Denton and Reddish)

Will the hon. and learned Gentleman confirm that Stepping Hill hospital does not have an accident department, and that therefore its costs are distorted? It would be helpful if we had the money for a first-class accident department in Stockport.

Mr. Mellor

I certainly take seriously the hon. Gentleman's comment, but he is wrong to think that the lack of an accident department influences the figures. 1 am sorry that he feels that, in the interests of defending his ideology, he has to sneer at the local hospital that looks after his constituents so well. That hospital is efficient and effective, and it also offers value for money for the NHS. That means that it can treat more patients. The NHS will never have anything but finite resources, so the less the unit cost of treating patients, the more patients can be treated. That is a fundamental point.

The problem with the Labour party was well pointed out by my right hon. Friend the Member for Brentford and Isleworth, who made it clear that, entertaining though the speech by the hon. Member for Livingston was, he completely wasted the opportunity to come to grips with the problems that the NHS faces and to set out what the Labour party would do about them. We are willing to defend our policies, but it would be interesting to know one day what the Opposition's policies are. I know that the hon. Member for Livingston will not tell us, but I am sure that he will not mind us basing our information on leaked documents which appeared in The Independent. The section on health has a strong flavour of the Government's White Paper—there is plenty of emphasis on quality. It seems that health authorities will be repaid for the work they do", which would appear to be a description of an internal market. What is missing is any way of bringing an internal market about.

Ms. Harman


Mr. Mellor

The document is full of references to preventive medicine, with no suggestions of how to bring it about. The Opposition want preventive medicine but they abuse the contract which is the only way of requiring general practitioners to practise it—

Ms. Harman

Hospitals being paid for how much work they do is a reference in our document not to the internal market but to activity-based budgeting.[Laughter.]

Mr. Mellor

That is illiteracy. One must be able to cost the activities before starting to budget for them.

The hon. Lady is on much safer ground when coming out with the old claptrap in the policy document about private practice, or saving the unions' bacon by not allowing competitive tendering, or about having health authorities that would consist of representatives of local government, health workers and voluntary agencies—so Southwark council, after the triumph of Nye Bevan lodge, would also run the local health service—

Dame Elaine Kellett-Bowman

Will my hon. and learned Friend give way?

Mr. Mellor

In the time that remains, I should like to turn to some of the constructive points that have been raised. I know that my hon. Friend the Member for Lancaster (Dame E. Kellett-Bowman) is very concerned about self-governing hospitals.

The expressions of interest in self-governing status are a sign that, whatever hostilities may exist towards the White Paper in some circles, people at the grass roots are recognising the opportunities that the White Paper offers. After all, many of our great hospitals were organised as self-governing hospitals before 1974. Self-governance represents the freedom of action that special health authorities already have.

The Secretary of State will determine, after representations, whether hospitals should be self-governing; he will examine the credibility of the plans put to him. We hope that they will succeed. There will be a phased implementation. Some hospitals will volunteer to come in, others will not initially, although no doubt they will when the scheme becomes a success. I guess that my hon. Friend the Member for Lancaster is particularly concerned to know whether, if a self-governing hospital does not work out, it can withdraw and return to its previous status within the NHS. There is no question of any hospital being outside the NHS—so suggestions to the contrary are spurious.

There will be no cash limits on what general practitioners may prescribe for patients—they can prescribe whatever they want—but they will have to justify their prescribing practices to show whether they are over-prescribing or prescribing over-expensive brands of drugs instead of generic alternatives. What business would ignore £2 billion of costs and allow those who spend the money to be wholly oblivious of value for money?

In the end, the ideas in the White Paper are far too serious to be treated with the derision that the Opposition direct at them. To describe what the White Paper sets out to do I can do no better than quote a document which says, referring to the White Paper: The programme seeks to preserve the basic principles on which the NHS was founded and to tackle its weaknesses through a series of incremental and imaginative reforms. These reforms centre on the introduction of incentives to doctors and hospitals to provide services that are more responsive to patients. In tandem, competition between providers will be used to stimulate greater efficiency in the use of resources. Those flashing insights come from Marxism Today. What better commendation to shatter the Opposition? I urge my colleagues to support the White Paper in the Division Lobby.

Question put, That the amendment be made:—

The House divided: Ayes 184, Noes 253.

Division No. 196] [10.00 pm
Abbott, Ms Diane Carlile, Alex (Mont'g)
Adams, Allen (Paisley N) Cartwright, John
Allen, Graham Clark, Dr David (S Shields)
Anderson, Donald Clarke, Tom (Monklands W)
Archer, Rt Hon Peter Clay, Bob
Armstrong, Hilary Clelland, David
Ashley, Rt Hon Jack Clwyd, Mrs Ann
Ashton, Joe Cohen, Harry
Banks, Tony (Newham NW) Cook, Frank (Stockton N)
Barnes, Harry (Derbyshire NE) Cook, Robin (Livingston)
Barnes, Mrs Rosie (Greenwich) Corbett, Robin
Barron, Kevin Cousins, Jim
Battle, John Cryer, Bob
Beckett, Margaret Cunliffe, Lawrence
Beith, A. J. Darling, Alistair
Bell, Stuart Davies, Rt Hon Denzil (Llanelli)
Benn, Rt Hon Tony Davies, Ron (Caerphilly)
Bennett, A. F. (D'nt'n & R'dish) Davis, Terry (B'ham Hodge H'l)
Bermingham, Gerald Dixon, Don
Bidwell, Sydney Dobson, Frank
Blair, Tony Doran, Frank
Blunkett, David Duffy, A. E. P.
Boateng, Paul Dunnachie, Jimmy
Boyes, Roland Evans, John (St Helens N)
Bradley, Keith Ewing, Mrs Margaret (Moray)
Bray, Dr Jeremy Fatchett, Derek
Brown, Nicholas (Newcastle E) Fearn, Ronald
Buckley, George J. Field, Frank (Birkenhead)
Caborn, Richard Fisher, Mark
Campbell, Menzies (Fife NE) Flannery, Martin
Campbell, Ron (Blyth Valley) Flynn, Paul
Canavan, Dennis Foot, Rt Hon Michael
Foster, Derek Morley, Elliott
Foulkes, George Morris, Rt Hon A. (W'shawe)
Fraser, John Morris, Rt Hon J. (Aberavon)
Fyfe, Maria Mowlam, Marjorie
Garrett, John (Norwich South) Mullin, Chris
Godman, Dr Norman A. Murphy, Paul
Gordon, Mildred Nellist, Dave
Gould, Bryan Oakes, Rt Hon Gordon
Graham, Thomas O'Brien, William
Grant, Bernie (Tottenham) O'Neill, Martin
Griffiths, Win (Bridgend) Orme, Rt Hon Stanley
Grocott, Bruce Owen, Rt Hon Dr David
Harman, Ms Harriet Pendry, Tom
Henderson, Doug Pike, Peter L.
Hinchliffe, David Powell, Ray (Ogmore)
Hogg, N. (C'nauld & Kilsyth) Prescott, John
Holland, Stuart Primarolo, Dawn
Home Robertson, John Quin, Ms Joyce
Hood, Jimmy Radice, Giles
Howarth, George (Knowsley N) Randall, Stuart
Howells, Dr. Kim (Pontypridd) Redmond, Martin
Hoyle, Doug Rees, Rt Hon Merlyn
Hughes, John (Coventry NE) Richardson, Jo
Hughes, Robert (Aberdeen N) Robertson, George
Hughes, Sean (Knowsley S) Rogers, Allan
Hughes, Simon (Southwark) Rooker, Jeff
Illsley, Eric Ross, Ernie (Dundee W)
Ingram, Adam Rowlands, Ted
Janner, Greville Ruddock, Joan
Jones, leuan (Ynys Môn) Sedgemore, Brian
Jones, Martyn (Clwyd S W) Shore, Rt Hon Peter
Kaufman, Rt Hon Gerald Short, Clare
Kennedy, Charles Sillars, Jim
Kilfedder, James Skinner, Dennis
Lamond, James Smith, Andrew (Oxford E)
Leadbitter, Ted Smith, C. (Isl'ton & F'bury)
Leighton, Ron Smith, J. P. (Vale of Glam)
Lewis, Terry Snape, Peter
Lloyd, Tony (Stretford) Soley, Clive
Lofthouse, Geoffrey Spearing, Nigel
Loyden, Eddie Steel, Rt Hon David
McAllion, John Steinberg, Gerry
McAvoy, Thomas Stott, Roger
McFall, John Strang, Gavin
McKay, Allen (Barnsley West) Straw, Jack
McKelvey, William Taylor, Matthew (Truro)
McNamara, Kevin Turner, Dennis
Madden, Max Vaz, Keith
Mahon, Mrs Alice Wall, Pat
Marek, Dr John Wallace, James
Marshall, Jim (Leicester S) Walley, Joan
Martin, Michael J. (Springburn) Warden, Gareth (Gower)
Martlew, Eric Wareing, Robert N.
Maxton, John Welsh, Andrew (Angus E)
Meacher, Michael Welsh, Michael (Doncaster N)
Meale, Alan Winnick, David
Michael, Alun Worthington, Tony
Michie, Bill (Sheffield Heeley) Wray, Jimmy
Michie, Mrs Ray (Arg'l & Bute)
Mitchell, Austin (G't Grimsby) Tellers for the Ayes:
Moonie, Dr Lewis Mr. Frank Haynes and
Morgan, Rhodri Mrs. Llin Golding.
Adley, Robert Biffen, Rt Hon John
Aitken,Jonathan Blackburn, Dr John G.
Alexander, Richard Blaker, Rt Hon Sir Peter
Alison, Rt Hon Michael Body, Sir Richard
Amery, Rt Hon Julian Boscawen, Hon Robert
Amess, David Boswell, Tim
Amos, Alan Bottomley, Peter
Arbuthnot, James Bottomley, Mrs Virginia
Arnold, Tom (Hazel Grove) Bowis, John
Ashby, David Boyson, Rt Hon Dr Sir Rhodes
Baker, Nicholas (Dorset N) Braine, Rt Hon Sir Bernard
Baldry, Tony Brandon-Bravo, Martin
Banks, Robert (Harrogate) Brazier, Julian
Batiste, Spencer Brooke, Rt Hon Peter
Bendall, Vivian Brown, Michael (Brigg & Cl't's)
Bennett, Nicholas (Pembroke) Browne, John (Winchester)
Bruce, Ian (Dorset South) Hordern, Sir Peter
Buck, Sir Antony Howard, Michael
Burns, Simon Howarth, Alan (Strat'd-on-A)
Burt, Alistair Howell, Rt Hon David (G'dford)
Butler, Chris Howell, Ralph (North Norfolk)
Butterfill, John Hughes, Robert G. (Harrow W)
Carlisle, John, (Luton N) Hunt, David (Wirral W)
Carlisle, Kenneth (Lincoln) Hunter, Andrew
Carrington, Matthew Irvine, Michael
Carttiss, Michael Irving, Charles
Channon, Rt Hon Paul Jack, Michael
Chapman, Sydney Janman, Tim
Chope, Christopher Jessel, Toby
Churchill, Mr Johnson Smith, Sir Geoffrey
Clark, Hon Alan (Plym'th S'n) Jones, Gwilym (Cardiff N)
Clark, Dr Michael (Rochford) Jones, Robert B (Herts W)
Clark, Sir W. (Croydon S) Kellett-Bowman, Dame Elaine
Clarke, Rt Hon K. (Rushcliffe) Key, Robert
Coombs, Anthony (Wyre F'rest) King, Roger (B'ham N'thfield)
Coombs, Simon (Swindon) Knapman, Roger
Cope, Rt Hon John Knox, David
Couchman, James Lawrence, Ivan
Cran, James Lester, Jim (Broxtowe)
Curry, David Lightbown, David
Davies, Q. (Stamf'd & Spald'g) Lilley, Peter
Davis, David (Boothferry) Lloyd, Peter (Fareham)
Devlin, Tim McCrindle, Robert
Dorrell, Stephen Macfarlane, Sir Neil
Dover, Den Maclean, David
Dunn, Bob McNair-Wilson, Sir Michael
Durant, Tony McNair-Wilson, P. (New Forest)
Dykes, Hugh Madel, David
Emery, Sir Peter Major, Rt Hon John
Evans, David (Welwyn Hatf'd) Malins, Humfrey
Evennett, David Mans, Keith
Fallon, Michael Maples, John
Favell, Tony Marland, Paul
Field, Barry (Isle of Wight) Marlow, Tony
Fishburn, John Dudley Marshall, John (Hendon S)
Fookes, Dame Janet Martin, David (Portsmouth S)
Forman, Nigel Mates, Michael
Forth, Eric Mawhinney, Dr Brian
Fowler, Rt Hon Norman Mayhew, Rt Hon Sir Patrick
Fox, Sir Marcus Mellor, David
Franks, Cecil Miller, Sir Hal
Freeman, Roger Mills, Iain
French, Douglas Miscampbell, Norman
Gardiner, George Mitchell, Andrew (Gedling)
Garel-Jones, Tristan Mitchell, Sir David
Gill, Christopher Moate, Roger
Glyn, Dr Alan Montgomery, Sir Fergus
Goodhart, Sir Philip Morrison, Sir Charles
Goodlad, Alastair Moss, Malcolm
Goodson-Wickes, Dr Charles Moynihan, Hon Colin
Gow, Ian Neale, Gerrard
Grant, Sir Anthony (CambsSW) Needham, Richard
Greenway, Harry (Ealing N) Nelson, Anthony
Greenway, John (Ryedale) Neubert, Michael
Gregory, Conal Nicholls, Patrick
Griffiths, Peter (Portsmouth N) Nicholson, Emma (Devon West)
Grist, Ian Norris, Steve
Ground, Patrick Oppenheim, Phillip
Grylls, Michael Page, Richard
Hague, William Paice, James
Hamilton, Hon Archie (Epsom) Patten, Chris (Bath)
Hamilton, Neil (Tatton) Patten, John (Oxford W)
Hanley, Jeremy Pattie, Rt Hon Sir Geoffrey
Hannam, John Pawsey, James
Hargreaves, A. (B'ham H'll Gr') Peacock, Mrs Elizabeth
Hargreaves, Ken (Hyndburn) Porter, David (Waveney)
Harris, David Portillo, Michael
Haselhurst, Alan Powell, William (Corby)
Hawkins, Christopher Price, Sir David
Hayes, Jerry Raffan, Keith
Hayhoe, Rt Hon Sir Barney Raison, Rt Hon Timothy
Heddle, John Rathbone, Tim
Hicks, Mrs Maureen (Wolv' NE) Redwood, John
Hicks, Robert (Cornwall SE) Rhodes James, Robert
Hind, Kenneth Riddick, Graham
Hogg, Hon Douglas (Gr'th'm) Ridley, Rt Hon Nicholas
Ridsdale, Sir Julian Townsend, Cyril D. (B 'heath)
Rost, Peter Tracey, Richard
Rowe, Andrew Tredinnick, David
Rumbold, Mrs Angela Trippier, David
Ryder, Richard Trotter, Neville
Sainsbury, Hon Tim Twinn, Dr Ian
Shaw, David (Dover) Vaughan, Sir Gerard
Shaw, Sir Michael (Scarb1) Viggers, Peter
Shelton, Sir William Waddington, Rt Hon David
Shephard, Mrs G. (Norfolk SW) Wakeham, Rt Hon John
Shersby, Michael Walden, George
Sims, Roger Waller, Gary
Skeet, Sir Trevor Ward, John
Smith, Tim (Beaconsfield) Wardle, Charles (Bexhill)
Spicer, Sir Jim (Dorset W) Watts, John
Spicer, Michael (S Worcs) Wells, Bowen
Stanley, Rt Hon Sir John Wheeler, John
Steen, Anthony Whitney, Ray
Stern, Michael Widdecombe, Ann
Stevens, Lewis Wiggin, Jerry
Stewart, Andy (Sherwood) Wilkinson, John
Stradling Thomas, Sir John Wilshire, David
Sumberg, David Winterton, Mrs Ann
Summerson, Hugo Wolfson, Mark
Tapsell, Sir Peter Wood, Timothy
Taylor, Ian (Esher) Woodcock, Dr. Mike
Taylor, John M (Solihull) Yeo, Tim
Taylor, Teddy (S'end E) Young, Sir George (Acton)
Tebbit, Rt Hon Norman
Temple-Morris, Peter Tellers for the Noes:
Thompson, D. (Calder Valley) Mr. David Heathcoat-Amory
Thompson, Patrick (Norwich N) and Mr. Tom Sackville.
Thurnham, Peter

Question accordingly agreed to.

Main Question put:

The House divided: Ayes 252, Noes 179.

Division No. 197] [10.13 pm
Adley, Robert Carlisle, Kenneth (Lincoln)
Aitken, Jonathan Carrington, Matthew
Alexander, Richard Carttiss, Michael
Alison, Rt Hon Michael Channon, Rt Hon Paul
Amery, Rt Hon Julian Chope, Christopher
Amess, David Churchill, Mr
Amos, Alan Clark, Hon Alan (Plym'th S'n)
Arbuthnot, James Clark, Dr Michael (Rochford)
Arnold, Tom (Hazel Grove) Clark, Sir W. (Croydon S)
Ashby, David Clarke, Rt Hon K. (Rushcliffe)
Baker, Nicholas (Dorset N) Coombs, Anthony (Wyre F'rest)
Baldry, Tony Coombs, Simon (Swindon)
Banks, Robert (Harrogate) Cope, Rt Hon John
Batiste, Spencer Couchman, James
Bendall, Vivian Cran, James
Bennett, Nicholas (Pembroke) Curry, David
Biffen, Rt Hon John Davies, Q. (Stamf'd & Spald'g)
Blackburn, Dr John G. Davis, David (Boothlerry)
Blaker, Rt Hon Sir Peter Devlin, Tim
Body, Sir Richard Dorrell, Stephen
Boscawen, Hon Robert Dover, Den
Boswell, Tim Dunn, Bob
Bottomley, Peter Durant, Tony
Bottomley, Mrs Virginia Dykes, Hugh
Bowis, John Emery, Sir Peter
Boyson, Rt Hon Dr Sir Rhodes Evans, David (Welwyn Hatf'd)
Braine, Rt Hon Sir Bernard Evennett, David
Brandon-Bravo, Martin Fallon, Michael
Brazier, Julian Favell, Tony
Brooke, Rt Hon Peter Field, Barry (Isle of Wight)
Brown, Michael (Brigg & Cl't's) Fishburn, John Dudley
Browne, John (Winchester) Fookes, Dame Janet
Bruce, Ian (Dorset South) Forman, Nigel
Buck, Sir Antony Forth, Eric
Burns, Simon Fowler, Rt Hon Norman
Burt, Alistair Fox, Sir Marcus
Butler, Chris Franks, Cecil
Butterfill, John Freeman, Roger
Carlisle, John, (Luton N) French, Douglas
Gardiner, George Miscampbell, Norman
Garel-Jones, Tristan Mitchell, Andrew (Gedling)
Gill, Christopher Mitchell, Sir David
Glyn, Dr Alan Moate, Roger
Goodhart, Sir Philip Montgomery, Sir Fergus
Goodlad, Alastair Morrison, Sir Charles
Goodson-Wickes, Dr Charles Moss, Malcolm
Gow, Ian Moynihan, Hon Colin
Grant, Sir Anthony (CambsSW) Neale, Gerrard
Greenway, Harry (Ealing N) Needham, Richard
Greenway, John (Ryedale) Nelson, Anthony
Gregory, Conal Neubert, Michael
Griffiths, Peter (Portsmouth N) Nicholls, Patrick
Grist, Ian Nicholson, Emma (Devon West)
Ground, Patrick Norris, Steve
Grylls, Michael Oppenheim, Phillip
Hague, William Page, Richard
Hamilton, Hon Archie (Epsom) Paice, James
Hamilton, Neil (Tatton) Patten, Chris (Bath)
Hanley, Jeremy Patten, John (Oxford W)
Hannam, John Pawsey, James
Hargreaves, A. (B'ham H'll Gr') Peacock, Mrs Elizabeth
Hargreaves, Ken (Hyndburn) Porter, David (Waveney)
Harris, David Portillo, Michael
Haselhurst, Alan Powell, William (Corby)
Hawkins, Christopher Price, Sir David
Hayes, Jerry Raffan, Keith
Hayhoe, Rt Hon Sir Barney Raison, Rt Hon Timothy
Heathcoat-Amory, David Rathbone, Tim
Heddle, John Redwood, John
Hicks, Mrs Maureen (Wolv' NE) Rhodes James, Robert
Hicks, Robert (Cornwall SE) Riddick, Graham
Hind, Kenneth Ridley, Rt Hon Nicholas
Hogg, Hon Douglas (Gr'th'm) Ridsdale, Sir Julian
Hordern, Sir Peter Rost, Peter
Howard, Michael Rowe, Andrew
Howarth, Alan (Strat'd-on-A) Rumbold, Mrs Angela
Howell, Rt Hon David (G'dford) Ryder, Richard
Howell, Ralph (North Norfolk) Sainsbury, Hon Tim
Hughes, Robert G. (Harrow W) Shaw, David (Dover)
Hunt, David (Wirral W) Shaw, Sir Michael (Scarb')
Hunter, Andrew Shelton, Sir William
Irvine, Michael Shephard, Mrs G. (Norfolk SW)
Irving, Charles Shersby, Michael
Jack, Michael Sims, Roger
Janman, Tim Skeet, Sir Trevor
Jessel, Toby Smith, Tim (Beaconsfield)
Johnson Smith, Sir Geoffrey Spicer, Sir Jim (Dorset W)
Jones, Gwilym (Cardiff N) Spicer, Michael (S Worcs)
Jones, Robert B (Herts W) Stanley, Rt Hon Sir John
Kellett-Bowman, Dame Elaine Steen, Anthony
Key, Robert Stern, Michael
King, Roger (B'ham N'thfield) Stevens, Lewis
Knapman, Roger Stewart, Andy (Sherwood)
Knox, David Stradling Thomas, Sir John
Lawrence, Ivan Sumberg, David
Lester, Jim (Broxtowe) Summerson, Hugo
Lightbown, David Tapsell, Sir Peter
Lilley, Peter Taylor, Ian (Esher)
Lloyd, Peter (Fareham) Taylor, John M (Solihull)
McCrindle, Robert Taylor, Teddy (S'end E)
Macfarlane, Sir Neil Tebbit, Rt Hon Norman
Maclean, David Temple-Morris, Peter
McNair-Wilson, Sir Michael Thompson, D. (Calder Valley)
McNair-Wilson, P. (New Forest) Thompson, Patrick (Norwich N)
Madel, David Thurnham, Peter
Major, Rt Hon John Townsend, Cyril D. (B'heath)
Malins, Humfrey Tracey, Richard
Mans, Keith Tredinnick, David
Maples, John Trippier, David
Marland, Paul Trotter, Neville
Marlow, Tony Twinn, Dr Ian
Marshall, John (Hendon S) Vaughan, Sir Gerard
Martin, David (Portsmouth S) Viggers, Peter
Mates, Michael Waddington, Rt Hon David
Mawhinney, Dr Brian Wakeham, Rt Hon John
Mayhew, Rt Hon Sir Patrick Walden, George
Mellor, David Waller, Gary
Miller, Sir Hal Ward, John
Mills, Iain Wardle, Charles (Bexhill)
Watts, John Wolfson, Mark
Wells, Bowen Wood, Timothy
Wheeler, John Woodcock, Dr. Mike
Whitney, Ray Yeo, Tim
Widdecombe, Ann Young, Sir George (Acton)
Wiggin, Jerry
Wilkinson, John Tellers for the Ayes:
Wilshire, David Mr. Tom Sackville and
Winterton, Mrs Ann Mr. Sydney Chapman.
Abbott, Ms Diane Davies, Rt Hon Denzil (Llanelli)
Adams, Allen (Paisley N) Davies, Ron (Caerphilly)
Allen, Graham Davis, Terry (B'ham Hodge H'l)
Anderson, Donald Dixon, Don
Archer, Rt Hon Peter Dobson, Frank
Armstrong, Hilary Doran, Frank
Ashley, Rt Hon Jack Duffy, A. E. P.
Ashton, Joe Dunnachie, Jimmy
Banks, Tony (Newham NW) Evans, John (St Helens N)
Barnes, Harry (Derbyshire NE) Ewing, Mrs Margaret (Moray)
Barnes, Mrs Rosie (Greenwich) Fatchett, Derek
Barron, Kevin Fearn, Ronald
Battle, John Fisher, Mark
Beckett, Margaret Flannery, Martin
Beith, A. J. Flynn, Paul
Bell, Stuart Foot, Rt Hon Michael
Benn, Rt Hon Tony Foster, Derek
Bennett, A. F. (D'nt'n & R'dish) Foulkes, George
Bermingham, Gerald Fraser, John
Bidwell, Sydney Fyfe, Maria
Blair, Tony Garrett, John (Norwich South)
Blunkett, David Godman, Dr Norman A.
Boateng, Paul Gordon, Mildred
Boyes, Roland Gould, Bryan
Bradley, Keith Graham, Thomas
Bray, Dr Jeremy Grant, Bernie (Tottenham)
Brown, Nicholas (Newcastle E) Griffiths, Win (Bridgend)
Buckley, George J. Grocott, Bruce
Caborn, Richard Harman, Ms Harriet
Campbell, Menzies (Fife NE) Henderson, Doug
Campbell, Ron (Blyth Valley) Hinchliffe, David
Canavan, Dennis Hogg, N. (C'nauld & Kilsyth)
Carlile, Alex (Mont'g) Holland, Stuart
Cartwright, John Home Robertson, John
Clark, Dr David (S Shields) Hood, Jimmy
Clarke, Tom (Monklands W) Howarth, George (Knowsley N)
Clay, Bob Howells, Dr. Kim (Pontypridd)
Clelland, David Hoyle, Doug
Clwyd, Mrs Ann Hughes, John (Coventry NE)
Cohen, Harry Hughes, Robert (Aberdeen N)
Cook, Frank (Stockton N) Hughes, Sean (Knowsley S)
Cook, Robin (Livingston) Hughes, Simon (Southwark)
Corbett, Robin Illsley, Eric
Corbyn, Jeremy Ingram, Adam
Cousins, Jim Janner, Greville
Cryer, Bob Jones, leuan (Ynys Môn)
Cunliffe, Lawrence Jones, Martyn (Clwyd S W)
Darling, Alistair Kaufman, Rt Hon Gerald
Kennedy, Charles Primarolo, Dawn
Kilfedder, James Quin, Ms Joyce
Lamond, James Radice, Giles
Leadbitter, Ted Randall, Stuart
Leighton, Ron Redmond, Martin
Lewis, Terry Rees, Rt Hon Merlyn
Lloyd, Tony (Stretford) Richardson, Jo
Lofthouse, Geoffrey Robertson, George
Loyden, Eddie Rogers, Allan
McAllion, John Ross, Ernie (Dundee W)
McAvoy, Thomas Rowlands, Ted
McFall, John Ruddock, Joan
McKay, Allen (Barnsley West) Sedgemore, Brian
McKelvey, William Shore, Rt Hon Peter
McNamara, Kevin Short, Clare
Madden, Max Sillars, Jim
Mahon, Mrs Alice Skinner, Dennis
Marek, Dr John Smith, Andrew (Oxford E)
Martin, Michael J. (Springburn) Smith, C. (Isl'ton & F'bury)
Martlew, Eric Smith, J. P. (Vale of Glam)
Maxton, John Snape, Peter
Meacher, Michael Soley, Clive
Meale, Alan Spearing, Nigel
Michael, Alun Steel, Rt Hon David
Michie, Bill (Sheffield Heeley) Steinberg, Gerry
Michie, Mrs Ray (Arg'l & Bute) Stott, Roger
Mitchell, Austin (G't Grimsby) Strang, Gavin
Moonie, Dr Lewis Straw, Jack
Morgan, Rhodri Taylor, Matthew (Truro)
Morley, Elliott Turner, Dennis
Morris, Rt Hon A. (W'shawe) Wall, Pat
Morris, Rt Hon J. (Aberavon) Wallace, James
Mowlam, Marjorie Walley, Joan
Mullin, Chris Warden, Gareth (Gower)
Murphy, Paul Wareing, Robert N.
Oakes, Rt Hon Gordon Welsh, Michael (Doncaster N)
O'Brien, William Winnick, David
O'Neill, Martin Worthington, Tony
Orme, Rt Hon Stanley Wray, Jimmy
Owen, Rt Hon Dr David
Pendry, Tom Tellers for the Noes:
Pike, Peter L. Mr. Frank Haynes and
Powell, Ray (Ogmore) Mrs. Llin Golding.

Question accordingly agreed to.

Resolved, That this House approves the programme of reform of the National Health Service set out in the White Paper, Working for Patients (Cm. 555), and the reaffirmation of the basic principles of the National Health Service which will continue to be available to all, regardless of income and financed mainly out of taxation; and believes that the proposals in the White Paper will raise the standards of all of the health service to the high standard of the best and will lead to an extension of patient choice, a more responsive health service, better value for money and an even better standard of health care for the decade to come.